Vaping Induced Lung Injuries

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Vaping is commonly seen as an alternative to traditional cigarette smoking. The public-at-large commonly view vaping as a potentially healthier or less harmful cigarette substitute. However, the effects of vaping are not well studied and can be unpredictable. 

In this course we will discuss the known and unknown effects of vaping on the human body and health. You will learn of vaping induced lung injuries that have become common during recent years.

Vaping Trends: The Appeal and Rise in Popularity

What started as a product designed for cigarette smokers wanting to wean off of the habit while still allowing them to have the physical ritual of smoking, vaping has now become a cultural phenomenon. Minimal odor, sleek packaging, and few, if any, regulations about when and where people can vape created an appeal even to those who had never used nicotine before and the market quickly turned its attention to gaining new customers through the addition of flavors, additives like THC, and devices that look like flash drives. 

The use of electronic cigarettes involves a battery operated device and a cartridge of nicotine-containing liquid. The liquid is heated into an aerosol which is then inhaled (or vaped). The devices are most popular among adolescents, with 27.5% of high schoolers having used e-cigarettes in the last 30 days in a 2019 survey (1). Adults are using them too, with as many as 2.8% of US adults regularly vaping in 2019, many of whom had never even been cigarette smokers (1). 

One of the main reasons vaping has become so popular so quickly is because of the common misconception that it is a low-risk alternative to cigarette smoking, with many companies claiming fewer toxins and not including complete ingredient lists. It is a commonly held belief that there are less odds of vaping induced lung injuries than cigarette-use induced lung injuries.  While e-cigarettes do contain fewer chemicals than traditional cigarettes, they are by no means a “healthy” alternative and contain their own slew of ingredients, including heavy metals such as nickel and lead, glycerin, carcinogens, and nicotine, which is a highly addictive substance (8). The nicotine level in the cartridges is also very high, with a typical “pod,” or cartridge, containing the same amount of nicotine as a package of cigarettes (6). This is enough to make even casual users quickly addicted. The FDA has cracked down on these loopholes in recent years, now requiring warning labels and attempting to regulate the production of flavors, but the popularity of vaping has already exploded and the effort to reverse the trend is an uphill battle. 

Health Risks – Vaping Induced Lung Injuries

EVALI (e-cigarette or vaping induced lung injury)  

Not surprisingly, the increase in vaping has been followed by a rise in health issues for the users. Most notably among emerging illnesses (and in the media recently) is lung damage referred to as e-cigarette/vaping associated lung injury, or EVALI (2). 

A recent Morbidity and Mortality Weekly Report classifies EVALI as a diagnosis of exclusion as there is currently no specific testing for the illness, but it is one that should be considered early on in the presentation of symptoms in order to not delay treatment (3). Nearly all patients affected presented with cough, chest pain, and dyspnea, with many others having fever, chills, weight loss, vomiting, or diarrhea. At least 30% of patients presented with an oxygen saturation of less than 95%. Tachypnea was not frequently noted, but tachycardia was common. X-ray revealed abnormal lung findings in 82% of patients and CT of the lungs was abnormal in 96% (3). This emerging issue is placing significant burden on the healthcare system, as most of these patients require inpatient management with steroids and supplemental oxygen, at least for the first 24-48 hours. 

When this diagnosis resulted in several deaths in mid to late 2019, it was met with panic in the media and general public as healthcare professionals scrambled to find what exactly about vaping was causing the decrease in lung function. Emerging evidence now strongly suggests that the injury to the respiratory tract is caused by Vitamin E acetate, an additive in many e-cigarette pods (3). Fluid collected from symptomatic patients’ lungs was found to contain Vitamin E acetate in almost all cases and buildup over time is believed to be responsible for this lung injury (3). It is too early to rule out damage from other additives (like the glycerin used for flavoring) and researchers note that while these components are safe for oral consumption and often found in food, the effects of inhalation have not been studied and frequent exposure to the lungs should not be considered safe (4). 

For now though, Vitamin E acetate is considered the main culprit and is most commonly found in cartridges containing THC, particularly those made informally by people at home rather than those purchased from a manufacturer (3). 

While all vaping should be avoided, for those who do use e-cigarettes it is safest to avoid cartridges containing THC and home-made cartridges.

Other Health Concerns

In addition to the potentially lethal complications of EVALI, routine nicotine use of any kind can have serious health implications, and e-cigarettes are no different. Cardiovascular health is affected, with increased heart rate and blood pressure within minutes of nicotine use. Risk of heart attack, stroke, chronic cough, compromised immune system, and impaired oxygenation, all are increased. Nicotine’s effects on a young, developing brain are well documented as well, with attention problems, impulse control issues, and an increased addiction response all posing serious risks to teens who vape regularly (6). Substance use of any kind is closely tied to mental illnesses such as anxiety and depression as well as ongoing struggles with addiction and substance abuse throughout adulthood (6). 

There is a possibility that vaping induced lung injuries can escalate quickly in severity.  The risk of cancer is also not solely tied to traditional cigarettes, with many substances found in e-cigarettes believed to be carcinogenic. A 2018 study tested urine and saliva samples from vaping teens and found the levels of carcinogens present to be significant and concerning (7). In general, the belief that vaping is a low-risk alternative to cigarettes is grossly erroneous. 

What Can Healthcare Providers Do to Prevent Vaping Induced Lung Injuries?

Screen for Vaping Use 

One of the best ways to prevent vaping related health issues and/or vaping induced injuries is to ensure that patients do not start vaping in the first place. Pediatric providers or those working with children and teens 11 years and older are in a particularly good position to start the conversations early and often. Ask questions about what they know about vaping, if they have any friends who vape, and if they themselves have tried vaping. Try to maintain a non-judgemental attitude and allow them to lead the conversation. Provide education to patients and their parents about the dangers and health risks of vaping. Talk about the strengths of the student (academics, sports, arts) and discuss how a nicotine addiction or disciplinary action for vaping at school could negatively impact these enjoyable activities. For any patients who are already vaping, create a plan for cessation (discussed below). Adult patients and established cigarette smokers should also be screened for vaping and health risks discussed (2).   

Early Detection of Vaping Related Lung Injury 

Screening for vaping is not only important at routine wellness visits, but also for acutely ill patients in the outpatient, inpatient, and emergency room settings. Any patient presenting with cough, chest pain, or other respiratory symptoms should be questioned about current or recent vaping habits, including the use of THC pods. Chest X-ray should be strongly considered in the workup for anyone with respiratory symptoms and a history of vaping, particularly those with a pulse oximetry <95%. Flu and pneumonia should be considered in the differential diagnosis, as vaping increases the risk of both of these illnesses. In patients hospitalized or treated outpatient for a suspected EVALI, close follow up for the first few weeks is recommended (2).   

Cessation 

For patients with or without acute lung injury related illness, vaping cessation should be counseled. For adults, many employers will offer smoking-cessation incentive programs which have been shown to be effective. Encourage your patients to ask their employer if this is offered and if they qualify. There are multiple nicotine products designed to help wean slowly from nicotine with the ultimate goal of cessation such as gum, patches, and lozenges. Either gain familiarity with prescribing these yourself or find a local provider who you can refer your patients to for these products (5). Psychotherapy or counseling can be very beneficial for patients trying to break an addiction and there are typically addiction counselors available at mental health facilities. There is a Substance Abuse and Mental Health Services Treatment Locator tool that can be found at https://findtreatment.samhsa.gov/ or patients can call 1-800-662-HELP (4357) to find the nearest resources (1). Finally, if you have patients using vaping as a method of stopping cigarette smoking, you should counsel that this is not a long term solution and has no current supportive evidence as an effective smoking cessation tool. The risks of vaping far outweigh any perceived benefits and vaping should not be counseled as a method of smoking cessation.

Case Study – Vaping Induced Lung Injuries

Austin is a 19 year old male presenting to the ED with 6 days of coughing, fever, lethargy, decreased appetite, and (in the last 2 days) increasing chest pain, particularly with deep inspiration. 

He is a student at the local university with a history of ADHD for which he takes 20mg of Adderall XR daily. No other pertinent medical history and no other medications. He reports drinking socially on the weekends. 

Vital signs are as follows: Temp: 100.9, HR: 147, BP: 134/85, RR: 20, SPO2: 87%. Physical exam reveals pallor, diaphoresis, diminished air exchange in all lung fields with crackles in the bases. Deep inspiration results in coughing fits with no improvement or clearance of crackles and rhonchi. He is most comfortable in the tripod position, but overall is restless. CBC with differential is normal, flu swab is negative. Chest xray reveals bilateral infiltrates. 

The nurse notices a Juul device in the clear plastic bag of the patient’s belongings and when asked, he admits to vaping ¾-1 cartridge per day for 2 years. He also states he will use a THC cartridge 2-3 times per week with friends. 

He is diagnosed with EVALI and admitted for treatment with corticosteroids and supplemental oxygen. He is discharged in stable condition after 2 days with scheduled follow up in 1 week. He is counseled on vaping cessation, particularly of THC cartridges, and makes a full recovery over the next 2 months. 

Conclusion

Vaping is a fairly new trend and health risks are still emerging as the number of people using e-cigarettes grows. Staying abreast of trends in vaping and the growing information about symptoms, treatment, and causes of EVALI are important responsibilities of healthcare providers. Key health issues, especially vaping induced lung injuries, are on the rise due to commonly held misconceptions.  Early detection of vaping related illnesses is key to best treatment outcomes and screening for vaping should become a routine part of all healthcare exams, both preventive and acute.

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