In early September of last year, we published the blog entitled Vaping Epidemic: A Public Health Crisis?
At that time, several hundred people had been hospitalized for severe respiratory illness presumed to be related to vaping, or e-cigarette use. According to the U.S. Centers for Disease Control and Prevention (CDC) (2020), the number of cases peaked in September and as of January 7, 2020, there have been over 2,600 hospitalizations due to e-cigarette, or vaping, product use-associated lung injury (EVALI). The CDC and the U.S. Food and Drug Administration (FDA) have been working with state and local health departments to investigate this “national outbreak” of EVALI. Their latest findings are summarized below.
- While emergency department (ED) visits associated with potential EVALI have decreased, they are still higher than levels before the outbreak began in June, 2019.
- The CDC noted a gradual increase in ED visits with e-cigarette use since 2017, followed by a sharp increase in June, 2019 (CDC, 2020).
- The number of EVALI cases have been declining since the peak in September, however new cases continue to be reported to the CDC weekly (CDC, 2020).
- The FDA is analyzing samples submitted by state health departments for chemicals including nicotine, tetrahydrocannabinol (THC, the psychoactive component of marijuana) and other cannabinoids, cutting agents/diluents, additives, pesticides, opioids, poisons, heavy metals, and toxins (FDA, 2019).
- No single substance or product has been identified in all of the samples tested.
- Vitamin E acetate has been identified as a “chemical of concern” and is closely associated with EVALI (CDC, 2020).
- Vitamin E acetate is an additive in some e-cigarettes containing THC and was identified in lung fluid samples from EVALI patients.
- It is usually harmless when ingested as a vitamin supplement or applied to the skin; however when vitamin E acetate is inhaled it may impair normal lung function.
- While vitamin E is suspected as a cause, there are other substances that may be contributors to the problem.
- THC has been found in most of the samples tested by the FDA to date, and most patients reported using THC-containing products (CDC, 2020).
- 152 different THC-containing product brands were reported by EVALI patients, the most commonly reported brands included Dank Vapes, TKO, Smart Cart, and Rove.
- The FDA and CDC recommend that people avoid THC-containing e-cigarette, or vaping, products, specifically from informal sources such as friends, family or in-person or on-line sellers.
- National data found that EVALI patients with advanced age or chronic medical conditions (cardiac disease, pulmonary disease, diabetes) are at high risk for hospital readmission, morbidity, and mortality (CDC, 2020).
- Fifty-seven deaths have been confirmed as of January 7, 2020 in 27 states and the District of Columbia.
The CDC (2019) has updated its guidelines
and recommended strategies for clinicians to minimize EVALI patient hospital readmission.
- EVALI patients should be clinically stable for 24-48 hours (without significant fluctuations in vital signs) prior to discharge.
- Schedule a patient follow-up visit with a primary care provider or pulmonary specialist, within 48 hours of discharge (previously recommended within 2 weeks of discharge). At the follow-up:
- Clinically assess for stable vital signs, physical exam, resolution of symptoms, and normalized lab tests.
- Continue to provide education about EVALI.
- Assess adherence with medication regimens.
- Reinforce abstinence from e-cigarette and vaping products.
- Refer patient to outpatient care.
- Long-term follow up with a pulmonary specialist typically occurs within 2-4 weeks following discharge (at completion of the corticosteroid taper). These visits involve:
- Assessment of pulmonary function and resolution of radiographic findings.
- Continued testing 1-2 months following discharge including spirometry, diffusing capacity of the lung for carbon monoxide, and chest x-ray.
- Plan for discharge care, early follow-up, and management of comorbidities.
- Schedule follow-up appointments prior to hospital discharge and assign patient navigators, community health workers, or nursing services to perform home health visits.
- Follow best practices for medication adherence.
- EVALI patients readmitted to the hospital often did not comply with prescribed corticosteroid tapers.
- Include inpatient pharmacist counseling as part of EVALI patient discharge planning.
- Evaluate EVALI patients for risk of secondary adrenal insufficiency and educate patients on signs and symptoms such as fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, and postural hypotension.
- Ensure social support, mental and behavioral health, and substance use disorder services.
- Patients should be supported in their efforts to stop e-cigarette or vaping product use.
- Physical therapy referral for patients who experienced prolonged immobilization during hospitalization.
Clinicians should continue to report EVALI cases to their state or local health department.
Ban on Vaping?
- If vaping product use is suspected as a cause of lung illness, obtain a detailed history of the substances used, the sources, and request the device itself. Ask the patient if there is any remaining product or liquids available for testing.
- As of December 19, 2019, the CDC and FDA are accepting case-associated product samples for aerosol or e-liquid testing if corresponding bronchoalveolar lavage (BAL) fluid samples are submitted to the CDC (samples do not need to be submitted at the same time).
- In EVALI-related deaths, CDC and FDA will continue to accept product samples for testing even if BAL fluid is not available for testing.
In October of last year, the American Medical Association contacted the Chief Operating Officers (CEOs) of the top e-commerce companies asking them to stop selling illicit vaping products as well as empty vaping cartridges which can be used to create counterfeit vaping products (AMA, 2019). On December 20, 2019, President Trump signed legislation to raise the federal minimum age to purchase tobacco products from 18 to 21 years. Many states are attempting to legislate bans on e-cigarettes however most are being challenged in court.
While the safety of e-cigarettes remains in question, vaping products should not be used by children, adolescents, young adults, or pregnant women. Adults who are using e-cigarettes should stop and consider other forms of FDA-approved smoking-cessation medications. Adults who choose to continue to use vaping products should monitor themselves for symptoms of lung injury such as cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fever, chills or weight loss (CDC, 2020) and seek medical attention should any of these occur.