Vaping Update 2020

In early September of last yr, we published a blog titled At that point, several hundred people were hospitalized with severe respiratory illness that was likely related to vaping or electronic cigarette use. According to the U.S. Centers for Disease Control and Prevention (CDC) (2020), cases peaked in September, and since January 7, 2020, there have been greater than 2,600 hospitalizations for electronic cigarette or vaping-related lung injury (EVALI). The CDC and the U.S. Food and Drug Administration (FDA) are working with local and state health departments to analyze this “national outbreak” of EVALI. Their latest findings are summarized below.

• Although the variety of emergency department (ED) visits related to potential EVALI infection has decreased, it continues to be higher than before the outbreak in June 2019.
  • The CDC has noted a gradual increase in ED visits for e-cigarette users since 2017, with a pointy increase in June 2019 (CDC, 2020).
  • The variety of EVALI cases has been declining because the peak in September, nevertheless recent cases are still reported to the CDC weekly (CDC, 2020).
• The FDA analyzes samples submitted by state health departments for chemicals akin to nicotine, tetrahydrocannabinol (THC, the psychoactive ingredient in marijuana), and other cannabinoids, adulterants/diluents, additives, pesticides, opioids, poisons, heavy metals, and toxins (FDA, 2019).
  • No single substance or product was identified in all samples tested.
• Vitamin E acetate has been identified as a “chemical of concern” and is closely related to EVALI (CDC, 2020).
  • Vitamin E acetate is an additive in some e-cigarettes containing THC and has been detected in lung fluid samples collected from EVALI patients.
  • Vitamin E acetate is normally harmless when taken as a vitamin complement or applied on to the skin. However, inhaling it will probably disrupt normal lung function.
  • While vitamin E is suspected to be the explanation for the issue, there are also other substances that will contribute to its occurrence.
• THC has been detected in most samples tested by the FDA thus far, and most patients reported using products containing THC (CDC, 2020).
  • EVALI patients reported 152 different brands of THC-containing products. The mostly reported brands were Dank Vapes, TKO, Smart Cart, and Rove.
  • The FDA and CDC recommend avoiding e-cigarettes and vaping products containing THC, especially from informal sources akin to friends, family, or in-person and online vendors.
• National data have shown that EVALI patients who’re elderly or have chronic medical conditions (heart disease, lung disease, diabetes) are at high risk of rehospitalization, morbidity, and death (CDC, 2020).
  • As of January 7, 2020, 57 deaths have been confirmed in 27 states and the District of Columbia.

The CDC (2019) has updated its guidelines and physician-recommended strategies to cut back hospital readmissions in patients with EVALI symptoms.

• EVALI patients must be in a stable clinical condition for twenty-four–48 hours (without significant fluctuations in vital signs) before hospital discharge.
• Schedule a follow-up visit together with your primary care physician or respiratory specialist inside 48 hours of discharge (previously beneficial inside 2 weeks of discharge). At the follow-up visit:
  • Perform clinical assessment for stability of important signs, physical examination, resolution of symptoms, and normalization of laboratory test results.
  • Continue educating yourself about EVALI.
  • Assessment of adherence to treatment regimens.
  • Strengthen abstinence from electronic cigarettes and vaping products.
  • Refer the patient to an outpatient clinic.
  • Long-term follow-up with a respiratory specialist normally takes place inside 2-4 weeks of discharge from hospital (after corticosteroid tapering is complete). These visits include:
    • Assessment of lung function and determination of radiographic findings.
    • Further testing must be performed for 1 to 2 months after hospital discharge, including spirometry, lung diffusion capability testing to ascertain for carbon monoxide, and a chest X-ray.
• Plan post-discharge care, early follow-up care, and treatment of comorbidities.
  • Schedule follow-up visits before the patient is discharged from the hospital and assign patient coordinators, community medical examiners or nurses to conduct home visits.
• Follow best practices for adherence to medical recommendations.
  • EVALI patients readmitted to the hospital often didn’t comply with the beneficial corticosteroid tapering.
  • Incorporate inpatient pharmacy counseling into EVALI hospital discharge planning.
  • Assess patients with EVALI for the chance of secondary adrenal insufficiency and inform them about signs and symptoms akin to fatigue, decreased appetite, gastrointestinal discomfort, myalgia, arthralgia, salt cravings, dizziness, and orthostatic hypotension.
• Providing social support, mental and behavioral health services, and substance use disorder services.
  • Patients must be supported of their efforts to stop using electronic cigarettes or vaping products.
• Referral to physiotherapy for patients who experienced prolonged immobilization during hospitalization.

Physicians should proceed to report cases of EVALI to their local or state health department.

• If vaping is suspected of causing lung disease, obtain an in depth history of gear used, sources, and ask for the device itself. Ask the patient if there are any products or liquids left to check.
• As of December 19, 2019, the CDC and FDA will accept case-related product samples for aerosol or e-liquid testing if corresponding bronchoalveolar lavage (BAL) fluid samples are submitted to the CDC (the samples don’t must be submitted at the identical time).
• For EVALI-related deaths, the CDC and FDA will proceed to simply accept product samples for testing even when bronchoalveolar fluid (BAL) isn’t available for testing.

Last October, the American Medical Association contacted the chief operating officers (CEOs) of leading e-commerce corporations asking them to stop selling illegal vaping products, in addition to empty vaping cartridges that might be used to create counterfeit vaping products (AMA, 2019). On December 20, 2019, President Trump signed a bill raising the federal minimum age to buy tobacco products from 18 to 21. Many states are trying to pass e-cigarette bans, but most of them are being challenged in court.

While the protection of e-cigarettes stays a controversial issue, vaping products mustn’t be utilized by children, adolescents, young adults, or pregnant women. Adults who use e-cigarettes should stop and consider other types of FDA-approved smoking cessation medications. Adults who resolve to proceed using vaping products should monitor themselves for signs of lung injury, akin to cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fever, chills, or weight reduction (CDC, 2020) and seek medical attention if any of those symptoms occur (CDC, 2020).

American Medical Association. (2019). AMA calls on e-commerce corporations to limit illegal sales of vaping products. Retrieved from https://www.ama-assn.org/press-center/press-releases/ama-appeals-to-limit-sales-of-illegal-vaporization-products-in-e-commerce-companies

Centers for Disease Control and Prevention (2020. Outbreak of lung injuries related to the usage of electronic cigarettes or vaping products. Retrieved from https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#what-is-new

Centers for Disease Control and Prevention (2019). Update: Interim guidance for healthcare professionals evaluating and caring for patients with suspected electronic cigarette or vaping use, product-related lung injury, and reducing the chance of hospital readmission and death after hospital discharge – United States, December 2019. Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/mm685152e2.htm?s_cid=mm685152e2_w

US Food and Drug Administration (2019). Lung disease related to the usage of vaping products. Retrieved from https://www.fda.gov/news-events/public-health-focus/lung-diseases-related-to-vaporization-products-use