Vaping – A Brief Handshake

Vaping – A Brief Handshake

Chandler Jones

BSRC, RRT, RRT-ACCS, RRT-NPS, CPFT

March 28, 2020

Abstract

Electronic cigarettes (E-cigs) have been referenced since the late 1920s and have only grown more and more popular. It is in this explosion of new E-cig users that complications have been observed. Respiratory Therapists and other healthcare providers should be aware of these complications and be knowledgeable in regard to how to treat conditions that may present due to the use of E-cigs. This review aims to enlighten Respiratory Therapists in regard to history, pathophysiology (brief), symptoms, diagnosis, treatment, public health concerns, and educational duty.

Vaping and Lipoid Pneumonia – A Brief Handshake

Introduction – A Recap

The first conception of electronic cigarettes (E-cig) began in the 1930s when Joseph Robinson first filed a patent in 1927. It wasn’t until the mid-1960s that the idea really took hold when prototypes created by Herbert A. Gilbert where first being assembled. As ideas flooded into the FDA from individuals and tobacco companies (with incentives, one can imagine) from the 60s, 70s, 80s, and 90s, electronic cigarettes became a highly debated topic. In 2003, in Beijing, China, the first commercialized device was patented. What followed was a storm of controversy.

            From 2003 until the present day, many governing bodies have been highly concerned with the effects of, essentially, unknown material being atomized and inhaled. Marketed as a safe alternative to smoking tobacco, the science just does not support the assumption. Many, many different high-profile scientists and governing bodies have ruled the matter unwise and misinformed. 

To combat the ever-growing evidence in support of the research, resistance was felt at every step from big tobacco, E-cig (and all the like) support groups and individuals alike. However, strides have been made to limit the access and use of E-cigs, and even laws that prohibit the use of tobacco products until the age of twenty-one. This is in light of a growing number of E-cig related cardiopulmonary complications, such as vaping associated lung injury, or E-VALI. A review of the disease process will be presented in an attempt to justify concern and provide information for practitioners.

As eluded to, the components of E-cigs, rather the liquids used, have been grossly manipulated across the board. According to the CDC, as of mid-February 2020, a total of 2807 individual cases or deaths were reported3. What can be found in multiple reports is that vitamin E/A acetate (~94%), plant oils, medium-chain triglyceride (MCT) oil, coconut oil (2%), petroleum distillates, limonene (2%) and diluent terpenes have been linked to EVALI cases reported via bronchoalveolar lavage3,1,4. Vitamin E is the primary cause of concern and of which causes oxidative stress and massive inflammatory responses, as well as acting as a drug carrier for substances like tetrahydrocannabinol (THC). To add, the heat generated (~500 F), as well as the use of heavy metals (lead, mercury, etc.), and many other substituents found in cartridges contribute to an overall “slap to the face” to the lungs. These are just a few of the ingredients and components found in the cartridges, however, many others have been discovered.

Pathophysiology

            With all the different variations in E-liquid components, the lungs prompt a massive immune response. As found in multiple studies, acute lung injury, including acute fibrinous pneumonitis, diffuse alveolar damage, usually bronchiolocentric and accompanied by bronchiolitis, foamy macrophages, pneumocyte vacuolization, as well as lipid-laden macrophages have been noted. With all this being said, disruption of the lipid balance, the innate response to foreign material, and the acute damage to the alveoli make the lung specifically prone to bacterial/viral infection, inflammation, and diffuse alveolar consolidation, or ARDS, in a sense1,3,4. Figure 1 provides a brief look into the mechanisms at large.

Fig 1

Symptoms

Objective and subjective symptoms include respiratory compromise (95%) which includes shortness of breath, decreased oxygen saturations <97% (57%), chest pain, coughing, fever and chills (85%), tachycardia (55%), and tachypnea (45%). Gastrointestinal symptoms may very well be present (~75%) such as abdominal pain, nausea, vomiting, and diarrhea. These statistics are based on a study conducted with 339 patients. As eluded to earlier, it is somewhat difficult to determine the exact source of the process. EVALI can allow pathogens to invade the alveolar pathways, which can mimic other respiratory illness, and present as other pathologies.

Diagnosis

            Diagnosis is also difficult and usually revolves around differential diagnostics (diagnosis of exclusion). Tests will be conducted, such as the influenza test, and specific cultures, yet it is the latter end of the spectrum that yields a definite diagnosis. This is what a detailed patient history can solve. A great majority of the time, based off differential diagnostics, one can deduce the presence of EVALI: If the patient admits to the use of E-cigs, and particularly THC containing, within 90 days, as well as portraying referenced X-ray and CT findings (ground glass, patchy opacities, etc.), with the noted signs and symptoms, increased white blood cell count, ESR, CRP, EVALI should be suspected.

Treatment

            Although diagnosis and etiology are somewhat hard to follow, the treatment plan should be quite familiar. Due to the flood of immune responses, and the damage after said response, broad-spectrum antibiotics should be considered due to the suspicion of pneumonia or other respiratory infections. Bronchodilator therapy can be administered as well as bronchopulmonary hygiene to lessen the burden of the lungs. Systemic and inhaled corticosteroids should also be a treatment variable in that it decreases the inflammation of the airways and alveoli, decreasing localized edema. This consideration should be made on an individualized approach (usually unless mechanically ventilated) as to not worsen bacterial/viral conditions via immunosuppression. On the far end of the spectrum, EVALI can lead to ARDS. Oxygen therapy of all types can be employed to meet the patients needs. In regards to mechanical ventilation, recommendations are to follow ARDSnet protocols and the current evidence-based practice in response to ARDS and severe lung compliance issues.

The Public 

As of now, the public health concern has been/still is being addressed. Multiple governing bodies and scholarly institutions have instituted laws and exceptions to the use of E-cigs, and the like. Actions fell short of demands, the data reveals an upward trend in the use of these devices across age groups, as can be found in figures 2 and 3. It is our (healthcare workers) job, above all others, to present the data and educate not only other healthcare providers, but the public in this matter. As with many other subject areas, beginning with the younger population, and those most prone to use these devices can possibly yield a decline in use as they become aware of the controversy and uncertainty that surrounds electronic cigarettes.

Fig 2

Fig 3

References

1.     Butt, Y. M., Smith, M. L., Tazelaar, H. D., Vaszar, L. T., Swanson, K. L., Cecchini, M.    J., …   Larsen, B. T. (2019). Pathology of Vaping-Associated Lung Injury. New            England          Journal of Medicine, 381(18), 1780–1781. doi:         10.1056/nejmc1913069

2.     CDC. (2019, October 17). Update: Interim Guidance for Health Care Providers     Evaluating and            Caring for Patients with Suspected E-cigarette, or Vaping,           Product Use Associated Lung Injury - United States, October 2019. Retrieved        from            https://www.cdc.gov/mmwr/volumes/68/wr/mm6841e3.htm

3.     CDC. (2020, February 25). Outbreak of Lung Injury Associated with the Use of E Cigarette, or    Vaping, Products. Retrieved March 28, 2020, from      https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung   disease.html

4.     Chand, H. S., Muthumalage, T., Maziak, W., & Rahman, I. (2020). Pulmonary Toxicity   and the Pathophysiology of Electronic Cigarette, or Vaping Product, Use          Associated Lung         Injury. Frontiers in Pharmacology, 10. doi:  10.3389/fphar.2019.01619

5.     Consumer Advocates for Smoke Free Alternatives Association. (2019, November 18).      Historical        Timeline of Electronic Cigarettes. Retrieved March 28, 2020, from        https://www.casaa.org/historical-timeline-of-electronic-cigarettes/

6.     Glantz, S. A. (2019, September 7). PG/VG in ecigs tied to lung damage in well-done        experiment.     Retrieved March 28, 2020, from https://tobacco.ucsf.edu/pgvg ecigs-tied-lung-damage          well-done-experiment

7.     The Learning Network. (2019, February 28). What's Going On in This Graph? | March 6, 2019.   Retrieved March 28, 2020, from            https://www.nytimes.com/2019/02/28/learning/whats           going-on-in-this          graph-march-6-2019.html

8.     Yale Medicine. (n.d.). E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI).        Retrieved March 28, 2020, from            https://www.yalemedicine.org/conditions/evali/