How doctors diagnose and treat vape pen lung disease

In September, the U.S. Centers for Disease Control and Prevention (CDC) reported 805 confirmed and probable cases of lung injury "associated with the use of e-cigarette, or vaping, products" in 48 states. There have been at least 12 confirmed deaths in the United States related to vaping.

The most common symptoms of VAPI - shortness of breath, dry cough, fatigue, chest pain, and coughing up blood - can often be found in other respiratory illnesses like pneumonia. This makes diagnosis challenging and can result in critical time loss as doctors prescribe medications that don't work. The only thing that seems to help with VAPI, according to several reports, are rounds of steroid treatment applied for several weeks.

Patients are going public

State and federal authorities have been consistent in updating statistics on VAPI cases and suspected deaths related to the syndrome. But it has been difficult to obtain information on how VAPI presents in the patients themselves. Due to the federal Health Insurance Portability and Accountability Act (HIPAA), it may be challenging for doctors to publicly discuss specific VAPI patients. Fortunately, some patients are sharing their own symptoms and experiences.

There is also a sudden recognition that a national health problem is emerging, without a clear and consistent product or specific toxin source in all cases. Easy answers about symptoms and treatments are not yet available.

Dr. Steve Feagins is vice president of medical affairs for the Mercy Health Hospitals network of 23 hospitals in Cincinnati and medical director of Hamilton County Public Health in Ohio. He is also impressed by how new this crisis is.

"We are a month away from what we know. The most important thing is finding cases we can confirm," says Feagins

What are the symptoms of VAPI?

On September 13, the federal Centers for Disease Control issued a national advisory on the VAPI outbreak. This guidance noted these symptoms, which may present individually or in some combination in VAPI patients:

• Shortness of breath
• Non-productive cough
• Pleuritic chest pain
• Rapid heartbeat (regular or irregular)
• Fever
• Chills
• Fatigue
• Gastrointestinal distress: nausea, vomiting, abdominal pain, diarrhea
• Hypoxemia (abnormally low level of oxygen in the blood)
• Acute or subacute respiratory failure

An important feature to watch for is hypoxia, where there is not enough oxygen in the blood. This occurs because the lungs are not able to transfer oxygen to the bloodstream. Hypoxia shows up as feeling tired, nauseous, dizzy. Suddenly, you can't climb stairs, walk the dog, or play tag anymore.

Patients are showing up at the hospital with blood oxygen levels so low (as low as 35%) that they should be dead.

Healthcare professionals say the damage caused by vaping falls under the category of "Bronchiolitis obliterans". This is a condition defined by the National Institutes of Health as a chemically induced inflammatory condition that "affects the smallest airways of the lung, the bronchioles" and results in oxygen blockage in the body.

Often misdiagnosed as infectious pneumonia

The CDC noted that many healthcare professionals initially misdiagnosed the patient's condition as pneumonia, for which they prescribed antibiotics - with no improvement in lung condition.

Feagins listed some of the symptoms he and his colleagues observed in VAPI patients: "Fever, night sweats, possibly even weight loss, depending on how long this has been going on". They also saw diarrhea or stomach pain accompanying these symptoms.

"All of these symptoms would be very consistent with pneumonia. Also: high white blood cell count, sometimes very high; some indication of inflammation and infection," he states.

What do X-rays show?

X-rays can help diagnose the problem. Sick lungs appear cloudy on the left radiograph and clear after treating a patient with suspected VAPI in Utah. (Courtesy of the University of Utah)

“All patients described in these reports so far have had abnormal radiographic findings,” reported the CDC, “including infiltrates on chest radiography and ground-glass opacities” on a chest computed tomography.

In VAPI patients, "when you look at a chest radiograph or a CT scan or a chest CT, there are things all over the place," says Feagins.

"These lungs have what they call a whiteout infiltration, obvious irritation, very similar to a lung injury," he adds. “And even when individuals seem to be feeling better, they continue to use oxygen. Some may need to be ventilated on a breathing machine for some time. But it takes longer than usual to wean off the oxygen and return home.

Fat in lung immune cells

One of the main causes of VAPI appears to be inhaled oil. Since late 2018, market vape cartridge manufacturers have been cutting THC cartridges with increasing amounts of a product known as "thickener", consisting mainly of a form of vitamin E oil known as tocopheryl acetate.

Symptoms of VAPI are often consistent with what is called lipoid pneumonia. Doctors can confirm this by taking a lung fluid sample and looking for oil in immune cells.

Pulmonologists will say inhaling oil can harm your lungs. A pharmaceutical chemist told Leafly that inhaled vitamin E oil can block the lining of lung fluids, preventing gas transfer. You suffocate in your own body.

Honest patient information is crucial

Honest conversations are crucial in these situations. Feagins notes that hospitals in southwest Ohio have been including vaping as a question on their patient admission forms since 2016. Including this question and verbally asking about vaping can save a patient's life.

Answering honestly can save a patient's life. But medical professionals should be aware that young and old patients may initially deny using vape devices, due to social stigma and because the main source of VAPI cases - illegal street THC vape cartridges - are illegal.

Patients may say they only vaped nicotine when in fact they were vaping street THC carts too. Patients don't like admitting federal illegal activity, especially to authority figures like doctors and nurses. They fear they will get in trouble with the law, their parents, a spouse - or simply face judgmental looks from the doctor. In recent VAPI cases, some doctors report having to move patients to a private space, ask only them, and assure no personal criminal charges will be brought. Here's a very common phrase: "We just need to know what you've been inhaling lately so we can save your life".

Treatment: Success with steroids

What can help treat VAPI? Doctors cannot say for certain. But so far, treatment with steroids has resulted in greater success. The CDC reports that "many of the patients who were treated with corticosteroids improved".

In a study with Wisconsin patients, four patients who received prompt steroid treatment survived. The fifth patient who did not receive steroids until 50 days after symptoms died.

Pulmonologists say steroids are a common treatment with lung inflammation. Steroids dampen the immune system's overreaction, which can cause more harm than the toxin itself.

And in the largest study, of 53 patients in Wisconsin: “Clinical team documentation that respiratory improvement occurred due to the use of glucocorticoids was found in the majority of patient notes (65%). All patients who began receiving systemic glucocorticoids were treated with at least 7 days of glucocorticoid therapy.”

While information remains scarce, some patients have stepped forward on their own to spread the necessary information and help others who may be fighting for their lives.

Source: Leafly