Vaping-Associated Lung Injury Related to Vaping/E-Cigarette Use

Posted September 30, 2019. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Over 380 reports (as of September 12) of confirmed and probable cases of lung injury associated with vaping/e-cigarette product use have been reported by 36 states and the U.S. Virgin Islands. Three have been confirmed in Washington, two of which were reported in Spokane. All three confirmed cases reported vaping prior to injury but to date we have not identified a product, device, or additive common to all three cases.  Investigations into the specifics of products, devices, or additives is ongoing. The Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Washington State Department of Health (DOH), and Spokane Regional Health District (SRHD) continue to monitor this rapidly evolving situation.

As this investigation continues, SRHD encourages clinicians to report possible cases of vaping-associated lung injury for further investigation. If vaping/e-cigarette product use is suspected as a possible cause for a patient’s acute lung illness, a detailed history of the substances used, the sources, and the devices used should be obtained, and efforts should be made to determine if any remaining product, devices, and liquids are available for testing.

Actions Requested:

  • Be aware of reports of vaping-associated lung injury from multiple U.S. states. Several cases have been reported from Washington State and one in Spokane County.
  • Ask all patients with severe acute pulmonary illness whether they have used any vaping/e-cigarette in the last 90 days.
  • Report patients hospitalized with severe acute pulmonary illness of unclear etiology and a history of vaping/e-cigarette or vaping product use within the past 90 days to Spokane Regional Health District at 509-324-1442.
  • If vaping/e-cigarette product use is suspected as a possible etiology of a patient’s severe acute pulmonary illness, obtain detailed history regarding substance(s) used, substance source(s), device(s) used, product modifications by the user, where the product(s) were purchased, method of substance use,  and other potential cases.
  • Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the local or state health departments.
  • Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and vaping/e-cigarette product use. Evaluate and treat for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as appropriate.
  • Remind patients that their healthiest option is to stop vaping and using tobacco products.

Other clinical considerations:

  • Clinical improvement of patients with vaping-associated lung injury has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.
  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by vaping/e-cigarette products has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.
  • Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
  • Patients who have received treatment for vaping-associated lung injury should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.
  • CDC is hosting a webinar for clinicians on “Severe Lung Illness Associated with Using E-Cigarette Products” on Thursday, Sept 19, 2019 at 11:00am-12:00pm. Information for this call is available at: https://emergency.cdc.gov/coca/calls/2019/callinfo_091919.asp?deliveryName=DM8936

Background:

As of September 12, 380 cases of vaping-associated lung injury have been reported to CDC from 36 states and six deaths have been confirmed. All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious cause has been discovered. Therefore, the suspected cause is a chemical exposure. Most patients have reported a history of using e-cigarette products containing THC. Many patients have reported using THC and nicotine. Some have reported the use of e-cigarette products containing only nicotine. No consistent e-cigarette or vaping product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to lung disease in patients. These investigations are ongoing.

Additional Resources:

CDC Clinician Outreach and Communication Activity (COCA) Call: https://emergency.cdc.gov/coca/calls/2019/callinfo_091919.asp?deliveryName=DM8936

Thursday September 19, 2019 11 am to 12 pm Pacific

CDC will review e-cigarette and vaping terminology, clinical features reported among cases of pulmonary disease in recent outbreak and CDC recommendations for clinicians.  Continuing education credit available. 

Centers for Disease Control and Prevention: Outbreak of Lung Disease Associated with E-Cigarette Use, or Vaping

MMWR: Severe Pulmonary Disease Associated with Electronic-Cigarette–Product Use — Interim Guidance

MMWR: Notes from the Field: Outbreak of Electronic-Cigarette Associated Acute Lipoid Pneumonia—North Carolina, July–August, 2019

New England Journal of Medicine: Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report