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As Vaping Lung Injuries Grow, Doctors Seek Answers

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Aug. 26, 2019 -- One person has died as a result of severe lung injuries linked to vaping. And it’s not clear yet what the prognosis for others will be as cases mount and public health officials seek clues about their cause.

The adult from Illinois who died is among 193 potential cases in 22 states of people hospitalized for the lung injuries, the CDC said last week.

Doctors say they are seeing injuries ranging from severe inflammation -- also called pneumonitis -- to bleeding in the lungs. “Injuries varied, with most including inflammation in the lining of the airway and some even have bleeding in their lungs,” said Louella Amos, MD, a pediatric pulmonologist at Children’s Hospital of Wisconsin, Milwaukee, who has treated some of the patients involved.

No cause has yet been identified, but a common thread joins each of the patients: All of them vaped.

“We have seen our previously healthy patients decline over the course of approximately a week to respiratory failure,” said Emily Chapman, MD, chief medical officer at Children’s Minnesota. Some needed respirators to help them breathe.

“While we have seen improvement in patients, we don’t know yet if they will recover fully or if the damage will have long-term effects. While patients may be out of the hospital, they aren’t necessarily out of the woods yet.”

Officials from the CDC, FDA, and other public health groups said during a news briefing Friday that they have not established that particular products are the culprit. In many of the cases, patients said they had recently vaped marijuana or other products that contain THC, the chemical in marijuana that causes its high.

Brian King, PhD, deputy director for research translation in the Office on Smoking and Health at the CDC, said there are a number of potentially harmful ingredients in e-cigarette aerosol, including lead, ultra-fine particles, volatile organic compounds, and cancer-causing chemicals. Diacetyl, a buttery flavoring used in e-cigarettes, has also been linked to severe respiratory illness.

While King can’t say for sure if they are the cause of the injuries, “we do know that e-cigarette aerosol is not harmless.”

Serious Symptoms

Before the first reports of lung injuries linked to vaping recently made the news, pediatrician Karen Wilson, MD, had a disturbing preview of what was to come. A family friend’s teenage son had been hospitalized for shortness of breath, nausea, and vomiting. He spent about a week in the hospital, including time in the intensive care unit, where he received respiratory support.

“This situation got very personal,” says Wilson, chief of the Division of General Pediatrics at the Icahn School of Medicine at Mount Sinai and Mount Sinai Kravis Children’s Hospital in New York City.

Vaping, or the use of battery-powered electronic cigarettes, has skyrocketed in recent years. The CDC estimates that one in five high school students and one in 20 middle school students now vape.

Chapman and her colleagues have treated 13 patients ages 16 to 23 so far

As symptoms worsened and no evidence of infection was found, Chapman’s team dug deeper. They used advanced imaging studies like CT scanning, direct inspection of the airways through bronchoscopy, and, in some cases, lung biopsy to confirm a pattern of disease consistent with vaping injury.

“Once confirmed, we generally treated the patients with steroids to suppress the immune reaction taking place in the lungs,” Chapman wrote in an email. “As with any treatment, this was tailored to each patient individually.”

Amos says that some of the symptoms included weight loss and fatigue, which began several weeks to months before more alarming symptoms set in.

“The respiratory symptoms like chest pain and cough progressed quickly and got them to the hospital,” she says. “Some of the patients needed to be hooked up to ventilators to help them breathe and were in our intensive care unit for multiple days, but treatment did vary depending on the severity of symptoms. Thankfully, they have all responded well to high-dose steroids.”

The Vaping Technology Association, a trade group that represents businesses involved in the vaping industry, pushed back against any rush to single out vaping.

“Current reports have failed to make a conclusive connection between industry standard nicotine containing vapor products and these hospitalizations, and in some cases, have conflated these vapor products with the use of THC- or marijuana-containing products,” the VTA says in a statement. “At this point, neither the treating physicians in these cases nor the Departments of Public Health have ascertained which products and substances are being used.”

Researchers Trying to Keep Up

Research into the safety of vaping is struggling to keep pace with its runaway popularity among young people.

“We’re just beginning to understand the impact, particularly the long-term impact,” says Wilson, who adds that vaping has been linked to heart problems in both human and animal studies. This and other research “is pushing us in the direction of [knowing] this is not safe.”

When you vape, a heating element in the e-cigarette raises the temperature of a liquid chemical mixture in what’s called a pod. The liquid, or vape juice, converts to an aerosol, or vapor, that users inhale. It often contains nicotine, the addictive chemical in tobacco products, as well as flavors.

Studies published in recent weeks are the latest to raise concerns about vaping chemicals. In one, researchers at Duke and Yale universities demonstrated that under a variety of conditions, the chemicals in vape juice can go through changes that can cause harm. Such reactions can happen even if the liquid is not heated.

“We now have more knowledge about chemical reactions taking place to form compounds that we find, in cell studies, to be more irritating than the flavored chemicals they result from,” says Sven E. Jordt, PhD, an associate professor of anesthesiology at Duke University School of Medicine in Durham, NC, and a co-author of the study. “Once you add the flavors, the nicotine, and the solvents, you have reactions going on that increases the number of chemicals.”

In another study published this month, researchers report vaping raises concerns even when it does not involve nicotine. They recruited 31 healthy nonsmokers and had them puff on nicotine-free e-cigarette aerosol. Data showed that vaping caused potentially harmful but temporary inflammation to the inner lining of their blood vessels.

“Even without nicotine, these chemicals can cause inflammation,” says lead author Alessandra Caporale, PhD, of the Laboratory for Structural, Physiologic, and Functional Imaging at the University of Pennsylvania School of Medicine. “The tiny drops of vapor, or aerosol, get into the respiratory tract and can reach the alveoli [in the lungs]. From there, they can get into the bloodstream and cause generalized inflammation.”

Caporale and her colleagues are studying the long-term impact of vaping. She says it’s logical to expect that multiple and repeated exposure, over years, could lead to chronic inflammation. But she says people need to be cautious about assigning blame to particular vaping products, pointing out that news reports note that some of those hospitalized vaped marijuana and possibly other substances.

‘There’s Very Little Oversight’

Albert Rizzo, MD, agrees that there are a lot of unknowns in these cases, but he also wants the public to understand there are many unknowns in general about the safety of vaping.

“These are products that have not been tested, and there’s very little oversight,” says Rizzo, the chief medical officer of the American Lung Association. “The FDA has not been able to protect the public because of their failure to act on these products.”

The FDA disputed that characterization in a statement: “The FDA is committed to continuing to tackle the troubling epidemic of youth e-cigarette use through all available regulatory tools. This includes taking action against manufacturers and retailers who illegally market or sell these products to minors, investigating counterfeit e-cigarette products, educating youth about the dangers of e-cigarettes, implementing the policies necessary to keep them out of the hands of America’s kids.”

In April 2018, the regulatory agency announced plans to crack down on the sale of e-cigarettes to minors by e-cigarette makers and retailers. They singled out JUUL, the most popular brand, whose vaping pods contain as much nicotine as a pack of cigarettes.

“[Recent] reports reaffirm the need to keep all tobacco and nicotine products out of the hands of youth through significant regulation on access and enforcement,” says a statement from JUUL Labs. “We also must ensure illegal products, such as counterfeit, copycat, and those that deliver controlled substances, stay out of the market.”

Duke researcher Jordt sees a hard road ahead for getting e-cigarettes out of kids’ hands: “Vaping has been so popular for the last 2 years that it’s going to be hard to clamp down on this.”

WebMD Health News Reviewed by Brunilda Nazario, MD on August 23, 2019

Sources

CDC telebriefing, Aug. 23, 2019.

Louella Amos, MD, pediatric pulmonologist, Children's Hospital of Wisconsin, Milwaukee.

Alessandra Caporale, PhD, post-doctoral researcher, Laboratory for Structural, Physiologic, and Functional Imaging, University of Pennsylvania School of Medicine, Philadelphia.

Emily Chapman, MD, chief medical officer, Children’s Minnesota, Minneapolis.

Sven E. Jordt, PhD, associate professor of anesthesiology, Duke University School of Medicine, Durham, NC.

Albert Rizzo, MD, chief medical officer, American Lung Association, Chicago.

Karen Wilson, MD, chief, Division of General Pediatrics, Icahn School of Medicine at Mount Sinai and Mount Sinai Kravis Children’s Hospital, New York City; chair, American Academy of Pediatrics’ Tobacco Consortium.

Caporale, A. Radiology, Aug. 20, 2019.

CDC: “CDC, FDA, States Continue to Investigate Severe Pulmonary Disease Among People Who Use E-cigarettes.”

CDC: “Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students -- United States, 2011-2018.”

Erythropel, H. American Journal of Preventive Medicine, July 26, 2019.

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