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To vape or not to vape…

To vape or not to vape…

I’m not one to say I told you so, but…

It’s been a little over a week since our discussion of vaping on the Poisonboy podcast and news coverage has exploded. Young, healthy people are getting very sick and even dying from something that is quickly destroying their lungs. The early evidence is pointing more and more fingers at the little flash drive-looking device in every millennial’s pocket. Also known as the vape. Let’s talk more about this. Who’s excited?!?

When the first generation of ‘vapes’ or electronic cigarettes hit the market back in the mid-to-late 2000s, it seemed like the perfect substitute for cigarettes. Get your nicotine fix without all of those pesky toxins like cyanide or arsenic. Sure the idea seemed great at the time, but as the science ball continued to roll forward, e-cigarette technology advanced into smaller and (more importantly) cooler-looking devices that lets the customer, ahem, I mean user, pick and choose what they get to vape.

Nicotine? Check. 

Tasty flavors? Check.

Meth? Check. (Wait…what? Hold that thought; we’ll circle back to that one)

Customize your smoking habit and look cooler than James Dean smoking a cig with Marilyn Monroe overlooking New York City while you’re at it. Yeah, even I could market and sell that. Plus it’s a “healthy” alternative to smoking. Right??

The devil is in the details

For those of you on the outside of the vaping craze, let’s break it down a little bit and talk technical for a second. When someone takes a vape hit, this little device takes a liquid from a reservoir, rapidly heating and atomizing it into a vapor that can be inhaled into those tiny little air pockets, or alveoli, that sit way down deep in the lungs.

Still with me? I hope so because here’s where the story gets interesting. Remember that e-liquid I mentioned a few seconds ago? Well it turns out inhaling vaporized liquid into the deep recesses of the lungs might not be so good after all. Basic ingredients like propyele glycol, vegetable glycerin, and of course nicotine are only part of the story. Now there’s an entire market devoted to flavoring your vape experience. I mean, who wouldn’t want to take a hit of Alien Piss?

But the fun doesn’t stop there. It turns out the vape is a nifty little tool to get you high. Vaping THC oil is fairly commonplace. Even more uncool, though, other street drugs like methamphetamines, K2, bath salts, are finding their way into vape liquids. No chemistry degree required. 

So what’s the problem?

Well, I’m glad you asked. For the longest time us doctor types didn’t have a good answer when it came to counseling patients about the dangers of vaping. We’d say things like “there isn’t enough data” or “they just haven’t been out long enough to know.” Doctor speak for I dunno ¯\_(ツ)_/¯

Well it looks like times are a changing. Health departments across the country are reporting more and more cases of very severe lung damage in young, otherwise healthy, patients. Currently, there are at least 193 cases of severe acute lung disease in 22 states that seem to be caused by e-cigarette use. This number will undoubtedly grow over the next few weeks.

And I’m not talking about a bit of a cough. I’m talking unable to breathe, needing to be put on life support level of sick. Dying level of sick. And it seems to be happening fast. Doctors who have taken care of these patients are reporting no infectious etiologies have been found. Meaning it seems to be the chemicals in the vape liquids that are destroying lung tissue and/or causing the body to generate a massive immune response that is destroying these otherwise healthy lungs [1].

How and why this damage is occurring is the focus of a lot of active research. Studies have shown that vaping causes release of enzymes that cause the same type of chronic lung damage typically seen with traditional smokers [2]; however, the acute destruction of the lung tissue seems to be related to pro-inflammatory signaling cascades that are at least partially mediated by the activation of alveolar macrophages [3]. Some case reports have linked vaping to lipoid pneumonia presumably from the vegetable glycerine component of the e-cigarette liquid [4]. Clinically, these patients are presenting with varying levels of cough, shortness of breath, and fatigue that progresses to hypoxia and respiratory failure. Radiologic imaging often shows bilateral ground-glass opacities in the lower lobes of the lungs. Pleural effusions can also be present and may require placement of chest tubes to drain the fluid. So far, supportive care, time, and high-dose steroids seem to be the only real treatment.

So why all of a sudden, you ask? Good question. Could there be a bad batch of e-liquid floating around? Probably not since the cases are happening across the country. Is it from vaping street drugs? Could be. Illegal pot farmers have been known to use highly toxic pesticides and other poisons to protect their crops. But I’m not sure all cases have that commonality. Are we as doctors asking better background questions leading us to recognizing it as a cause of acute lung injury more? Maybe. As of now the jury is still out, but sounds like a good time to unplug the vape.

CDC, you’re up.

References

  1. Sommerfeld CG, Weiner DJ, Nowalk A, Larkin A. Hypersensitivity Pneumonitis and Acute Respiratory Distress Syndrome From E-Cigarette Use. Pediatrics. 2018 Jun;141(6).
  2. Ghosh A, Coakley RC, Mascenik T, et al. Chronic E-Cigarette Exposure Alters the Human Bronchial Epithelial Proteome. Am J Respir Crit Care Med. 2018 Jul 1;198(1):67-76. 
  3. Scott A, Lugg ST, Aldridge K, et al. Pro-inflammatory effects of e-cigarette vapour condensate on human alveolar macrophages. Thorax. 2018 Dec;73(12):1161-1169.
  4. Viswam D, Trotter S, Burge PS, Walters GI. Respiratory failure caused by lipoid pneumonia from vaping e-cigarettes. BMJ Case Rep. 2018 Jul 6;2018.
Written by Russ Richardson

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