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Vaping-Associated Pulmonary Disease: What Pharmacists Need to Know

Monday, October 28, 2019  
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Alexus Rivas, Pharm.D. Candidate, Class of 2020, Philadelphia College of Pharmacy

Precepted by: Karen Tietze, Pharm.D., Professor of Clinical Pharmacy, Philadelphia College of Pharmacy


Background

 

E-cigarettes, commonly known as vapes, are aerosolizing devices that heat liquids for inhalation.1 Commonly vaped substances include nicotine, tetrahydrocannabinol (THC), and cannabinol (CBD) oils. Vaping devices come in a variety of shapes and sizes and contain many different chemicals. While vaping devices generally contain less toxic chemicals than cigarette smoke, many devices contain potentially harmful chemicals such as ultrafine particles, heavy metals, volatile organic compounds, and flavorings. Vaping devices are sold legally; however, some products may be modified to contain illicit substances and sold illegally.

 

E-cigarettes have been the most commonly used tobacco product used by youth since 2014.2 Miech, et al. reported that vaping prevalence has doubled in 8th, 10th, and 12th graders since 2017.3 In 2019, 40.5% of 12th graders reported use of vaping products, and 25.4% reported use in the past 30 days.

 

Vaping-Associated Pulmonary Disease

 

In July 2019, five cases of pulmonary disease potentially related to e-cigarette use were reported to the Wisconsin Department of Health Services and the Illinois Department of Public Health.4 All five patients were young, previously healthy and reported e-cigarette use before symptoms began. Reports of additional cases prompted a public health investigation.  The following case definition was used:  history of e-cigarette use within 90 days of symptom onset, pulmonary infiltrates on imaging and the inability to attribute the case to another cause.  Of the 53 cases identified, 83% were male, mean age was 19 years and 98% presented with respiratory symptoms.  Symptoms reported by the majority of the 53 cases included shortness of breath, chest pain, cough, nausea, vomiting, subjective temperature, and chills; 91% had abnormal chest radiographs.  Nationally, vaping-associated lung injuries include acute eosinophilic pneumonia, organizing pneumonia, lipoid pneumonia, diffuse alveolar damage and acute respiratory distress syndrome (ARDS), diffuse alveolar hemorrhage, hypersensitivity pneumonitis and giant-cell interstitial pneumonitis.5

 

As of October 15th, 2019, 1,479 cases have been identified in 49 states, the District of Columbia, and 1 U.S. territory.6 Thirty-three deaths have been confirmed in 24 states. Demographics of 1,358 of the 1,479 cases have been reported, with 70% of patients being male, 79% being under the age of 35, and 15% being under the age of 18; the median age of patients is 23, and ranges from 13 to 75.

Due to the wide variety of chemicals found in different vaping devices, the exact cause of vaping-associated lung illness has not been determined. To date, 78% of people reported use of vaping products containing THC alone or THC with nicotine—with many of these products obtained off the street—while 10% of patients reported use of nicotine-containing products alone.7 The Centers for Disease Control and Prevention (CDC) currently recommends avoidance of all e-cigarette or vape products, especially those containing THC, while the investigation is ongoing.6 

 

Pharmacist Counseling Recommendations                      

 

Pharmacists should:8

  • Obtain vaping history as part of the routine medication history/medication reconciliation interview;
  • Determine if patients who use e-cigarettes have experienced symptoms associated with acute lung illness;
  • Advise vaping patients presenting with new pulmonary symptoms to seek medical care urgently;
  • Educate patients regarding vaping risks and recommend to avoid all vape products, especially THC products, until the investigation is complete. 

                                                                                       

References

  1. About Electronic Cigarettes (E-Cigarettes) [Internet]. Centers for Disease Control and Prevention; [cited 2019 Sep 30]. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html
  2.  Know the Risks: E-Cigarettes & Young People: U.S. Surgeon General’s Report [Internet]. U.S. Department of Health and Human Services; [cited 2019 Sep 30]. Available from: https://e-cigarettes.surgeongeneral.gov/
  3.  Miech R, Johnston L, O'Malley PM, Bachman JG, Patrick ME. Trends in Adolescent Vaping, 2017-2019. N Engl J Med. 2019 Sep 18. doi: 10.1056/NEJMc1910739.
  4.  Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614
  5.   Christiani DC. Vaping-Induced Lung Injury. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMe1912032.
  6.  Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping [Internet]. Centers for Disease Control and Prevention; [cited 2019 Sep 30]. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html
  7.  THC Products May Play a Role in Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping [Internet]. Centers for Disease Control and Prevention; [cited 2019 Sep 30]. Available from: https://www.cdc.gov/media/releases/2019/p0927-thc-vaping.html
  8.  For Healthcare Providers [Internet]. Centers for Disease Control and Prevention; [cited 2019 Sep 30]. Available from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html

 


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