Lung Injury Associated w/ E-cigarette Use or Vaping: Info for Clinicians
30
September

By Adem Lewis / in , , , , , , , , , , , , , , , , , /


>>Good afternoon. I’m Commander Bat Kahn, and I’m representing the
Clinician Outreach and Communication Activity, COCA, with the Emergency Risk
Communication Branch at the Centers for Disease Control and Prevention. I would like to welcome you to today’s COCA
Call, Outbreak of Lung Injury Associated with E-cigarette Product Use or
Vaping: Information for Clinicians. You may participate in today’s presentation
via webinar, or you may download the slides if you are unable to access the webinar. The PowerPoint slides in the
webinar link can be found on our COCA webpage at emergency.cdc.gov/coca. Again, that web address is
emergency.cdc.gov/coca. Continuing education is not
offered for this webinar. After the presentation, there
will be a Q and A session. You may submit questions at any time during the
presentation through the Zoom webinar system by clicking the Q and A button at the bottom
of your screen and then typing your question. Please do not ask a question
using the chat button. Questions regarding the webinar should
be entered using only the Q and A button. For those who have media questions, please
contact CDC Media Relations at (404)639-3286 or send an email to [email protected] If you are a patient, please refer your
questions to your healthcare provider. At the conclusion of the session, participants
will be able to accomplish the following, provide e-cigarette and vaping terminology, summarize frequent clinical laboratory
radiographic and pathologic findings and outcomes among cases, and discuss
CDC recommendations for clinicians. I’d like to welcome out presenter, Lieutenant
Commander Tara Jatlaoui to today’s webinar. Lieutenant Commander Jatlaoui is a
medical epidemiologist at the Centers for Disease Control and Prevention. She’s currently serving as
the clinical team lead for the 2019 CDC Lung Injury Emergency Response. Lieutenant Commander Jatlaoui graduated
from New Jersey Medical School. She completed her MPH at the Rollins School of
Public Health of Emory University epidemiology and obtained her Bachelors in Engineering
Sciences from Dartmouth College. Lieutenant Commander Jatlaoui, please begin.>>Thank you. And, good afternoon, everyone, and thank you
for taking time out of your busy schedules to join us and learn about
cases of lung injury associated with e-cigarette product use or vaping. For the next 30 minutes or so, I’d like to go
through background information on this outbreak, provide a basic course in
e-cigarette or vaping products, and then describe common
clinical features of cases. Finally, we will review CDC
recommendations and discuss the limitations and knowledge gaps at this point in time. As of September 17th, 530 cases of lung injury
associated with the use of e-cigarette products or vaping has been reported to CDC
from 38 states and one U.S. territory. Seven deaths have been confirmed among cases. Data are being updated weekly
at the outbreak website. To date, no specific etiology
has been identified. All cases have reported using
e-cigarettes or have reported vaping. From data reported in a recent case series, most patients have reported
tetrahydrocannabinol or THC product use. Many have reported using both THC and nicotine,
and some have reported using only nicotine. Other initial findings have been published in
CDC’s Morbidity and Mortality Weekly Report or MMWR and the New England Journal of Medicine. By nature of the case definition for this
outbreak, all cases have reported use of e-cigarette products or
vaping within 90 days of illness. According to recent publications, most
patients seem to report symptoms within days of last vaping exposure,
but some have been longer. As stated previously, data from publications
describe that most have reported THC or CBD use, and some reported nicotine use alone. It is important to note that at this time, no single device type has been reported
consistently, and no single e-cigarette or vaping product or substance
has been reported consistently. This is the most current
confirmed case definition. Please note that these case
definitions are meant for surveillance and not clinical diagnosis. These case definitions are subject
to change and will be updated as additional information becomes available. Cases have the following, a history of using
e-cigarette products, vaping, or dabbing, and pulmonary infiltrates on chest
x-ray or ground glass opacities on test computed tomography or CT,
and absence of pulmonary infection, and no evidence in the medical record
of alternative, plausible diagnoses. For probable cases, reports include a history
of using e-cigarettes or dabbing and findings on test imaging and infection identified. But, the clinical team caring for the patient
does not believe infection is the sole cause of the underlying respiratory
illness or minimum criteria to rule out infection is not met or performed. And, again, the clinical team does not believe
infection is the sole etiology of illness. And, no evidence of alternative, plausible
diagnoses are found in the medical record. The largest case series reported and
published earlier this month describe 53 cases from Illinois and Wisconsin, all with
a history of e-cigarette product use. Of 41 cases who were extensively
interviewed, 61% reported nicotine use, 80% reported THC use, and 7% reported CBD use. Thirty-seven percent reported THC use
alone, and 17% reported nicotine use alone, while 44% reported using both products. Various brands and flavors have been reported. Ninety-four percent of overall cases
used e-cigarette products or vaped within one week before a symptom onset,
and 88% of cases reported daily use. I’ll now move on to a basic course
in e-cigarette or vaping products. E-cigarette products include devices, liquid,
flavorings, refill pods, and cartridges. The actual devices heat liquid to produce an
aerosol which is then inhaled by the user. This aerosol may contain harmful
substances such as those listed here. Devices vary in appearance and by manufacturer. Patients may use different terms to describe
these devices such as e-cigs, vapes, e-hookahs, vape pens, mods, tanks, and you may hear
the term electronic nicotine delivery system or ENDS. To the right, you see the different generational
products going from first generation of disposable e-cigarettes which look more
like a regular cigarette, to second generation that have prefilled pods to the refillable
tanks or mods of the third generation products, and finally fourth generation mod pods or
prefilled mods which may use nicotine salt. Liquid in the cartridge may
contain the following. Nicotine, THC, CBD, or butane hash oil along
with other components such as flavorings, propylene glycol, and vegetable glycerin. Liquid types may be either
commercial, refillable, e-liquids, nonrefillable e-liquid also
purchased commercially, and homemade or street sourced liquid. Some other useful terms are related
to how these devices may be used. Hacking describes the modification
of a device in a way that was not intended by the manufacturer. This could mean refilling a single use cartridge
with either homemade or illicit substances. Dripping is another way to hack a device
and means dropping liquid directly onto the device’s heating coal to get higher
concentrations of compound into the aerosol. Dabbing, on the other hand, means superheating
a substance containing high concentrations of THC or other cannabis products. Let’s now review frequent clinical
features seen during this outbreak. Information from this section
comes from both anecdotal and verified reports CDC has
received from health departments. Formal and informal discussions have
taken place between CDC clinicians and medical professional societies. Several publications this month
in the MMWR New England Journal of Medicine contribute to the bulk findings. Most patients have been young and otherwise
healthy, reporting a gradual onset of symptoms over the course of a few days to weeks. These include respiratory symptoms such
as cough, chest pain, shortness of breath, gastrointestinal or GI symptoms, and
constitutional symptoms such as fever, chills, fatigue, weight loss, or malaise. GI symptoms have preceded respiratory symptoms,
and we have heard that these symptoms tend to resolve quickly after hospital admission, and evaluation for GI related
illnesses have not been revealing. While almost all cases have been hospitalized,
many have had one or more evaluations prior to hospitalization in outpatient
settings such as urgent care. Upon presentation and hospital admission,
patients have been noted to have fever, tachycardia, tachypnea, and decreased
oxygen saturation on room air. This hypoxemia has been reported for one
patient in the New England case series without any respiratory symptoms. Frequent lab findings include
leukocytosis with neutrophil predominance, elevated inflammatory markers, and transient
mild elevations in serum transaminases. Chest imaging, which is required for case
definition, include either bilateral opacities on chest x-ray or ground
glass opacities on chest CTs. Abnormal findings may not be present on
initial imaging, but may develop gradually. The only remarkable findings
from CT abdomen pelvis have been from the cuts of lower lung fields. For many patients, initial therapies
have focused on presumed infection, mostly antibiotics for community
acquired pneumonia with or without steroids or observation. Many cases experience subacute or acute hypoxemic respiratory failure
requiring oxygen supplementation which of range from nasal cannula to intubation and ventilation
or extracorporeal membrane oxygenation or ECMO. Patients who did not respond to antibiotics
alone have tended to respond to steroids, either steroids alone or added onto antibiotics. When searching for an etiology, workup
for infection has been completed without an identified cause which his part
of the definition of a confirmed case. Reports of pulmonary function
testing or PFTs have been variable. Some patients have been evaluated
with bronchoscopy and have had bronchoalveolar
lavage or lung biopsy performed. Patients who did not have bronchoscopy may
have been either too well or were considered for the procedure or were not stable enough. Routine and special evaluations of
lung specimens have been performed. The New England Journal K series did report
that 7 of 14 patients who had lipid staining with oil red o reported for BAO
analysis had lipid lead in macrophages. It’s very important to note that routine
processing of tissues includes the application of alcohol which removes lipids from tissue. Therefore, in order to test for lipids,
lipid staining such as oil red o or Sudan black must be performed
on fresh tissues and BAL fluid. The clinical and pathologic diagnoses that
have been noted include findings consistent with acute lung injury or ARDS
such as diffuse alveolar damage. Diagnoses besides diffuse alveolar damage
have also included lipoid pneumonia, acute necrotizing pneumonitis, organizing
pneumonia, nonspecific inflammation, hypersensitivity, pneumonitis,
and eosinophilic pneumonia. Consultation with specialists have
included pulmonary medicine, critical care, infectious disease, pathology, and toxicology. Despite the severity, most
patients have survived to discharge. Again, most patients have been young
and healthy prior to presentation. Some who did not return to pulmonary
function baseline at the time of discharge did show improvement with post discharge evaluation while others
still have had reduced pulmonary function, according to anecdotal reports. As of September 17th, seven patients
have died after being hospitalized. We’ll now move on to CDC
recommendations for clinicians. Current CDC recommendations are published in
both the MMWR and a Health Advisory Network or HAN alert which can be
found on the outbreak website. As we learn more, CDC will provide
updates as soon as possible. In the next slide, we’ll
review those recommendations. The first recommendation is simple,
but we may not be doing it routinely. We need to ask patients specifically
about e-cigarette product use or vaping. Depending on the patient’s age or product
use, this may be a sensitive topic. Depending on where you work, this may
require educating additional staff or updating intake forms
regarding social history. For those patients who report e-cigarette use or
vaping within the last 90 days, ask about fines and symptoms of respiratory illness. Conversely, for patients who
present with respiratory illness, ask about e-cigarette use or vaping. If you suspect e-cigarette product use as a
possible etiology for your patient’s symptoms, obtain a more detailed history
regarding product use. This includes what substances
have been used, THC, nicotine, CBD or others, and what liquids have been used. How are those liquids obtained? Were they bought from a store? Were they mixed at home, or
were they bought off the street? What device has been used, and
where were those purchased? Were they used as intended,
or did any hacking occur? And, did anyone else vape
with the patient recently? In making a diagnosis, remember that the
case definition is for surveillance purposes and is not intended for diagnosis. Consider all possible causes of illness, depending on patient symptoms
and signs on physical exam. Depending on the severity of
presentation, consultation may be indicated. While lipoid pneumonia has been associated with
inhaling the lipids in aerosol from e-cigarettes or vaping, the decision to perform BAL with
or without bronchoscopy should be based on the individual clinical picture. Remember that not all BAL
specimens that have been reported with lipid staining among cases have
noted lipid lead in macrophages. Similar to BAL specimens, lung biopsies
have been performed on some patients, and the decision to perform the procedure
should be based on the individual clinical case. If biopsy is performed, consider lipid staining. CDC has guidance on the provider outbreak
webpage with the link at the bottom of this slide and at the end of our
slides regarding lipid staining. Before performing, consider consultation
with specialists to inform your evaluation. Whether or not lipid staining is performed or
possible at your institution, routine processing and histopathology is still important
and valuable to the evaluation. Contact your state or local public health
officials for assistance with testing, retaining specimens, and storage if desired. For management of these patients, decisions should be made based
on the individual clinical case. This pertains to the decision to admit to the
hospital, initial evaluation and treatment, and decision to consult with specialists. Clinical improvement has been
reported with the use of steroids. Dosing, route of administration,
duration, and timing have varied for both inpatient and outpatient management. Again, the decision to administer steroids
should be made on case by case basis, considering the likelihood of other etiologies. Follow up evaluation may be considered as clinically indicated depending
on the severity of the disease. As mentioned, CDC has guidance for evaluation
of pathologic specimens, with the link, again, here at the bottom, and a pdf can be found
on CDC’s provider page for this outbreak. CDC is accepting lung tissue for evaluation through CDC’s Infectious
Disease Pathology Branch. If possible, submission of formal and fixed
or wet lung tissue is encouraged in order to perform lipid staining
using osmium tetroxide. This must occur before routine tissue
processing and paraffin embedding. This lab will also review tissue histopathology
and perform additional testing as indicated. If you have lung tissue for evaluation
for a case of lung injury associated with e-cigarette product use or
vaping, please first report the case to your state or local health department. Preapproval is required before
submitting tissue specimens to CDC and the contact email for
preapproval are listed here. In the unfortunate event of a fatality,
autopsy can be considered and recommendations for autopsy can be found within CDC
guidance on the provider webpage. Again, fresh lung tissue
for lipid staining prior to processing should be considered
along with routine histopathology. Infectious disease testing should also be
considered depending on the patient’s history, clinical course, or any additional
autopsy findings. Regardless of the ongoing
investigation, please note the following. E-cigarettes should not be used by
youth, young adults, pregnant women, or adults who do not currently
use tobacco products. Anyone who uses e-cigarette products
should not buy products off the street, should not modify products or
substances at home in a way that was not intended by the manufacturer. Tell your patients who use these products to
monitor themselves for symptoms such as cough, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, or diarrhea and to seek medical attention
if they’re having any symptoms. For those trying to quite tobacco
products including e-cigarettes, there are evidence based treatments including
counseling and FDA approved medications. There are links to resources for
more information on our webpage. If your patients are concerned about these
specific health risks seen in this outbreak, please tell them to consider refraining
from using e-cigarettes or vaping products. If they are using these products
to quit cigarette smoking, they should not return to smoking cigarettes. If patients continue using e-cigarette
products as stated before, tell them to monitor for symptoms and seek care with any concerns. Patients and providers can find their local
poison control center at this 1800 number. Any detailed reports of e-cigarette related
health or product issues can also be reported to the FDA via their online safety
reporting portal at this link. In order to inform this investigation
and know what is causing it, we need your help in reporting cases. If there are any remaining products,
the actual device or e-liquid, please coordinate with your state or
local health department for testing. As we learn more, CDC will provide updates
as soon as information is available. So, please visit the CDC website for
updates and additional resources. Finally, I’ll spend the last few slides
reviewing our limitations and knowledge gap. Information that we have so far includes small,
published case series compared with a number of cases that have been reported to this point. We also have anecdotal data
to generate some hypotheses. As mentioned, the case definitions for
outbreak surveillance is not intended for diagnosis or to guide clinical decisions. As of yet, there’s no diagnostic criteria
that exists, and as we have discussed, there have been a multitude
of histopathologic findings. Most cases have been severe and
hospitalized, but the true spectrum of this illness could be unrecognized. Investigations at the state
level have been ongoing, and national efforts have been
underway since mid-August. CDC is updating the website regularly
as data come in and analyses continue. Beyond published case series, there
are no systematic data for exposure or additional clinical information. The available data do not suggest
a purely infectious etiology, but there may be concurrent processes in play. There are no decision making tools to
distinguish infection versus noninfection at presentation, so it’s important to rule out
and empirically treat infectious etiologies as appropriate, even in patients
with exposure history. Patterns of illness could also change with
the approaching respiratory viral season. Furthermore, it remains unclear
whether this is a new syndrome or a newly recognized syndrome
previously thought to be a pneumonia or a pneumonitis of unclear etiology. The long term prognosis of
lung injury associated with e-cigarette use or vaping is not yet known. Age related differences have
not yet been assessed. We do know the outbreak has
predominately affected younger patients and updated information is now
available on the CDC website. However, defining a case among
adults with chronic lung disease or other comorbidities may be more
difficult leading to under reporting. It is still unclear whether
adults have more severe illness, who have more severe illness are
more likely to result in death. Lipoid pneumonia has been reported, but, as
mentioned, diagnoses have been heterogeneous. Questions still remain such
as whether lipid lead in macrophages are markers
of disease or of exposure. BAL has not been attained universally
on bronchoscope evaluation, and in turn, nor has lipid staining which
is a nonroutine procedure. So, the frequency of this finding is unclear. Characteristics of the cellularity of BAL fluid
are uncertain because they could be altered by antibiotics or steroids and influenced by
the timing of these therapies and interventions. Autopsy has not been preformed
for all cases resulting in death, and the results from those
have not been reported for all cases when they’ve been performed. To summarize, this investigation has yet to identify any specific substance
or product linked to all cases. Most patients have reported using THC or CBD,
and some have reported nicotine use alone. Most patients have been hospitalized with
respiratory illness and received treatment for presumed infectious etiologies. Some have responded to steroids
with or with out antibiotics. Please report cases to and
coordinate product testing with your local or state health department. CDC will provide updates with
information as it becomes available. The link to our healthcare provider
website for this outbreak is found here. This slide deck will be available on our
website in the next few days for anyone who wish to share or give additional talks. We will be updating the website
with information, resources, and recommendations as we learn more. Thank you again for joining us. We can now take your questions.>>Thank you so much Lieutenant Commander
Jatlaoui for providing our audience with such a wealth of information on this
important emerging public health challenge. We appreciate your time and value
your clinical insights on this matter. We will now begin our Q and A session. Joining us today for the Q and
A session from the clinical team of CDC’s 2019 Lung Injury Emergency
Response will be Commander Maleeka Glover, Dr. Sarah Raegan-Steiner, Dr.
David Wiseman, and Dr. Ahmed Jamal. Please remember you may submit questions to the
webinar system by clicking the Q and A button at the bottom of your screen
and then type in your question. Again, please do not ask a
question using the chat button. Our first question is regarding
the specific products. The question asks are there
any specific products that clinicians should inform
their patients to avoid.>>This is Tara Jatlaoui. Thank you for that question. Our investigation is ongoing, and as we stated,
we have not identified any specific products. So, that includes devices, liquids, pods,
or substances that are linked to all cases. Most patients have reported a history of
using e-cigarette products containing THC, but there are many patients that have
reported using THC and nicotine and some that have reported the use of nicotine alone. Thus far, illnesses involving products
containing THC have been primarily associated with liquid based e-cigarette devices. These devices are sometimes called mods,
vape pens, vapes, and pink systems. If you are concerned about
these specific health risks, CDC recommends that you tell
your patients to refrain from using e-cigarette or vaping products. CDC further recommends if someone,
that if someone is an adult who use e-cigarettes containing
nicotine to quit cigarette smoking, they do not return to smoking cigarettes. If people have recently used an e-cigarette
or vaping product and have symptoms like these reported, they can
see a healthcare provider. And, please remind patients to not purchase
illicit products or substances off the street or modify products in a way not
intended by the manufacturer.>>Thank you for that. Our next question follows a theme. We have multiple questions on this topic, and
these are providers that would like to know, that if they’re at a local public health
department and their patients bring samples or leftover vaping product
what they should do with that. If they need to be sent for testing,
is that within the purview of CDC or the Food and Drug Administration?>>Can you, I’m guessing
to clarify the question. If there are samples and my suggestion would
be for a provider to contact their local or state health department in
order to coordinate testing. That testing is being performed through the FDA.>>Thank you for that. Our next question is regarding are there,
are you aware of cases that might be mild that are taking place where patients
are not reporting to the hospital? This is Tara Jatlaoui again. Reported cases may have been
ascertained from various data sources, and we know that we have seen patients in
both the inpatient and outpatient facilities. So, if you as a provider, if you think your
patient may have lung injury associated with either e-cigarette product use or
vaping, please report the case to your state or local health department
regardless of your clinical setting.>>Thank you. Another question we have is a clinician
writing in to ask for an explanation on the age distribution, if there’s any
idea why the age distribution is as it is.>>Thank you for that question. We’re just starting to understand more about
the patient population that has been affected by this illness, but we don’t, at this time, understand why certain populations may be more
affected than others, how it may be related to the incidents of the exposure
in certain populations. May be of importance, but that’s still
something that’s under investigation.>>Thank you. If a provider was to see a patient
that’s reporting with respiratory illness and reports having recently vaped, used
vaping, what should the provider do? This is Tara Jatlaoui. Patient should be evaluated and
treated for other possible causes of illnesses as clinically indicated. So, approach the patient as you
would in any other manner as far as doing testing or evaluation or treatment. Depending on the severity, you can
consider consultation with specialists such as pulmonary specialists, infectious
disease, critical care, and medical toxicology, and also consider close follow up as
indicated by the individual case presentation.>>Thank you. Our next question asks if he problem with
oil inhalation is specific to a certain oil or is it likely to be a factor
for multiple types?>>This is Tara Jatlaoui. That’s still under investigation. We haven’t been able to link any particular
specific product, whether that’s substance, [inaudible], or any other device that
may be contributing to these illnesses. So, we don’t have further information on a
consistent exposure that may be causing these.>>Thank you. There are a few questions that would
like you to reiterate the use of steroids in treating patients and
managing their treatment. When are they appropriate,
and how should they be used?>>So, we do know that clinical improvement
of patients with lung injury associated with e-cigarettes has been reported
with the use of corticosteroids. However, the decision to use steroids should
be made, again, on a case by case basis based on the risks and benefits and the
likelihood of other etiologies. Currently, we do not have sufficient information
to recommend any specific steroid dosing or administration for either
inpatient or outpatient care.>>Thank you. Can you please address the occurrence, if any, of present GI symptoms associated
with these cases?>>This is Tara Jatlaoui again. Yes, we do know that according to the 53
patients in the case series from Wisconsin and Illinois GI symptoms, any GI symptom
occurred in just over 80% of patients. The most common symptom was
nausea with, you know, about 70% of those patients reporting nausea
closely followed behind with vomiting in 66%. And then, some had diarrhea and abdominal pain. Generally, what we have heard is that the
GI symptoms tend to resolve after admission or shortly after before the onset of any more
severe respiratory findings and that workup for any GI illnesses have been
inconclusive or have been negative.>>Thank you. Our next inquirer asks if there are any
recommendations you have for clinicians who might be seeing patients as far as how
they should screen for use of vaping devices.>>So, our recommendations, and I guess
just going to just basic history taking is to include e-cigarette or vaping history within your normal intake of
taking a patient’s history. So, asking about what products they are using,
if they have any recent history of vaping. And, in particular, if you have a patient
who has any symptoms of respiratory illness, specifically ask about e-cigarette product
use your vaping within the last 90 days. And, if that’s present, I would pursue
additional questioning that we have laid out in these slides, and then also in our
Health Advisory Network Alert that went out at the beginning of September
which lists out what specific questions around substances used, sources,
devices, where products were purchased, how the device was used, whether
aerosolization, dabbing, or dripping. And then, any potential sharing
with other people.>>Thank you. Our next question asks are we aware of
symptom onset after initial imaging? How long does the symptom onset take, and does
the initial chest imaging show the findings?>>We know that patients have had an onset
of various symptoms over days to weeks. However, the timing and the actual course of
illness, we don’t have as clear of a picture. So, from when the initial onset of maybe
symptoms to presentation to imagine findings to worsening disease is still
unclear or may be varied.>>Thank you for that. Our next question inquires
about what percentage or number of total cases used commercial
products versus either homemade, hacked, or otherwise altered products?>>We don’t have information
based on reported cases to CDC for specific product use or type at this time.>>Thank you. Our next question asks are you aware of any
cases such as this outside the United States?>>To our knowledge, there’s. I’m sorry. This is This is Tara Jatlaoui. To our knowledge, there are no concurrent
outbreaks of lung injury associated with e-cigarette products or
vaping in other countries, although there may have been cases reported.>>And, this is David Wiseman. There was a report in the general
media today about a case in Ontario, but we don’t have any specific
knowledge of that.>>Thank you. We have received a couple of questions
regarding biopsies and tissues and pathology. Can you please elaborate on when a patient needs
a lung biopsy, and then what is the procedure for the clinician to send pathology
samples to specimens to CDC?>>Hello. This is Dr. Sarah Raegan-Steiner. So, lung biopsy is an invasive procedure. The decision to perform a lung biopsy is
at the discretion of the clinical team and should include consultation with
pulmonary, critical care, and other specialties. Lung biopsies have been performed
on some patients. If a biopsy is performed, lipid staining
can be performed and is best to be performed on fresh tissues because routine
tissue processing of formal and fixed tissues involves applying alcohols
which remove lipids prior to paraffin embedding. So, please consider consultation with
specialists in pulmonary medicine and pathology to help inform any evaluation plans. The roles and frequencies of different
biopsy methods preformed on patients as part of this outbreak are not known at this time. If there is interest in submitting
pathology or tissue specimens to CDC, please first report any possible cases of lung
injury associated with e-cigarette product use or vaping to your state or
local health department. And, preapproval is required to
submit any tissue specimens to CDC. Information including email addresses for the, for how to obtain preapproval
is on the resources provided.>>Thank you. Our next question is a theme of sorts that we have received regarding Vitamin
E acetate’s role in these cases. Can you please elaborate on the role Vitamin
E acetate has to play in these cases?>>This is Tara Jatlaoui. So, we don’t yet know the specific
cause of these lung injuries. The investigation has not identified any
specific e-cigarette or vaping product. So, devices, liquids, refill pods,
and cartridges, brand or substance that has been linked to all the cases.>>Thank you. Have there been any renal
abnormalities reported as well in these patients, and can
you please address that?>>From either the published information
or anecdotal reports and conversations that we’ve had with clinicians, we’ve only seen
one case of acute kidney injury in a patient from the Illinois and Wisconsin case series. But, otherwise, we haven’t heard of any
renal disease associated with this outbreak.>>Thank you for that. Our next question asks about empiric
antibiotic use, which antibiotic or antibiotics would you recommend?>>The recommendations for
antibiotics shouldn’t change. You know, it should be according to the
patient’s, the population that you’re seeing and the individual case presentation
that you’re evaluating. The evaluation and the treatment of
the patient should not change based on any exposure to e-cigarette or vaping.>>Thank you. Our next question is regarding a clinician
who’s asking that they’re aware of patients that sometimes report using both
cigarettes in tandem with vaping products. Is there any suggestion of
exaggerated injury or augmented harm?>>At this time, we don’t
have that information yet. Similar to the fact that we
don’t have any singular source that we’ve identified being linked to all
of these cases or even a majority of cases. We don’t understand yet the relationship
between those who may smoke cigarettes and use e-cigarettes or vape at the same time.>>Thank you. Our next question is sort of a theme as well. It seems to be a popular concern. And, the question is is there
any evidence to show that there is long term injury
associated, or is it too early to tell?>>It seems to be too early to tell. We have spoken to some clinicians who
are following patients who have more of an ARDS type picture and following
them up with pulmonary function tests, and there have been anecdotal reports
of some patients returning to normal. Some patients that still have
reduced pulmonary function. But, we don’t have enough
information to give a full and clear picture as to what prognosis may be. We haven’t been able to, you
know, to examine these patients for long enough to give a clear answer to that.>>This is David Wiseman. The lung function test that we anecdotally told
is the one that’s most [inaudible] has been carbon monoxide diffusing [inaudible].>>Thank you. I’m going to move on to the next question. Our next question is regarding
comorbidities or preexisting conditions. Have any of these patients presented with respiratory comorbidities
or preexisting conditions?>>This is Tara Jatlaoui. In the case series from Illinois and Wisconsin
of the 53, I’m sorry, of the 53 patients that were included in that publication,
about 30% of them had asthma, but there was otherwise no underlying chronic
lung disease process, and we have heard the same that there’s been some pulmonary comorbidities
like asthma, but we haven’t been hearing that any other pulmonary diseases frequently. But, that’s, again, that’s not something that
at the time we have enough information to say.>>Our next question’s about presentation and
the question essentially asks what are some of the initial presentations or symptoms
to look out for when assessing patients.>>This is Tara Jatlaoui again. So, patients have had an
onset of various symptoms. Some have been over days,
and some have lasted weeks. Those have primarily been respiratory symptoms
such as cough, chest pain, shortness of breath. Some have had [inaudible],
GI symptoms as mentioned, abdominal pain, nausea, vomiting, diarrhea. And, there’s also been some constitutional
symptoms like fatigue, fever, weight loss, malaise, that have been reported. And, as we mentioned during the presentation, the GI symptoms have sometimes preceded
respiratory symptoms, and again, a lot of patients have sought
initial care in ambulatory settings, some with a few visits before presenting
and being admitted to the hospital.>>Thank you very much. And, we have time for one last question, and the
question is can you elaborate a little bit more on the phenomena of lipoid pneumonia and
what are the best ways to test for it?>>This is Tara Jatlaoui. Lipoid pneumonia is a rare condition where
fat enters the lungs either exogenously from, you know, outside factors or endogenously. So, it’s been associated with inhalation
of lipids and aerosols generated by either e-cigarette products or vaping,
and it’s been reported in some cases based on the detection of these lipid laden
alveolar macrophages obtained on BAL. Lipid staining can be performed including
oil red o or Sudan black in order to see these lipid laden macrophages. The decision about whether
to perform a BAL in order to find the lipid laden macrophages should be
based on individual clinical circumstances. Lipoid pneumonia can also be
identified with lung biopsy by identifying lipid laden macrophages, by lipid
staining performed on fresh tissues as well as routine histopathologic
evaluation of regular processed formal and fixed paraffin embedded tissues.>>Thank you very much. On behalf of COCA, I would like to
thank everyone for joining us today with a special thank you to our presenter
Lieutenant Commander Tara Jatlaoui and to Commander Maleeka Glover, Dr.
Sarah Raegan-Steiner, Dr. David Wiseman, and Dr. Ahmed Jamal for joining
us for the Q and A session. A recording of this call will be posted
within the next few days to the COCA website and available on demand at
emergency.cdc.gov/coca. Again, the web address is
emergency.cdc.gov/coca. Please join us for our next COCA call. That will be held one week from today on
Thursday, September 26th at 2:00 PM Eastern time where the topic will be the
2019 2020 recommendations for influenza prevention
and treatment for children. An update for pediatric providers. To receive information on upcoming COCA
calls or other COCA products and services, join the COCA mailing list by visiting the COCA
webpage at emergency.cdc.gov/coca and click on the join the COCA mailing list link. To stay connected to the latest news from
COCA, be sure to like and follow us on Facebook at facebook.com/cdcclinicianoutreach
andcommunicationactivity. Again, thank you for joining
us for today’s call. Have great day.


7 thoughts on “Lung Injury Associated w/ E-cigarette Use or Vaping: Info for Clinicians

  1. Corruption enforced by The Federal & Local Dept.s of Health and ignored by the CDC: 1) Doctors Upcoding through Medical Gaslighting to spread 33% kickbacks to referring physicians status quo? Private insurance forwarding expensive Diagnosis to Medicaid and Medicare? Workers in the CDC gettiing dumber and dumber due to corruption? Vaping scapgoated for STAPH INFECTIONS biofilm related? Usa300-st8 not .000001% in the media as much as vaping?

  2. CDC promoting Healthcare Corruption by ignoring Staph Pneumonia outbreaks such as USA300-ST8 and ignoring biofilm at the least, especially with public media announcements?

  3. This is why no one, especially minors, should consume illegal black market products. Instead of regulating legal products that are proven at least 95% safer than cigarettes (according to Public Health England) maybe the government should actually enforce the laws they already have in place. Just a thought.

  4. Seeking answers, NBC News commissioned one of the nation's leading cannabis testing facilities to test a sampling of THC cartridges — 18 in all — obtained from legal dispensaries and unlicensed dealers.

    The findings were deeply troubling.

    Of the three purchased from legal dispensaries in California, the CannaSafe testing company found no heavy metals, pesticides or residual solvents like Vitamin E.

    But 13 out of the other 15 samples from black market THC cartridges were found to contain Vitamin E.

    CannaSafe also tested 10 of the unregulated cartridges for pesticides. All ten tested positive.

    The products all contained myclobutanil, a fungicide that can transform into hydrogen cyanide when burned.

    "You certainly don’t want to be smoking cyanide," said Antonio Frazier, the vice president of operations at CannaSafe. "I don’t think anyone would buy a cart that was labeled hydrogen cyanide on it."

    Pirzada described the existence of myclobutanil as "very disturbing." "It’s going to cause a very toxic effect on the lungs," she said.

    Latest finding!

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