Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALI

Chemical Constituents Involved in E-Cigarette, or Vaping Product Use-Associated Lung Injury (EVALI)

The Centers for Disease Control declared e-cigarette, or vaping, product use-associated lung injury (EVALI) a national outbreak due to the high incidence of emergency department admissions and deaths. We have identified chemical constituents in e-cig counterfeit cartridges and compared these to medical-grade and CBD containing cartridges. Apart from vitamin E acetate (VEA) and tetrahydrocannabinol (THC), other potential toxicants were identified including solvent-derived hydrocarbons, silicon conjugated compounds, various terpenes, pesticides/plasticizers/polycaprolactones, and metals. This study provides additional insights into the chemicals associated with EVALI cartridges and thus may contribute to the underlying disease mechanism of acute lung injury.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016-2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.

The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries

In high-income countries, the biggest cause of premature death, defined as death before 70 years, is smoking of manufactured cigarettes. Smoking-related disease was responsible for about 41 million deaths in the United States, United Kingdom and Canada, cumulatively, from 1960 to 2020. Every million cigarettes smoked leads to one death in the US and Canada, but slightly more than one death in the UK. The 21^st century hazards reveal that smokers who start smoking early in adult life and do not quit lose a decade of life expectancy versus non-smokers. Cessation, particularly before age 40 years, yields large reductions in mortality risk. Up to two-thirds of deaths among smokers are avoidable at non-smoking death rates, and former smokers have about only a quarter of the excess risk of death compared to current smokers. The gap between scientific and popular understanding of smoking hazards is surprisingly large.

E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI) with Acute Respiratory Failure in Three Adolescent Patients: a Clinical Timeline, Treatment, and Product Analysis

Introduction

E-cigarette, or vaping, product use associated lung injury (EVALI) has become a recent concern among public health officials. Factors that contribute to the concern include an increasing number of cases over time, the severity of the illness, and an unknown understanding of the pathophysiology and etiology of the illness.

Case Series

We cared for three adolescent patients with acute respiratory failure secondary to EVALI. All three patients were treated with high-dose steroids in addition to antimicrobials, which resulted in clinical improvement and resolution of their respiratory failure. Pulmonary function testing was performed on these previously healthy patients both acutely and subacutely. Additionally, we report the results from the laboratory analysis of one vaping device fluid which revealed previously unpublished components within these products.

Discussion

EVALI is a recent public health concern without a known etiology which can cause life-threatening lung injury in patients without prior lung pathology. We hope these cases will highlight the importance of return precautions in adolescents with vague respiratory symptoms and provide a cautionary tale to providers while they counsel patients regarding the use of these products.

Use of Electronic Cigarettes in European Populations: A Narrative Review

The increasing popularity of electronic cigarettes in past decades has aroused public health concern. This study aims to review the literature on the prevalence of e-cigarette use among the general adult and young populations in Europe. We searched Medline and Google Scholar from September 2019, and included "prevalence of e-cigarettes", "electronic cigarettes" or "e-cigarettes", and "electronic nicotine delivery system" or "vaping". The prevalence of current e-cigarette use ranged from 0.2% to 27%, ever-use ranged from 5.5% to 56.6% and daily use ranged from 1% to 2.9%. Current smokers of conventional cigarettes showed the highest prevalence for the use of e-cigarettes, ranging from 20.4% to 83.1%, followed by ex-smokers, with ranges from 7% to 15%. The following socio-demographic factors were associated with a higher chance of using e-cigarettes: male sex and younger age groups; results for economic status were inconclusive. In European countries, there is a higher prevalence of e-cigarette use among males, adolescents and young adults, smokers of conventional cigarettes, and former smokers.

E-cigarettes and their impact on health: from pharmacology to clinical implications

Worldwide, cigarette smoking is the major cause of premature mortality and diseases that can be prevented. Given that people continue smoking despite associated health risks, delivering nicotine without combustion should be considered a valuable and much less harmful way to reduce the public health burden caused by smoking. E‑cigarettes could play such a role if they were proven to be less harmful than combustible cigarettes. Although the number of clinical trials and human studies assessing the safety of e‑cigarettes is limited, numerous in vitro and in vivo studies reported on the potential harmful effects of the aerosol generated from e‑cigarettes. This article reviews the results of major clinical trials and laboratory studies with regard to cancer as well as cardiovascular and respiratory risk associated with the use of e‑cigarettes. Additionally, it also discusses the potential application of e‑cigarettes as smoking cessation tools. Most studies have indicated so far that e‑cigarettes are less harmful, but this applies only to smokers who completely switched to e‑cigarettes. In the opinion of the authors, good-quality research is crucial to establish the tolerance, safety, efficacy, and harm reduction potential of new technologies. Considering a significant role that physicians and other health providers play in helping smokers, there is an urgent need for evidence‑based guidelines and recommendations for clinical practitioners on potential benefits and risks of e‑cigarette use.

Potential for release of pulmonary toxic ketene from vaping pyrolysis of vitamin E acetate

The Centers for Disease Control and Prevention has recently reported an increasing number of clinically cases of lung injury following use of vaping products. The cause(s) of this growing epidemic of vaping-associated pulmonary injury remain unidentified, although vitamin E acetate has been identified as one possible causative agent. In this research, a combined analytical, theoretical, and experimental study has shown that the vaping of vitamin E acetate has the potential to produce exceptionally toxic ketene gas, which may be a contributing factor to the upsurge in lung injuries associated with vaping products. Our important results will help inform medical practitioners, research scientists, and the public, which may assist in bringing this medical crisis under control.

A combined analytical, theoretical, and experimental study has shown that the vaping of vitamin E acetate has the potential to produce exceptionally toxic ketene gas, which may be a contributing factor to the upsurge in pulmonary injuries associated with using e-cigarette/vaping products. Additionally, the pyrolysis of vitamin E acetate also produces carcinogen alkenes and benzene for which the negative long-term medical effects are well recognized. As temperatures reached in vaping devices can be equivalent to a laboratory pyrolysis apparatus, the potential for unexpected chemistries to take place on individual components within a vape mixture is high. Educational programs to inform of the danger are now required, as public perception has grown that vaping is not harmful.

Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Final Report

BACKGROUND

E-cigarettes are battery-operated devices that heat a liquid and deliver an aerosolized product to the user. Pulmonary illnesses related to e-cigarette use have been reported, but no large series has been described. In July 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health received reports of lung injury associated with the use of e-cigarettes (also called vaping) and launched a coordinated public health investigation.

METHODS

We defined case patients as persons who reported use of e-cigarette devices and related products in the 90 days before symptom onset and had pulmonary infiltrates on imaging and whose illnesses were not attributed to other causes. Medical record abstraction and case patient interviews were conducted with the use of standardized tools.

RESULTS

There were 98 case patients, 79% of whom were male; the median age of the patients was 21 years. The majority of patients presented with respiratory symptoms (97%), gastrointestinal symptoms (77%), and constitutional symptoms (100%). All case patients had bilateral infiltrates on chest imaging. A total of 95% of the patients were hospitalized, 26% underwent intubation and mechanical ventilation, and two deaths were reported. A total of 89% of the patients reported having used tetrahydrocannabinol products in e-cigarette devices, although a wide variety of products and devices was reported. Syndromic surveillance data from Illinois showed that the mean monthly rate of visits related to severe respiratory illness in June through August of 2019 was twice the rate that was observed in the same months in 2018.

CONCLUSIONS

Case patients presented with similar clinical characteristics. Although the definitive substance or substances contributing to injury have not been determined, this initial cluster of illnesses represents an emerging clinical syndrome or syndromes. Additional work is needed to characterize the pathophysiology and to identify the definitive causes.

Diagnosis of EVALI: General Approach and the Role of Bronchoscopy

A 23-year-old man arrives at the ED with a 3-week history of dyspnea, dry cough, fevers, and night sweats. Two weeks previously, he was evaluated in an outpatient clinic and given a course of azithromycin for presumed infectious pneumonia. His symptoms did not improve, and he was seen 1 week later in an urgent care center and given a prescription for doxycycline, which he has been taking without improvement. He states that he feels miserable, has severe nausea and vomiting, and has not eaten in several days. His only medical history is childhood asthma. He reports no surgeries and takes no medications. He has no risk factors for HIV, does not smoke combustible cigarettes or use IV drugs, and has not recently traveled. Examination shows a room air saturation of 89%, a temperature of 38.3°C, and a respiratory rate of 22 breaths/min. Results of his examination are normal, and there are no rales or wheezing heard in the lungs. Chest radiograph shows bilateral, consolidative opacities. WBC count is 14,000, with left shift. Results of biochemistries are normal. Erythrocyte sedimentation rate is 104, and procalcitonin is 0.08. Urine toxicology screen is positive for tetrahydrocannabinol (THC). Asked specifically about vaping and e-cigarette use, he reports that he recently began using THC "carts" that his friend gets from an unknown supplier. What is the diagnosis and what additional steps are necessary to confirm it? Is bronchoscopy indicated?

E-cigarette use related lung disease, review of clinical and imaging findings in 3 cases

Electronic-cigarette use (vaping), has gained popularity among the young adult population, causing an alarming rise in electronic-cigarette, or vaping, product use-associated lung injury (EVALI). The specific chemical agent(s) responsible for lung injuries remains to be further investigated, but tetrahydrocannabinol, the active ingredient in marijuana, and vitamin E acetate are involved in most cases. A variety of pulmonary diseases causing different imaging findings have been described with EVALI. The clinical and imaging findings of three cases recently seen in our emergency department are reviewed.

Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury - United States, August 2019-January 2020

Since August 2019, CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders have been investigating a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) (1). This report updates patient demographic characteristics, self-reported substance use, and hospitalization dates for EVALI patients reported to CDC by states, as well as the distribution of emergency department (ED) visits related to e-cigarette, or vaping, products analyzed through the National Syndromic Surveillance Program (NSSP). As of January 14, 2020, a total of 2,668 hospitalized EVALI cases had been reported to CDC. Median patient age was 24 years, and 66% were male. Overall, 82% of EVALI patients reported using any tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, product (including 33% with exclusive THC-containing product use), and 57% of EVALI patients reported using any nicotine-containing product (including 14% with exclusive nicotine-containing product use). Syndromic surveillance indicates that ED visits related to e-cigarette, or vaping, products continue to decline after sharply increasing in August 2019 and peaking in September 2019. Clinicians and public health practitioners should remain vigilant for new EVALI cases. CDC recommends that persons not use THC-containing e-cigarette, or vaping, products, especially those acquired from informal sources such as friends, family members, or from in-person or online dealers. Vitamin E acetate is strongly linked to the EVALI outbreak and should not be added to any e-cigarette, or vaping, products (2). However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC- or non-THC-containing products, in some reported EVALI cases.

Pulmonary Toxicity and the Pathophysiology of Electronic Cigarette, or Vaping Product, Use Associated Lung Injury

New emerging tobacco products, especially electronic cigarettes (E-Cig) or electronic nicotine delivery systems (ENDS), have gained a huge popularity, particularly in younger populations. The lack of sufficient evidence-based health effect studies has promoted widespread use/abuse with the assumption that E-Cig or ENDS and/or vaping products are safer and less toxic than conventional tobacco smoking. However, the recent escalation in acute lung injuries and their associated fatalities among ENDS or vaping product users has now brought attention to this silent epidemic via investigation into the constituents of ENDS/vaping products and their toxic effects on pulmonary health. Accordingly, CDC has declared an "outbreak" of the e-cigarette or vaping product use associated lung injury (EVALI). EVALI is characterized by sterile exogenous pneumonitis like reaction with substantial involvement of innate immune mechanisms. Vitamin-E acetate (VEA) is found in counterfeit cartridges and bronchoalveolar lavage fluid of EVALI patients. Other reports implicated the presence of aromatic/volatile hydrocarbons and oils consisting of medium-chain triglycerides (MCT oil), including terpenes and mineral oil in tetrahydrocannabinol (THC) containing counterfeit vaping products. These compounds are involved in oxidative stress and inflammatory responses in the lung. Here, we provide the perspectives on the recent case reports on EVALI, etiology, and discuss pulmonary toxicity as well as the mechanisms underlying EVALI susceptibility and lung pathophysiology.