Severe Lung Injury Associated With Use of e-Cigarette, or Vaping, Products—California, 2019

Abstract

more than 2700 patients have been hospitalized with e-cigarette, or vaping, product use-associated lung injury (EVALI) across the United States. This report describes the outbreak in California, a state with one of the highest case counts and with a legal adult-use (recreational) cannabis market. OBJECTIVE To present clinical characteristics and vaping product exposures of patients with EVALI in California. DESIGN, SETTING, AND PARTICIPANTS Case series describing epidemiologic and laboratory data from 160 hospitalized patients with EVALI reported to the California Department of Public Health by local health departments, who received reports from treating clinicians, from August 7 through November 8, 2019.EXPOSURES Standardized patient interviews were conducted to assess vaping products used, frequency of use, and method of product acquisition. Vaping products provided by a subset of patients were tested for active ingredients and other substances.MAIN OUTCOMES AND MEASURES Demographic and clinical characteristics, level of care, and outcomes of hospitalization were obtained from medical record review.RESULTS Among 160 patients with EVALI, 99 (62%) were male, and the median age was 27 years (range, 14-70 years). Of 156 patients with data available, 71 (46%) were admitted to an intensive care unit, and 46 (29%) required mechanical ventilation. Four in-hospital deaths occurred. Of 86 patients interviewed, 71 (83%) reported vaping tetrahydrocannabinol (THC)-containing products, 36 (43%) cannabidiol (CBD)-containing products, and 39 (47%) nicotine-containing products. Sixty-five of 87 (75%) THC-containing products were reported as obtained from informal sources, such as friends, acquaintances, or unlicensed retailers. Of 87 vaping products tested from 24 patients, 49 (56%) contained THC. Vitamin E or vitamin E acetate was found in 41 (84%) of the THC-containing products and no nicotine products.CONCLUSIONS AND RELEVANCE Patients' clinical outcomes and vaping behaviors, including predominant use of THC-containing products from informal sources, are similar to those reported by other states, despite California's legal recreational cannabis market. While most THC products tested contained vitamin E or vitamin E acetate, other underlying cause(s) of injury remain possible. The California Department of Public Health recommends that individuals refrain from using any vaping or e-cigarette products, particularly THC-containing products from informal sources, while this investigation is ongoing.

Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use–Associated Lung Injury Among Patients Treated at an Academic Medical Center

“…In the series by Blagev et al, 12 33 of 60 patients (55%) were admitted to an ICU, and 19 patients (32%) underwent bronchoscopy. More recent additions to the literature, including those by Zou et al, 20 Henzerling et al, 14 and MacMurdo et al, 16 demonstrated similar ICU admission rates (range, 46%-47%) and bronchoscopy rates (range, 19%-47%). By comparison, only 8 (26%) of our patients were treated in an ICU, and a much larger proportion of all patients (22 [77%]) underwent bronchoscopy.…”

“…All patients survived, and 20 patients (65%) were seen in follow-up. Median (IQR) time to follow-up after hospital discharge was 16 (11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)…”

“… 6 , 7 , 8 , 9 , 10 , 11 Our understanding of this syndrome is based on 4 large patient series, which together comprised approximately 315 patients, less detailed CDC data, and some smaller case series. 1 , 8 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 Despite these reports, numerous uncertainties remain, including information on bronchoscopic findings, characteristic radiographic patterns, and longitudinal outcomes.…”

Vaping cartridge heating element compositions and evidence of high temperatures

“…An outbreak of e-cigarette or vaping product use associated lung injury (EVALI) in 2019–20 resulted in hospital admissions and deaths. Vitamin E acetate (VEA) inside tetrahydrocannabinol (THC) vaping devices was identified as the most likely indicator of injury [ 1 , 2 ]. Acute lung injury has been reported in EVALI lung biopsies and autopsies [ 3 , 4 ], and it has been hypothesized that VEA may have chemically reacted to create toxic ketene (ethenone) in the presence of high temperatures [ 5 ].…”

Notes from the Field: E-cigarette, or Vaping, Product Use–Associated Lung Injury Cases During the COVID-19 Response — California, 2020

“…California identified 210 EVALI cases hospitalized during June 18, 2019-February 23, 2020, † and 65 of 87 (75%) interviewed patients reported using THC vaping products obtained from informal sources (1) * California has suspended use of the probable case definition, in which the patient has infection identified via culture or PCR but clinical team caring for patient believes this is not the sole cause of the underlying respiratory disease process; or patient has no evidence of pulmonary infection, but minimum criteria to rule out pulmonary infection not met (testing not performed). † Includes using an electronic device (e.g., electronic nicotine delivery system [ENDS], electronic cigarette, e-cigarette, vaporizer, vape(s), vape pen, dab pen, or other) or dabbing to inhale substances (e.g., nicotine, marijuana, tetrahydrocannabinol (THC), THC concentrates, cannabidiol, synthetic cannabinoids, flavorings, or other substances).…”