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Health Alert – Vaping-Associated Pulmonary Injury

Published:  August 29, 2019

 To: Health Care Providers, Healthcare Facility Leadership
 From:Barbie Robinson, MPP, JD - Director;
Celeste Philip, MD, MPH, Health Officer
 Questions: Disease Control Unit - Public Health (707) 565-4566
 cc: Please Share with all Medical Staff

Key Messages

  • Since June, 36 cases of vaping-associated pulmonary injury requiring hospitalization have been reported to the California Department of Public Health (CDPH). Most patients report vaping the cannabis compounds THC and/or CBD, and some patients also report vaping nicotine products, although the exact cause of illness is not yet known.
  • Clinicians who identify cases similar to those described in this health alert are asked to report the cases to their local health department.
  • Report suspect cases to Sonoma County Public Health Disease Control at (707) 565-4566 within one business day and arrange pick up of available vaping products for testing.

Current Situation

Physicians in California and at least 22 other states have documented over 200 cases of acute pulmonary disease associated with vaping over the past three months. Most patients in California report vaping cannabis products such as THC or CBD, and some report vaping nicotine-containing liquids as well. Some patients have reported using vaping products that they purchased from unlicensed, unregulated entities.

Patients typically present to the hospital with cough, difficulty breathing, fever, and sometimes vomiting and diarrhea. In many cases, the initial diagnosis was presumed to be infectious, but no evidence of infection or other process to explain the pulmonary disease was found. All cases in California have been hospitalized, with most requiring respiratory support with supplemental oxygen, high-flow oxygen, or bi-level positive airway pressure (BiPAP). At least ten patients had respiratory failure requiring mechanical ventilation. No deaths have been reported to date in California.

Local health departments are collecting information on vaping habits and products used from patients who are suspected of having vaping-associated pulmonary injury (VAPI).

The numbers in California as of 8/27/2019

  • Total: 36 cases (24 men, 12 women)
  • Ages: 14-70 (median age 27)
  • Total counties: 13 counties across the state       

Information for Physicians and Hospitals

The clinical presentation of VAPI can initially mimic common pulmonary diagnoses like pneumonia, but patients typically do not respond to antibiotic therapy. High clinical suspicion is necessary to make the diagnosis of VAPI. In some cases, patients sought care at outpatient clinics in the days prior to hospital presentation and received antibiotics for presumed pneumonia or bronchitis, which did not improve their symptoms.

Action Items for Physicians:

  1. Ask patients presenting with respiratory complaints in both outpatient and inpatient settings about their use of vaping or “dabbing” devices, especially patients who had an initial diagnosis of pneumonia or bronchitis that did not respond to antibiotics. For patients who do vape, ask these follow-up questions:
    • Type of vape used
      • Do you vape nicotine-containing substances
      • Do you vape substances that contain cannabis or cannabinoid compounds like THC and CBD?
    • Amount of use
      • When was the last time you vaped?
      • How often do you vape?
      • How long have you been vaping?
    • Source
      • Where do you purchase your vaping supplies?
      • What brands are your vaping devices, cartridges, and oils?

  2. Report suspected cases to Sonoma County Public Health Disease Control at (707) 565-4566 within one business day. One of our Disease Control staff will:
    • Interview the patient or family members.
    • Contact the hospital lab to arrange the transfer of biospecimens remaining from the patient to the public health lab. You do not have to order any specific cultures or tests on blood or urine that you would not normally request for the care of the patient.
    • Attempt to collect vape devices and cartridges from the patient or family for testing.

Clinical Information on Vaping-Associated Pulmonary Injury

Clinical course

Patients typically present for care within a few days to weeks of symptom onset. At the time of hospital presentation, patients are often hypoxic and meet systemic inflammatory response syndrome (SIRS) criteria, including high fever. In some cases, patients had progressive respiratory failure following admission, leading to intubation.

Time to recovery for hospital discharge has been from days to weeks.

Symptoms

Commonly reported symptoms include:

  • Shortness of breath, cough
  • Fatigue, body aches
  • Fever
  • Vomiting, diarrhea

Laboratory findings

  • Non-specific laboratory abnormalities have been reported, including elevation in white blood cell count, transaminases, procalcitonin, and inflammatory markers.
  • Negative infectious disease testing (influenza, respiratory viral panel, cultures, etc.).

Imaging

Imaging abnormalities are typically bilateral and may be described as:

  • Chest x-ray: pulmonary infiltrates or opacities
  • Chest CT: ground-glass opacities

Diagnosis

VAPI is a clinical diagnosis of exclusion when infectious, rheumatologic, neoplastic, cardiac, or other processes cannot explain an acute pulmonary illness in a patient known to vape cannabinoids and/or nicotine. The diagnosis is commonly suspected when the patient does not respond to antibiotic therapy, and testing does not reveal an alternative diagnosis.

Common documented hospital diagnoses for these patients have included: acute respiratory distress syndrome (ARDS), sepsis, acute hypoxic respiratory failure, pneumonitis, and pneumonia.

Treatment

Guidelines for treatment of VAPI are not yet available.

  • Most patients require supplemental oxygen via nasal cannula, high-flow oxygen, bi- level positive airway pressure (BiPAP), or mechanical ventilation.
  • Anecdotally, treating physicians have trialed the use of steroids with some possible benefit. Information on dosing and duration of steroids is not available.

Contact Information

Disease Control Unit

Public Health Division

Health Services

Contact us by Phone
Address

Public Health Division

625 5th Street

Santa Rosa, CA 95404
38.441691, -122.713746

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