SCCM Resource Library-Up in Smoke: Managing e-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) in the ICU

Video Transcription

Good afternoon, everybody. I want to thank all of you for coming so late in the afternoon on this gorgeous day outside to our flip classroom session entitled Up and Smoke  Managing E-cigarette or Vaping Produced Product Use Associated Lung Injury. So I'm Steven Greenberg.  I'm the Director of Critical Care at Evanston Hospital and Vice Chair of Education in Anesthesiology, and I'm pleased to introduce my co-chair in this session, Dr. Amos from  Medical College of Wisconsin Children's Hospital. She's Associate Professor of Pediatrics there.  So, for those of you who don't know, and I hope you all do, this is actually a flip classroom style session.  So what does that mean? That means that we want this to be as interactive as possible. So while we have enough slides to take the entire time up,  we want to also hear from you. And so you're more than welcome to come up to the  microphones and ask questions or generate comments and concerns  based on your own experiences or the the information that we provide you today.  And in fact, raise your hands, how many of you have actually gone on the website and looked at the articles that we referred to  that were posted on the website? Can you raise your hand?  Okay, so some of you. And we'll provide our slides for you  afterwards. And please go back to that website and check, and we'll be completely updating it as well. So  without further ado, we're going to start. The objectives today are to describe an overview of a valley crisis in terms of the cases,  number of deaths, age distribution, and outcomes. And then we're going to provide you two very interesting cases. One,  where a patient with a valley actually presented to the operating room and the difficulties that that presented for the perioperative team. And then Dr. Amos will talk about a case  management of an adolescent with EVALI.  So without further ado, I will be starting and talking to you about vaping-induced lung injury and the perioperative period.  Those are my disclosures, none of which have anything to do about our talk today.  So let's start with a question. How many of you have ARS capability right now?  Nobody, okay. Do we have  the ability?  Okay. Okay, so why don't everybody vote if you have the ability to vote how many patients in the US have died since December 2009 from EVALI. Please put in your answers.  And there's the way you actually pull in, texting Critical Care 1.  Alright, we're changing on the dime, we're getting a couple more people, that's good.  We'll let this go for about 10 more seconds.  Five more seconds. All right, we're going to close the polling now. So, most people answered C. In fact, very interestingly, we'll advance this. Wow, I can't even advance it.  All right. Can we advance to the next slide, please? Actually, the answer is greater than 40. And in fact, as of December 2019, and most recently, as of January 21, 2020,  60 patients have died in the United States, including its two territories, as well as the District of Columbia. So, a big problem. Of the following agents listed,  which seems to be the most common etiologic agent in many of the EVALI cases? Please answer.  Give about three more seconds. Everyone's catching on to this. Okay, so a little more unity there. Let's advance the slide please. Correct, vitamin E acetate in a  recent New England Journal of Medicine article. 51 patients with EVALI were compared to 99 healthy controls and vitamin E acetate was identified in the  BALF fluid obtained from 94% of the cases in 16 states but not in any healthy controls. So you're right. Most common one so far, although there are a  lot a lot of issues out there and we'll talk about it, seems to be vitamin E acetate. So here's a little bit of an overview of EVALI. E-cigarettes have  doubled, the use of them have doubled, from 2017 to 2019 and in fact over 41 million people in the United States are using e-cigarettes today. 41 million. As  of one, as of January 2020, we've got 2711 cases of EVALI in the United States, 60 deaths and 78% of these cases have been in patients of less than 35 years old  with the median age of 24 years old. In fact the median age of death is about 50-51 years old. Most common symptoms that you're gonna see, 95% of them come  up with respiratory, 85 constitutional, fever, dyspnea and exertion, night sweats, fatigue and 77% nausea, vomiting, diarrhea, so on and so forth. Over about 80% of the  cases are reported using THC products of which 78% of those are from illicit vendors or illegal vendors. And as you all rightly answered, vitamin E  acetate seems to be, seems to be the most commonly implicated etiologic agent. So what is our problem? The problem is, is that one size really doesn't fit  all and you can find this on the CDC website, but if you look at this, there are tons of model vaporizers and e-cigarettes out there. In fact, 180  different devices are out there and used today in the United States and abroad. We went from the first generation, which were disposable, then to refilled and  pre-filled cartridges, tanks or models where you can actually see how much you fill and put your own fluid in, and then modify these tanks to provide yourself  with more aerosol. And the interesting part of this is that each one of these devices heats up the solutions at a different temperature. And the higher  temperature that these solutions are heated up, then generates reactive, different reactive oxygen species, which are lung irritants. So that's why one  size doesn't fit all. We're seeing a multitude of phenotypes in our ICUs and how these patients actually present. And then you look at the liquids.  Tons of different liquids. We have cannabis, we got nicotine, we have vegetable oils, propylene glycol, acetyl or diacetyl, which are some of the  flavoring liquids. And all those put together provide us different presentations of these patients, which implicates how we actually are able to  manage these patients as intensive care providers. So the suggested diagnostic criteria, you have to use e-cigarettes. We don't have a lot of data  on secondhand vaporizing smoke. That is still yet to come to fruition. Pulmonary infiltrates on chest x-ray or ground glass capacities on CT. Elevated white  blood cell count. Inflammatory markers. You have to rule out pulmonary infections. Respiratory viruses have to be negative. HIV negative. And you can  take a look at bronchial alveolar lavage samples to make sure that there aren't any bacteria. Foamy macrophages containing vitamin E acetate. And when we  had our case, we didn't even know any of this. So we didn't have the necessary staining or do the necessary staining. And then no evidence of alternative  medical causes. So really rule out cancer reasons, heart failure, so on and so forth. Management is really supportive. A really early consultation with  pulmonology and toxicology. You really want to make sure that you send a urine tox screen. A lot of the original cases weren't identified as associated with  THC because they did not send urine tox screens in the emergency room or outpatient centers. Lung protective strategy. And we'll talk a little bit  about that later. Empiric antibiotics, at least for the first 48 hours until you're ruling out other causes for the acute lung injury. And systemic  corticosteroids is still very controversial. There are three sort of phenotypes that may be more beneficial in terms of implication or in starting  corticosteroids. That is eosinophilic pneumonia, hypersensitivity pneumonia, and lipoid pneumonia. Others may have some benefit, but we really don't know what  the dosing and right duration is. And it really needs to be considered on a case-by-case basis. Follow-up is of utmost importance. Reporting this stuff  to the local poison center, as well as your own State Department of Public Health. Something we did a lot in Illinois. We had some of the most cases  out of the United States. And considering ECMO in really, really refractory cases. That's something that I'll go through with my case. This is an updated CDC  volume management suggestion and follow-up. In fact, Dr. Lilly is just presenting an article in the late break recession as we speak on their  experience at UMass that is similar to this dichotomy. But I'm going to go through this one. Has the patient used e-cigarettes in the past 90 days or vape?  And if so, start looking at vital signs. Pulse oximetry is really, really important. And if those patients have pulse oxes of greater than or equal to  95% with no respiratory distress and no other comorbidities, you might want to consider this form of outpatient evaluation. Chest x-ray, making sure you  connect them to addiction substance programs, and administer routine vaccinations, but also ensure follow-up. That is so important. Some of the  inpatient data registries suggest that about 25% of the folks that were re-hospitalized or died did so within the 48 hours post-discharge. So it's  really important to get these people plugged in right after you discharge them from the hospitals. Okay, so inpatient clinical evaluation. Again, low  saturation on room air, less than 95%. Respiratory distress or comorbidities that would lead patients to get sicker in a very short period of time, you want  to consider an inpatient clinical evaluation. So what's different as of about three weeks ago is really that discharge planning, which is in blue.  It's really, really important to focus in on the fact that you need to follow up not only within the first 24 to 48 hours, but also ensure clinical stability of  the patients, making sure those SATs are okay and the vital signs are stable for at least 24 to 48 hours prior to telling the patients they can go home. That's  really, really important. Preventative strategies. Obviously, the most straightforward one is don't use these things. Don't use these  cigarettes or vaping products altogether. But it is so easy to gain access, even for our children. There was an article in one of the newspapers in Colorado that a  nine-year-old could go on the internet and get any type of vaping product and vaping device. And in fact, this nine-year-old talked to her legislator  body and they're trying to actually outlaw the fact that there's so much ease in terms of access to these not only devices, but chemicals. Don't buy  anything, don't modify or add any substances to e-cigarettes or vaping products, and reframe from the use of all of them altogether. Pretty  straightforward. So I'm going to go into the case study now and please interrupt me if you have questions or comments or I'd like you to absolutely share your  experience as well. This was a 29-year-old man presented with daytime sweats, progressive shortness of breath. He had a past medical history of multiple  sclerosis, but was in complete remission. He had chronic night sweats at baseline, but a seven to ten day history of nasal congestion and daytime chills. He  presented to the urgent care where the providers gave him a Z-Pak and sent him home, but in the next 24 hours his wife noticed that he was really breathing  hard. So she rushed him to our emergency room where the review of systems again showed day and nighttime sweats, chills, fevers, and dyspnea on  exertion. So how many...somebody already voted. I guess that was me. How many patients have you managed with vaping-induced lung injury? Please answer.  Okay, so we can end this. So it's about 23 or so. So we actually participated in a podcast through SSCM in October of 2019, and there were 112  participants at the time of that podcast. And so here were those responses. So only about 38% chose one and 33% chose zero. So at that time, there weren't that many.  A lot more of you have taken care of these patients since then. So that's interesting to note.  So the vaping history of this particular patient started vaping five years before admission, constantly. He was vaping all the time.  I don't know how that's possible, but he told us that it is. And his THC concentrations in the urine were greater than 500 nanograms per cc.  To give you an idea of what that really means, negative is around 15 nanograms per cc. So he was doing a lot of this and all the time.  Interestingly enough, he also vaped both nicotine and THC and added a mango flavor fluid, diacetyl.  He smoked cigarettes 10 years before, he's only 29 years old, 10 years before a pack a day. So a lot of smoking.  Physical examination, laboratory findings, he was really tachypneic on presentation emergency room.  He had sat around 95 to 96 on an FiO2 of 80%, crackles in the bases, elevated white count with neutrophilia, and obviously his urine tox screen was positive for cannabis.  So this was his presenting chest x-ray, and you can see he had opacities right greater than left, and again, there was a big enough concern to send him to the intensive care  unit at that point. You have to remind yourself that we did not know anything, Dr. Layden's article in the  New England Journal had not come out yet when this patient presented to our hospital. So the intensivist who was actually providing care for him at the time started him on BiPAP  and said, we're going to have a low threshold for intubation, started on broad spectrum antibiotics, cultures were sent, they sent a respiratory viral panel, which was negative,  and he actually did a bronchoscopy, which really showed mild inflammation, but no other positivity for bacteria or malignant cells or any acid vasculi.  So empirically, this intensivist started the patient on methylprednisolone at 40 milligrams twice a day. This was hospital day one.  Again, you can start to see diffuse, patchy, hazy infiltrates bilaterally, right greater than left. So not so great.  Well actually, on hospital day four, he started to sort of improve a bit. He actually, we took him off BiPAP and the high flow nasal cannula FO2 concentrations  were coming down until that night. And on the night of the hospital day four, he all of a sudden complained of really intense  shortness of breath, he desaturated, and he had no breath sounds on the left side. This chest x-ray was obtained at that point.  So how many patients with a vaping-induced lung injury have you seen with the following chest x-ray?  Okay, so just like us, most people have not seen attention pneumothorax in these particular patients, and it really frightened our providers.  This was one of our, actually the patient was in one of our community hospitals, and so it was, to say the least, frightening.  Of 122 participants in October, again, most of them, as like you, had never seen attention pneumothorax in a New Valley patient.  So going back, we placed a chest tube, fortunately, with instant symptomatic improvement, and then the patient was transferred to our more tertiary care hospital.  So interval hospital course, he required another chest tube for a persistent air leak, was intubated for three days, and then extubated.  He remained on and off BiPAP and high-flow nasal cannula, and really six days after his attention pneumothorax, the thoracic surgeon got involved and suggested that the patient  undergo a video-assisted thoracoscopic surgery, pleurodesis, and blebrus section. That's where I got involved. The CT of the chest is as it is there.  You can see a large left-sided pneumothorax, despite two chest tubes placed, and significant parenchymal bilateral infiltrates with a right upper lobe bleb that we didn't think was  a pneumothorax at the time. So this patient showed up in my ASU area, our holding area, and we placed the appropriate  IV axis with a radial arterial line, and the plan was to do an isolation, one lung isolation with a double lumen tube.  So how many vaping-induced lung injury patients have you seen proceed to surgery? Please vote now.  All right, so I think we're getting the gist and for you know, we were on an island at that point and again We had no idea  What we were really seeing or or any evidence to suggest how we were supposed to manage these patients  So similarly to October in 2019 really most of the folks like yourselves had never seen a patient like this  Go to the operating room. Well, this is a complicated anesthetic record and I won't bore you with all the details for those of you Who are not anesthesiologists?  However, I want you to focus on three things when we pre-oxygenate the patient with a hundred percent FiO2  Immediately on induction of anesthesia this patient SATs dropped to 50% and it took us quite a lot of time after  Securing the airway to get the patient SATs back up to about 89 to 90 percent on one lung ventilation It was a near disaster  The dead space ventilation was substantial as indicative of his end title to PaCO2 gradient  44 versus 78 and despite FiO2 of a hundred percent and peep his PaO2 remained in the low 60s at best  It was a struggle to say the least the one lung that we were actually ventilating you saw wasn't so good on the right  So once we got to too long ventilation, I told the surgeon we need to really hurry up the situation here because again It was life-threatening at that point  We were better off with the two lungs and and then the but the completion of the blood resection so fortunately  The patient was extubated on post-operative day one without a complication. However  Before I get to that x-ray  The left upper lobe pathology revealed diffuse alveolar damage and reactive pneumocyte hyperplasia  We thought we had just dodged a huge bullet and on post-operative day three he was recovering well, but guess what?  suddenly developed acute shortness of breath desaturation low blood pressure and  Who knows what this is all at once  another attention pneumothorax chest tube was placed and  Same thing back to the operating room for a persistent  Air leak. So this time, you know, my colleague got it got off a little bit easier than I did He was a lot more stable because his left lung was working a little bit better  But again, you can still see that in the operating room his SATs were low  And the end title co2 was high and they never got a blood gas, but I'm sure the pa o2 was significantly high Again, fortunately, I guess it's good to be young  But he was extubated a post right thoracoscopy with an apical blood blood resection and again same pathology diffuse alveolar damage  organizing Diffuse lung involvement with interstitial fibrosis any event he continued to improve and was sent to rehabilitation  And stayed there in our ICU for 22 days and in the hospital for a total of  34 days This is his three month follow-up Recently he had mild to moderate emphysematic changes within the lungs. This young man is now 30 years old  parenchymal scarring Fortunately for him the bilateral infiltrates had resolved but there is some suggestion of chronicity here  He had a chronic fatigue with exercise still his PFTs had normal sperm sperm Spermatogenic measures, but his DLCO was reduced at rest his SATs were 98% with exercise  it was about 94% so we continued to suggest that he continues exercises and He remains abstinent from any vaping products as of now. So take home points from this case  Vaping induced lung injury mimics many other causes of acute respiratory distress syndrome this specific type seems to have a propensity for the formation of blebs and then a  Subsequent formation of pneumothoraces and further registries are actually indicating that dr Layton's original article only reported one pneumothorax in our 53 cases  So at this time, this was a very novel fortunate novel case for for the patient and for us  Interoperative management can be very challenging a low titan volume ventilation is an absolute whether volume or control or pressure control  controlling positive end expiratory pressure in this particular case is probably judicious and  The use of if I could have done it differently I would have had our ECMO group in the operating room  Maybe even put the patient on ECMO before I even took the patient to the operating room knowing what I know now  So without further ado, I'm gonna end there and we're gonna actually move on to our next speaker. Dr  Amos so she can have a chance to get through her stuff and then we'd love to hear your feedback on these particular cases Okay. Thank you  You  Know now now you can okay  When disclosure, I'm a pediatric pulmonologist. I work with pediatric intensivists, but I am NOT one of them  and I come from Milwaukee, Wisconsin, which is where Children's Wisconsin is and  There was an oops. What did I do? I just did something  All right. Okay. And then lastly, it's kind of interesting that Dr. Greenberg mentioned that case because last week or two weeks ago, I saw a patient come to my clinic because  he divulged that he has been vaping. THC mothers, by the way, a journalist who was kind of investigating  vaping in our city. And she was quite upset with this. And he was coughing for a while. And the only thing we saw on chest CT were apical blubs. He's a tall, thin kid, but  I'm going to have to talk to mom after this. Okay. So no financial disclosures. And just kind of so you know our involvement with the vaping epidemic is that at Children's, we  had about five cases in July of teens that were previously healthy, came to our hospital with severe respiratory distress and abnormal findings on chest X-ray. It was summertime.  They shouldn't have pneumonias. They were otherwise healthy. So we reported these cases  to the Department of Health Services in Wisconsin. And after that, there were several more cases  that presented to our hospital. We reported them to the Department of Health Services. And by this time, our state was a little concerned because it was becoming a little bit more  like a cluster. So by July 25th, there were eight teens that were hospitalized with acute lung injury related to e-cigarette use. And then Children's had the news conference and  then the Department of Health Services sent an alert to the rest of the state saying make sure you keep an eye out for these cases in case you run into them and report them so  we can try to figure out what's going on. We thought it was going to be more of a local issue, but we were very mistaken. So then between the 25th of July to August 2nd, other  states started reporting cases. And by that time, I think we had about 11 teens that were  admitted to our hospital. And then unfortunately, by August 20th was the first death in Illinois.  So until, I don't even remember, maybe November, because after the major case, especially after the first death, every Thursday there's an update on the CDC website of the number of  cases, the number of deaths, and which states were involved. So all states have reported at least one case, including Alaska. Alaska was the last state to present, to report a  case. And you can see where we are right now. So Texas has the most, and Illinois has the most. Wisconsin's kind of in the middle. We're in Florida, so that's about 150, 100 to 149  cases, I believe. Yeah. Okay, so what is in an e-liquid? Dr. Greenberg already mentioned some humectants, the propylene glycol, vegetable glycerin. And then there could be nicotine.  There could be THC. There could be other drugs like methamphetamine as well. And there are thousands of flavorings that are proposed to be healthy, not healthy, but safe, excuse me,  safe for oral consumption. But in terms of pulmonary toxicity, especially when it's thermally  degraded, is not known. Benzaldehyde has been found in the fruity flavors. Cinnamaldehyde in the cinnamon flavors. We already mentioned diacetyl and acetone for the buttery flavors.  And alcohol tends to be in these e-liquids, but we really don't know what is in these e-liquids.  I did purchase cinnamaldehyde online, and they did not require any age proof of purchase  when it was delivered. So the reason why I did that was because when I went to the American  Thoracic Society meeting, and someone there had mentioned sort of this experiment she did with  her lab. And what she did was she put cinnamaldehyde e-liquid in a petri dish, and then formaldehyde in another one, and then water in another one. And then she took her lab out to  dinner, which is really nice of her. And then they came back, and that petri dish containing  the cinnamaldehyde had a hole in it. And so I tried to reproduce this, because I really want  to go out and show teenagers what this can do to you. I wasn't quite able to get that effect, but I'm working on it. And this is just a summary of the effects of e-cigarettes,  regardless of what is being used in these devices, how it's affecting the airways, the respiratory epithelium. It affects the CFTR protein, affects mucous production,  the cilia and the nasal airways, as well as in the bronchial airways. It can affect the  pulmonary vasculature. And so it's pretty global. There's a lot of inflammation that can happen as  well. One thing that we also have to kind of keep in mind is what are the risks of vaping cannabis?  This is really important to keep in mind. There are pesticides and fungicides that are used to  grow cannabis. So we don't know how much of this is being flushed out or washed out when we are  using cannabis in our vape pens. And then the chemical solvents that are being used to create  concentrate, they contain butane, hexane, alcohol, isopropyl. The flavors I already kind of mentioned,  we don't know what's in them, as well as cutting agents. So this is the vitamin E acetate thing.  It's the oil that kind of is used to dilute THC oil. It has a similar viscosity, so it's a very good option as a cutting agent or diluent.  And we already went over this. I'm not going to review that again. But we know that vitamin E acetate is safe for topical use and oral consumption, but we don't really know how,  you know, it doesn't seem to be good for the lungs. It may affect surfactant function, as well as  create this lung irritant when it's heated.  So now I'm going to go into my case. We had a 17-year-old who presented with several days of  not feeling great. It's important to also note that she has a history of depression and anxiety.  She had some fatigue, abdominal pain, nausea, vomiting, and diarrhea. She presented to her  local urgent care and was diagnosed with a viral syndrome and was sent home. Unfortunately, that  night she developed worsening vomiting and also had some dyspnea, so she then went to the ER because urgent care.  OK. It looks like it's slowing down. We can move on. So they got the CBC ProCal CRP in a, what was it? Sorry, I have to go back. Test X-ray, thank you. There was a leukocytosis.  The ProCal was 0.26, which is elevated. They got a CMP as well, which was normal. The lactate was 1.5, and the ABG looked not too good.  Because she was vomiting and having GI symptoms, they got a CT of the abdomen. And they saw the lower lobe consolidation in the lungs.  So they admitted her for possible sepsis and pneumonia, which they thought may be from aspiration due to vomiting.  They got a chest X-ray, and this is what it looked like. So there's bilateral ground glass opacities in the lungs, mostly in the dependent areas.  Finally, a chest CT was done, and it shows pretty much the same thing with a little bit of subplural sparing. You can kind of see on the left here.  So she was still able to talk at this point, but really dyspneic. She reported that she'd been vaping for a year and using marijuana. Her mom was not aware, of course.  And by the way, when you look back in her chart, she was seen in a GI clinic six months prior for chronic abdominal pain, nausea, and daily vomiting.  This is kind of the symptoms that we see. It's very constitutional. It could be fatigue, fever, night sweats, GI symptoms. Sometimes there's weight loss.  We've had patients have about 25 to 40 pound weight loss before presenting to the hospital. And she was missing a lot of school last year because she was just not feeling  well with these GI complaints. Interestingly, again, the GI complaints often preceded the pulmonary complaints because usually it was the pulmonary complaints that  brought them to the hospital.  So she worsened at the outside hospital, was placed on IV antibiotics. She needed up to 30 liters of hyphalonase cannula and then was placed on non-invasive ventilation.  Our hospital was then called to the outside hospital for a ground transport because she needed more critical management.  By the time she arrived to our ICU, she was actually able to stay on BiPAP, or bi-level non-invasive ventilation. But then she needed to go back to the hospital  But then she needed to be intubated. And actually, they couldn't ventilate her unless they gave her a neuromuscular blockade.  So after this, what would be your next step in management? Would you broaden IV antibiotic coverage, start IV steroids, 60 milligrams daily without antibiotics,  continue IV antibiotics, and start pulse steroids, bronchoscopy with BAL?  So, they continued IV antibiotics, but they actually switched it to IV subtriaxone and vanco, and they upholstered her pretty much because of the critical nature, and she was  very difficult to ventilate. They were able to stop IV antibiotics after 48 hours, and a bronc with BAL was performed  prior to extubation, and it was helpful to get that BAL because then we were able to feel pretty confident there was no infection, so we could stop antibiotics.  So, the cultures were negative, and the cytology did show moderate lipid-laden macrophages. She was extubated about five days after she was transferred initially to our ICU.  She had some post-extubation delirium and anxiety, which was treated with PR and diazepam, and it did resolve by the time she was actually transferred up to the floors.  Her mom actually brought this big bag of vaping products to me, and I'm like, what do I do with this?  So, I was asking everyone, like, I don't want to have this in my office, but it had THC and nicotine, and, you know, you just kind of look at it, there's a certain, she had  some e-liquids with refillable cartridges, and she also had what they call carts that contain THC, and it's like a vape pen.  I don't know if you guys have seen vape pens, but usually it's a vape pen that they use for THC.  We did some pulmonary function testing prior to discharge, and this is what it looked like. So, she had pretty severe restrictive lung disease.  You can see her TLC was decreased at 61 percent, with FEV1-FVC at 44 percent, really no change with albuterol or bronchodilator therapy, and her DLC was also reduced at 42 percent.  We did a six-minute walk, and she went down to 85 percent, and she actually took some rests in between, so she couldn't quite do the whole six minutes.  She had to walk, and then stop, and then walk, and then stop. So, she needed some oxygen with activity upon discharge.  After that three-day course of IV pulse steroids, we started an immediate steroid wean. One month in pulmonary clinic, she reported she was no longer vaping, and her GI symptoms  had resolved by then, so she had no nausea, vomiting, diarrhea, nothing, and we were able to discontinue her oxygen. You can see her FEV1-FVC went to the 86-90 percentile.  Her TLC was up to 96 percent, it was 61 percent, and she was able to maintain her oxygen saturations in the six-minute walk, with a minimum of 92 percent.  Now in terms of, that was just one month later, we haven't done the repeat imaging at the six-month mark, but in terms of her recovery, what do you think will be the biggest hurdle?  Severity of her lung injury, prolonged nature of e-cigarette use, depression, anxiety, or chronic GI symptoms.  Oh, well that's, I guess the answer. So the answer is depression and anxiety. You guys got it.  When our, I would say she was pretty forthcoming and she said she's no longer vaping, but that's one month out. We've had some kids come back saying that they have restarted.  And the reason why they say is like, I can't, I'm so stressed out. I'm really anxious. I can't stop. And even the kids who haven't been vaping  for about a month, they still crave it. And it's not like they're necessarily physically addicted, perhaps, because they literally say that they haven't had it  for a month, but they just feel like they need it. They're no longer doing it for social reasons. They're doing it to medicate themselves. And so I think that's a major issue  that we're starting to see in the follow-up is that there's a lot of stress and anxiety in our patients, which I think probably led  to the use and the development of their lung injury.  Yeah, that's about it, I think. Are there any questions for either?  So we'd love to hear from the audience. First, if you have any questions, but some of your experiences, and I know they're based on the results, there are folks in the audience  who've managed these patients. You probably have managed them somewhat differently or had different experience. So please come forward and questions, comments, concerns. Go ahead.  Hi, I'm Paul Murray, Critical Care in Florida, Clearwater. I've seen a couple of cases in our ICU, but my question is, where is the data on steroids? We're using high doses.  As far as I know, there's no real evidence for that. For the prototypical ARDS patients, non-infectious, there's been a lot of saying we don't use steroids  until later on in the late part of the disease where it helps improvement. So how do we know, 60 milligrams a gram, what's right, what's wrong? Does it help or harm initially?  Yeah, no, we really don't have data right now. I think a lot of the stuff that we've done over the past six months is something that we are hoping to put together  to sort of figure out what was the best approach because we do worry about adrenal suppression, especially when we're trying to wean them off. It just seemed that once,  they often came in on antibiotics and didn't get better,  and so the next thing that we thought could help were the steroids, and they really did turn around very quickly, like most people in general, I think,  on high-dose steroids who come in looking like that. Okay, good. So I'll chime in as well. In our podcast in October, all the healthcare professionals that were involved  with that, all of them had started folks on steroids empirically. Well, nobody's allowed to die without steroids, right? Correct, exactly. And so I would imagine that we're going  to start seeing some longer-term data on when those folks were started, what the dose was. A lot of people are saying one milligram per kilogram.  I think there's already starting to be a focus on sort of the phenotypes and targeting the more inflammatory phenotypes that we see,  the hypersensitivity, the eosinophilic, which is rare, and sort of the lipoid pneumonia, which seem to be the highest responders. But again, this is a data-free zone.  And so I think this is a great opportunity for all of us to figure out how we can input our data and see what the overall longer-term outcomes are.  We don't even have the long-term outcomes for these patients based on steroids. So it's a great question, one that we can't answer at this point. And it might be difficult, too,  because all these patients are managed a little differently, too.  The question is how much they were vaping, what they were vaping, what types of fluids they were vaping. All that plays a role, I would imagine, in their overall long-term outcomes.  So great question. Unfortunately, we still have the question. Thank you. Yeah. Yes, sir. Hi, this is Gagan Kumar. I'm one of the intensivist and pulmonary care doctors in Georgia.  Nice presentation. I have a couple of questions about your patient. You saw a lot of blood formation. The exit that you showed with the chest tube and persistent pneumo,  what are you guys thinking about trapped lungs? Because that should not exist, right? Yeah, it was, and we were on significant high suction,  and we could not get rid of the persistent air leak.  So that's why we then proceeded to the operating room. What did you find in the pleura? Was it like a rend? Typically, what we see is lung entrapment. That's what you saw? Correct.  Yep. Okay. And the unfortunate thing is that the similar thing was found on the right side. And he wasn't even on high positive pressure  after that post-operative day one. So this just spontaneously occurred, and they were very refractory. I mean, a lot of these, as you know,  closed through just conservative management with chest tubes over time. Right. So. Yeah, so in my means, I have seen possibly four or five cases. One of them obviously died.  But I had one other question. I know we have been trying to figure out why this has been, and I saw your data on, you have vitamin E possibly causing this.  I'm pretty certain people have been looking at what kind of these things are. Because vaping has been going on for, not yesterday, not this year,  it's been going on for possibly 10, 15 years. The right question to ask is why now? Why are we seeing this now? Is something different? I think that's going to give us a more  clearer picture about the etiology of this thing.  And the interesting part was, when I was looking at your state distribution graph that you showed me, those data are not THC friendly. So the question is, is it all THC,  or is it something else? That's going to, you know, I think whenever we throw THC, we throw THC in everything. But I think unless we really figure out  what that is, what that new component is, people have been smoking marijuana for years. But this is just happening for the past one year. And you're right, means THC is there.  But I think there's something more chemical, means there's so many things that are adding. I think we have to get to the bottom of that before we really figure it out.  Well, I think, you know, Dr. Amos, you can chime in, but I think we've already found one, you know, real issue, and that is the cutting issue with the vitamin E.  And, you know, so illicit vendors are cutting THC to save money and to provide a, you know, more product for a variety of folks. And that heating up of that particular component  has real problems in terms of the, as we talked about, lung irritation. Will it be useful to talk to those vendors and see what they have changed in the past couple of years?  Say it again? Will it be useful to talk to those vendors to see what they have changed in the past couple years? Because this is so new,  they must have added something in the past couple of things because this is possibly unheard of before. So I think the utilization of the internet and social media  and the rise of that over the last several years has made it fairly simple to do things like this and to go on YouTube, so on and so forth.  And again, I don't have experience with this, but bottom line is to look at how you can do things  in your house and make it very profitable. And I don't, you know, again, I think you're right. I think it'd be interesting to get firsthand knowledge of this,  but I think when they're doing whatever they're doing, I think it's very easy to go on the internet and find ways to sort of provide products  that look the same, but don't treat the body the same. And so that's, and I think this, somebody asked me if we're done with this.  We've seen it all, and it was something of last year. I think we've only begun, because I think more devices are gonna come out, more temperature changes are gonna come out,  more liquids are gonna be available. Who knows what's going to be vaporized? I mean, I think this is just the beginning of a major, major long-term problem. So I think you're right.  I think more information from the people that are selling this, but you know, again, there are cases that are not just with illicit use too.  So there are cases with products of nicotine,  and at least of what we know. So it's not just the illicit liquids. I expected California to be number one, but it is not. It has the most number of population,  and it's a free state. I'm sad to say I live in the state of Illinois. We're the number one. We're number one with Texas, I guess. And I think it's important for everyone to know  that none of the e-cigarettes out there are FDA regulated.  So May 2020 is the deadline for the PMTAs, for the pre-market authorization. So they're not regulated. They're modifying them, and there are different substances that they're using.  And so it's so hard to keep on top of what is being used.  And it's really quite frustrating because we're way behind the eight ball, right? They've been here since 2006. It's 2020, and they're gonna be around.  And they're just needing to submit their applications by 2020, May 2020. Doesn't mean that they're gonna be authorized. So we have a couple.  And the saddest thing is that these products are being marketed for the young population on TV shows like Nickelodeon, and you know it.  I mean, and the companies originally put out data  that really hasn't really been validated that using e-cigarettes will allow you to stop smoking, which again, that data isn't necessarily true.  So I think, you know, a lot of falsehoods have come out, and a lot of people, 40 million people are using these devices. Go ahead. So in Kubota, Galveston, Texas.  So it's obvious that not everybody getting sick. So I'm wondering what is the determining factor? Is that history on how long one has been vaping,  or the frequency, or there's some background lung disease? So that the people that getting sick are they previously completely healthy, or they had some kind of the comorbidity  like a background lung disease or something like that? Do you have any data on that?  I would say, I mean, our population, the pediatric population, they have really no comorbidities, right? These kids that came in may have needed Albuterol  for, you know, before sports, but that's about it. So we have a population that is pure, and they got really sick. And so I am thinking it's what they vaped,  and how often they were vaping. And, you know, to be honest, around the time our patients presented was a time of something called Summerfest.  It's a huge festival where a lot of high schoolers go out and, you know, have fun, and they have a lot of freedom to do whatever they want.  And so I have a feeling the amount of vaping increase, what they were using, they were getting it off the street, you know. I think that's probably what caused a lot of the illness.  So then we're talking about months, or years, or a few days vaping? What are we talking about? So some of them were vaping for a while.  I would say they did have some symptoms before then, but what brought them in, there might've been something, I don't know what went on in June,  but some of them lost 40 pounds over a period of six months prior to presenting with severe respiratory distress, and something just tipped them over. Again, I don't have an answer,  but I think that the patients that we saw are the ones that we're gonna study, because they have nothing other than being, you know, healthy lungs that were harmed. Thank you.  Hi, thank you for your presentation. My name is Alex Kwasnik. I'm home critical care, currently in Montana. But your presentation, which great, thank you,  made me think of something, actually back to fellowship. One of my attendings, very experienced, had a case of, a file of cases of not vaping related,  but simply smokers, habitual smokers of THC containing marijuana. And bolus emphysema was almost universally kind of seen in those cases.  And while this acute inflammatory ARDS appearing process does seem convincingly mediated by the vaping process, to what degree do we think that underlying  or bolus type changes are in any way specific to the THC containing vaping?  That's a fantastic question.  It's hard to know. I mean, I would have loved to have an x-ray or some type of radiograph on my patient before we got all the x-rays that were, so it's hard to know,  did he have some of these changes already? One would think he was an intense smoker, even before he vaped. And so, you know, but usually, unless you have a, you know,  alpha one antitrypsin type of deal, I mean, you still don't, you shouldn't have emphysematic changes that early. I mean, that's what's quite incredible about the case that I had.  And yet, it seems as though, you know, he ended up with it. So, but we don't have that, you know, control comparison within the patient population to compare it to. So I don't know.  I mean, I don't know the answer. Dr. Amos, do you have suggestions on that? It's just, we have a lot more questions than answers. This is why.  Yeah, it really makes me wonder as well. And it was just a very interesting thing to consider as all the legalization questions regarding marijuana were, you know, were coming up  and we just didn't have the support for arguing this side of the story, so. Yeah, I think we're really just on the brink of finding out more and more about  the longer term effects of all these products, in particular THC when it's vaporized. Thank you. Yep, thank you.  Yes, yes, please. Good afternoon, Brittany, Orlando, Florida. I work at a limited resource institution and we haven't really treated any of these patients yet,  but thinking ahead to what we're capable of doing, I was wondering if, to your knowledge, there were any cases that used or had success  with like inhaled bupropanol or inhaled prostaglandins. I'm not even sure if that would be effective in this type of lung injury, but just curiosity,  thinking about what we could implement before we have to institute a transfer on our patient. That's a great question, thanks for that.  Yeah, no, I, we haven't used anything like that, to be honest.  I would say the folks that are in tertiary care centers have utilized sort of the refractory modalities that are employed in ARDS, so prone positioning,  even nitric oxide, even though it hasn't shown to improve any mortality, and it's extremely expensive, but I have talked to folks from tertiary care centers  around the country, and it seems most providers are using that modality, but we just simply don't have enough data to say you should be doing this or that.  We don't even know that these patients, you know, benefit from all the refractory modalities that are employed from ARDS, but people are doing that. Thank you.  Yep, thank you, great question. It's an excellent question. Go ahead. Hi, my name is Pedro Almerde from Delaware. I'm an intensivist. We had a few cases of baby abuse lung injury,  and one of them was from dabbing or using wax, THC. Is that something that you guys see, too, dabbing causing lung injury? Yep, so you wanna explain what that is.  Yes, absolutely, so a dab is concentrated cannabis, and it's in the wax form. You can actually use it in a modified vape pen as well, kind of like the THC oil.  It's just a different way of using concentrated cannabis. The nice thing for the vapors is that you get a really strong high with very little hit,  and so yeah, I think that is one of the reasons why we have some of these kids coming in with really bad GI issues, like almost like hyperemesis syndrome,  cannabis hyperemesis syndrome, and so they're really sick, like almost toxic. Absolutely.  Hi, Lou Romer from Hopkins. I'm a pediatric intensivist. We've had about 10 of these kids, I think, over the last eight months,  and my question is, not meaning to sound like an alarmist, but public policy-geared or oriented, I wonder at what point should, and this is a great society to do this, the SECM,  should we be partnering with the FDA, with Department of Health and Human Services, to really blanket social media as well as standard media  with a call for just a moratorium on selling these products  and on buying and using these products for whatever good it will do, because what we see, a recurrent pattern, many of our patients have been early to mid-adolescence,  almost all males, very athletic, who by all appearances, at least in the subacute phase, a few months after, have really crippled their pulmonary function.  And it's not clear to me from your presentations that you know, it's not clear that anybody knows, how reversible are these pretty severe and global changes in the lung?  Until we understand what's causing it, what are the agents out there, what are people doing that are selling these things nefariously for their own profit,  what is the long-term prognosis?  Shouldn't we be jumping all over this as a society in a public policy initiative?  So I think that's a fantastic point, and the answer is yes, yes, and yes. I can go back and tell you kind of what historically has done in the last five months,  is that actually we've seen a substantial decline in the amount of cases. The peak of cases were in September. I think the middle of September,  there was 215 cases in one week in the United States. So that's declined dramatically, and I think it's because of public awareness that these devices are killing people,  and now the young population is getting a lot, you know, they're just frightened about it. I think the DA is taking action with the illicit vendors.  As I said, 78% of those cases were from illicit products, but that doesn't absolve the non-illicit products. Those have gone way down, and I think you're right.  I think it's time for us to get together, whether it's SSCM or all of our intensive care organizations to develop a registry, a more systematic registry  on how these patients are being treated, how are they being followed up, and what's the long-term prognosis, and getting that information out to the public,  and then also partnering with legislation to say, these things are not good for people. They've been around forever, somebody said. I mean, you know, even in Europe,  they've been around even longer than that, and yet we haven't seen, it's interesting, we haven't seen a lot of these cases abroad, and they've done this for even longer  than we have in the United States. So what is going on? And I think it's important, and coming on all of us, to really try to use these cases collaboratively  and analyze them, and then, you know, reach out to our legislative branches and say, this is something that has to go. But I think this is a start.  We gotta, you know, I think the public awareness between, I would say, September and December was substantial. I couldn't turn on the television or go on any news feed  without seeing something about a negative ad or negative about vaping, where there was so much positivity before that.  And again, even my young kids who were watching shows, and in between, there were vaping commercials. So this is why, you know, this is why there has been a substantial rise,  particularly, I think, in the pediatric population. I think it's incumbent on us all to get together and figure out how we can maybe develop a registry  so we can look at this stuff long-term, because no one has the long-term data yet. When you ask an adult smoker when they started smoking,  majority will say, you know, when they were teenagers. So about 99% by age 26, 95% by age 21, and 90% by age 18. And so by getting the kids to start using e-cigarettes,  they've created a lifelong consumer, potentially. So that's a huge thing. There's also something called T21, Tobacco 21, which is actually, now, federally, the feds have,  by, I think, right after Christmas, they implemented a law that you cannot sell e-cigarettes under age 21.  Now, you have to look at your state, because Wisconsin, where I'm from, we have a law that doesn't quite mirror that, and so it actually undermines that federal law.  So we thought we were good, we're not good. So now we're working with the AHA to try to really talk to our legislators. We gotta get this through to get everything to match  so we can at least prevent access as much as we can. And then the second thing is to deter them by getting rid of those flavors.  So.  All right. Any other questions, comments? I think we're about to end here. Thank you for all your participation. Appreciate it. Thank you.

Video Summary

The presenters discussed the rise of vaping-related lung injuries and the need for further research and public policy initiatives to address the issue. They highlighted the lack of data on the use of steroids in treating vaping-induced lung injuries and the need for a registry to track patient outcomes. They also emphasized the potential long-term effects of vaping and called for a moratorium on the sale and use of vaping products. The presenters also mentioned the importance of public awareness and collaboration with legislative bodies to address the issue. They encouraged healthcare professionals to work together to better understand and combat the growing problem of vaping-related lung injuries.

Asset Subtitle

Pulmonary, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Review the current state of e-cigarette or vaping product use-associated lung injury (EVALI) in the United States (knowns, unknowns, statistics and recurrent patterns)
Illustrate how ICU providers manage critical illness sustained from EVALI
Discuss how vaping illness in adolescents may be particularly unique in presentation, management strategies, and psychosocial implications

A Case of EVALI in the Perioperative Setting

Steven Greenberg

EVALI and the Adolescent Patient: Lessons Learned by All

Louella Amos

Panel Discussion and Questions and Answers

Louella Amos
Steven Greenberg

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Acute Lung Injury

Year 2020

Keywords

vaping-related lung injuries

research

public policy initiatives

steroids

registry

patient outcomes

long-term effects of vaping

moratorium on sale

public awareness

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