This is the primary a part of a four-part series on vaping.
April 25, 2023 – Rashelle Bernal smoked e-cigarettes and was in an induced coma for per week. She was one among nearly 3,000 people hospitalized with severe lung damage from vaping in 2019 and early 2020, becoming part of what’s now generally known as the epidemic of “e-cigarette or vaping product-induced lung injury” (EVALI).
For many, the EVALI epidemic is a distant memory from the pre-COVID-19 era.
But injuries from vaping still occur. And for Bernal, the implications are her reality. Her pulmonologist described the damage attributable to the ingredients in e-cigarettes as an oil spill in her lungs. Eventually, the toxins will probably disappear. But she’s going to probably need to cope with the injuries for a really very long time.
More than three years later, she incessantly leads to the emergency room.
“If I get sick or something irritates my lungs – it can be something as simple as pollen in the air – I get a bacterial infection or other problems and can't breathe,” said Bernal, now 30. “I'm so out of breath that I feel like I've run a mile when I walk up the stairs.”
In 2019 and 2020, a media storm erupted when hospitals notified the general public of outbreaks of lung injuries attributable to e-cigarettes. Headlines reported that e-cigarettes were killing teens from Texas to the Bronx. CDC investigators pursued most cases to vitamin E acetate, an additive in illegal cannabis vaping products that’s designed to spice up the metabolism of THC, the compound that produces the “high” from marijuana. The agency stopped monitoring EVALI in February 2020.
But in April 2020 National Center for Health Statistics has introduced a diagnostic code, U07.0, for the primary time for healthcare providers within the United States to diagnose EVALI. The code can be used for lung damage related to using e-cigarettes and dabbing, a way of inhaling cannabis. Damage could be Inflammation of the lungsPulmonary hemorrhage and a variety of lung infection.
The variety of cases appears to have risen sharply since 2020. In the last three months of 2020, 11,300 medical claims included the code U07.0. That number rose to 22,000 in 2021 and reached 31,600 in 2022, in keeping with data compiled and provided to Medscape — WebMD's sister site for healthcare professionals — by Komodo Health, a healthcare technology company. Komodo has a database of greater than 330 million U.S. patients from the medical, pharmaceutical, and laboratory claims of Medicare, Medicaid, and personal insurers.
The harms attributable to vaping, including EVALI, persist.
“We still see a number of patients diagnosed with vaping disorder, but that is not our primary focus,” said Usha Periyanayagam, MD, MPH, director of clinical products and real-world evidence at Komodo Health and a former emergency physician.
Where all the pieces began
Devika Rao, MD, a pediatric pulmonologist at UT Southwestern Medical Center in Dallas, has treated most of her EVALI patients within the hospital, with essentially the most recent case being in early 2023. But in January, she saw an EVALI patient in an outpatient clinic for the primary time. The person had not been hospitalized, as most were before the pandemic. And like most treated throughout the pandemic, this patient had milder symptoms and didn’t require intubation or take-home oxygen.
In 2019 and early 2020, many EVALI patients who were ultimately hospitalized initially sought assist in emergency centers or from general practitioners and were sent home with suspected pneumonia or gastrointestinal inflammation.
“But their condition worsened and they came to our emergency room. Their chest X-rays and CT scans showed severe lung disease,” Rao said, adding that the damage was evident in all patients under 18. “They suffered from shortness of breath. Their oxygen levels were low. They had reduced lung function. And they had a lot of gastrointestinal problems like abdominal pain and weight loss due to nausea and vomiting.”
The effects of EVALI are different from cigarette smoking, says Karen M. Wilson, MD, MPH, a pediatrician on the University of Rochester Medical Center in New York and a tobacco researcher. “Normal inhalation of smoke or aerosols can cause microvascular changes, but macrovascular changes like those seen in EVALI.”
In late 2019, CT scans of patients with EVALI were released, catching the eye of Dr. Arun Kannappan, an assistant professor of pulmonary sciences and significant care medicine on the University of Colorado Anschutz School of Medicine in Aurora. Kannappan knew that a patient with such severe lung damage could develop acute respiratory distress syndrome, meaning the patient would should be placed on a ventilator because their inflamed lungs cannot supply the blood with oxygen.
“That means a 30 to 50 percent risk of death. That's what prompted all pulmonologists to make sure we keep an eye on it,” Kannappan said.
CT scans of the lungs proved to be a very important diagnostic tool for doctors. Most images of patients showed acute inflammation and diffuse lung damage. Ehab Ali, MD, a critical care and lung disease specialist in Louisville, KY, said the damage was often spread across each lungs and appeared cloudy and blurry, generally known as “ground glass.” COVID, however, appeared in a different way on lung scans, often with damage that was more isolated.
However, many diseases have a “frosted glass” appearance and might have many causes, corresponding to infections, cigarette smoke or an autoimmune disease.
“Before you even talk to the patient, you may immediately think, 'I'm going to ask this patient if he or she vapes,' when I see the distribution of the frosted glass image,” Ali said.
Ali said other aspects, corresponding to the patient's age — about three-quarters of EVALI patients are under 34, in keeping with the CDC — would prompt him to ask about vaping. But because so many patients were young, it wasn't at all times easy to seek out out in the event that they were vaping.
“If you talk to teenagers and ask them on admission while the parents are in the room, they will say 'no,'” said Dr. Rachel Boykan, a pediatrician at Stony Brook Children's in Stony Brook, N.Y. She added that her hospital remains to be seeing cases.
Rao said it is commonly crucial for 2 or three people to ask a patient about his or her e-cigarette use before she or he makes a confession.
Bernal, who was 27 on the time of her admission for EVALI, said she bought vapes containing THC at a retail store in California. She was a standard marijuana smoker and used the leaf product, but switched when someone told her it was healthier to vape THC than inhale smoke from burnt marijuana leaves into her lungs. “I thought it was safe.”
Rao and her colleagues recently published a study of 41 adolescent patients with EVALI treated at Children's Medical Center Dallas between December 2018 and July 2021. All but one reported using e-cigarettes containing THC, and the CDC reported in its most up-to-date report in February 2020 that about 80% of patients had used e-cigarettes containing THC.
The CDC also found that vitamin E acetate was present in many, though not all, lungs of EVALI patients. Vitamin E acetate is an oily substance that enables THC to travel quickly from the lungs to the brain and is utilized in the food and cosmetic industries.
The consequences
The outcomes of the hundreds of patients who’ve had and should still be affected by EVALI are largely untracked.
Bonnie Halpern-Felsher, PhD, director of the Stanford Reach Lab and a researcher on youth tobacco use, said she and lots of of her colleagues are frustrated that the CDC is not any longer collecting data on EVALI.
“I know a lot of colleagues who have said they're still seeing EVALI, but because of COVID-19 they've stopped collecting the data, and that's very frustrating because it's hard to say whether the type of lung problems you're having are related to e-cigarettes in general or related to EVALI,” Halpern-Felsher said.
Researchers and physicians from the American Thoracic Society in January published a report with solutions on how EVALI could be higher tracked. They really helpful the establishment of a national case register and a biobank.
Doctors also fear that many cases have been missed. Boykan said that while protocol requires nurses and other health care providers to ask a few history of vaping, which is a very important a part of EVALI diagnosis, many didn’t. Ali said EVALI symptoms corresponding to nausea, cough and fever are linked to viral infections.
Rao also said the treatment regimen at Children's, which included high-dose intravenous steroids, looked as if it would help, but the most effective treatment approach or long-term follow-up has not been studied.
The report in Annals of the American Thoracic Society Studies have shown that many EVALI patients suffer from persistent respiratory problems in addition to cognitive and mood disorders. Rao said a lot of her EVALI patients suffered from significant stress in school or within the family, which led them to vaping to alleviate the stress.
That was definitely the case for Bernal before she was admitted to the hospital. She had recently moved across the country for her husband's job, tried to purchase a house, and spent months in a hotel together with her three children. She was vaping to manage.
But she said her mental and cognitive state had worsened. Back in Louisville, she went to see a neurologist who told her her brain had shrunk, she said. In Portland, Oregon, where her family moved a yr after the EVALI incident, she hasn't found a brand new neurologist.
But she often feels overwhelmed and overstimulated by tasks she never had trouble with before. She tears up when she talks concerning the latest restrictions. She struggled to seek out a GP who could take care of her mental health and a therapist who could understand what she was going through with EVALI.
But “a lot of doctors aren't trained in this and don't know how to respond or what to do,” Bernal said. “And that makes me feel like what I had wasn't important.”
Bernal has a brand new pulmonologist and can soon be undergoing a series of lung tests because she often has trouble respiratory while doing easy tasks. She is uninterested in continually running to the emergency room. She wants answers or treatment that may help her feel normal again.
“I feel like it's my fault,” Bernal said. “If I hadn't smoked, I'd be fine, and it's hard to live with it every day and tell yourself, 'It's your fault.' How many years has it been now? And I still haven't found peace. I don't know if I ever will.”