VAPING. LET’S CLEAR THE AIR...• Current cigarette smokers, 10.8% usage • Former smokers, 4.8% usage • Never smokers,

VAPING. LET’S CLEAR THE AIR

• Jan Lester C Pring, DO

• Pulmonary and Critical Care Medicine

• Las Vegas, Nevada

• NOMA Winter Symposium 2020

DISCLAIMER

• I do not represent a pharmaceutical or medical device company

• There is no financial obligations attached today’s lecture

• Any specific mention of medications, devices, commercial products is done for the sole purpose of education and does not imply advertisement

• I would like to express my gratitude to Bruce Fong, DO and the Nevada Osteopathic Medical Association for the invitation to speak today

• Views expressed during this presentation are those of the speaker and may not represent those of the Nevada Osteopathic Medical Association

JAN LESTER C PRING

• Touro University College of Osteopathic Medicine, Class of 2007

• Valley Hospital Medical Center, Las Vegas, NV. Internal Medicine Internship/Residency, 2007-2010.

• Valley Hospital Medical Center, Las Vegas, NV. Pulmonary and Critical Care Medicine Fellowship, 2010-2013.

• Pulmonary Associates of Las Vegas, 2013-Current

• Spring Valley Hospital Medical Center

• Speaker for Nevada Osteopathic Medical Association, American Lung Association, various Graduate Medical Education Programs

ELECTRONIC CIGARRETES

• Remember those bubble gum cigarettes?

TERMINOLOGY

• Electronic cigarettes

• Vapes/Vaping

• Electronic hookahs

• Dipping

• Dabbing

ELECTRONIC CIGARETTES

• Electronic Nicotine Delivery System (ENDS)

• Liquid-containing nicotine + Atomizer + Battery

• Atomizer is activated by direct inhalation or button activation

• VAPING

• Once activated, the atomizer heats and aerosolizes liquid that creates a vapor that emulates tobacco smoke BUT is not tobacco smoke.

• DRIPPING

• Few drops of liquid nicotine are dripped directly on atomizer’s heating element creatine a vapor that is inhaled


• Created in 2003 by pharmacy company in China, Hon Lik, in attempt to offer alternative to conventional tobacco use

• Since 2011, significant increase in prevalence in US

• Electronic cigarette sales surpassed tobacco cigarette sales in 2016


• In 2016, 15% of adults HAVE used e-cigarettes. Current use 3.2%

• Current cigarette smokers, 10.8% usage

• Former smokers, 4.8% usage

• Never smokers, <1% usage

• In 2018, current use among high school students is 21%

• UP from 12% in 2017

• 5% of middle school user report use

• Reported increase between 2011-2018 was greater than the increase in use of any other tobacco products

2016 National Health Interview SurveyCullen KA et al. Notes from the field. Use of electronic

cigarettes and any tobacco product among middle and high school students. MMWR Morb Moratal Wkly Report 2018


• NICOTINE

• Variable (None to 36mg/ml)

• Average traditional cigarette has 8-20mg

• Inconsistency in level of nicotine and manufacturer’s label

• Nicotine-free cartridges have been found to have nicotine

• PROPYLENE GLYCOL

• Hydrophilic moisturizer

• Some use Ethylene glycol

• Tetrahydrocannabinnol (THC), Cannabinoid (CBD), Hash Oil

• Dissolved in oils or solvent

• FLAVORING

• 7000 flavors.

• There is a flavor out there for you. (Sorry, I had to add this)

Cheng T. Chemical evaluation of electronic cigarettes. Tobacco Control. 2014


• E-cigarette users

• Younger

• More educated

• Higher incomes

• Generally non-daily users

• Most e-cigarette users are traditional cigarette smokers

• Perception is that this is a tool to quit conventional cigarettes or reduce their risk for tobacco-related disease

• Male predominance

• White > Nonwhites

Berg CJ et al. Cigarette users interest in using or switching to ENDS: a cross sectional survey of American adults. Nicotine

Tobacco Res 2015


• Battery sends a current to liquid-soaked wick

• This wick is wrapped around a coil

• When activated, coil heats up which heats liquid to vapor

• Vapor is inhaled and puffed



• Looks very nondescript

• Almost like thumb drives

CASE PRESENTATION

• 25-year old male with no significant medical history presented to Las Vegas hospital following a 1-day history of acute, rapidly progressing shortness of breath with associated altered mental status. On arrival to emergency department, noted respiratory distress while on nonrebreather oxygen mask with SpO2 86%, respiratory rate 30, heart rate 130, afebrile. He was confused and agitated, pulling at mask. Tachycardic rate with regular rhythm. Lungs with mild crackles and decreased breath sounds. No accessory muscles in use. Laboratory studies demonstrated WBC 18, Hb 13, Plts 370. Lactic acid 17. BNP 26. Troponin < 0.005. Urine toxicology was negative for abused drugs. Influenza A/B PCR was negative.

CASE PRESENTATION

• Intubated on arrival to emergency department.

• Chest X-ray demonstrated bilateral infiltrates

• Initial ABG on Pressure Control mechanical ventilation

• pH 7.28, PaCO2 52, PaO2 46, HCO3 24, SpO2 75%

• Add PEEP


• Transition to APRV (airway pressure release ventilation)


• FINALLY!!!

CASE PRESENTATIONEmpiric antibiotics

Solumedrol

Bronchodilators

Enteral nutrition

Sedation

Paralytics

Blood, Urine, Sputum cultures all negative

CASE PRESENTATION

• After 36-hours of trying to not allow this young man to die, we obtained additional history. He is very capable male currently in design school for fashion. No occupation exposures reported. He completed his last project involving nylon fabric 2-months prior. Family did confirm that he has been vaping since 2014. He vapes marijuana and nicotine flavors. They state that he does not share devices.

CASE PRESENTATION

• He was extubated on hospital day 4. After extensive physical and occupation therapy, he was discharged home after a 7-day hospital course.

• I am still waiting for him to follow up

VAPING INDUCED LUNG INJURY

• Per CDC guidelines

• Confirmed Case

• Use of an electronic cigarette 90 days prior to symptom onset

• Pulmonary infiltrates on chest X-Ray or ground glass opacities on CT Chest

• Absence of pulmonary infection on clinical work up

• Negative sputum, influenza, other viral syndromes

• No other probable diagnosis

• Probable Case

• Use of an electronic cigarette 90 days prior to symptom onset

• Pulmonary infiltrates on chest X-Ray or ground glass opacities on CT Chest

• Presence of pulmonary infection on clinical work up

• But infection cannot be sole reason for clinical presentation

• No other probable diagnosis


• As of October 1, 2019, 1,080 lung injury cases associated with e-cigarettes or vaping products reported to CDC

• 18 deaths have been confirmed

• There is historical connection to THC-containing products

• 70% are male

• 80% are under 35-years old. Average age is 23 years old (13-75)

• 16% are under 18-years old

• 21% are between 18-20-years old

VITAMIN E ACETATE

• Presumed etiology for vaping-induced lung injury

• Lipophilic oil

• Traditionally is an antioxidant used for creams or lotions

• Serves as a thickening agent in conjunction with THC products

• This substance was found in BAL samples from affected patients

VITAMIN E ACETATE

• Mechanism of action of injury

• Direct endothelial injury

• Coats respiratory surfactant or destabilizes surfactant

• LIKELY

• Initiate immune response, similar to pathophysiology of lipoid pneumonia• NO

• This has been disproven by open lung biopsies


• Vadavas CI et al. Short term Pulmonary Effects od Using an Electronic Cigarette. CHEST June 2012. Vol 141. Issue 6. Page 1400

• 30 smokers vs 10 control individuals

• Immediate decrease in FENO, decreased in airway impedence,

• OVERALL increase in peripheral airway resistance

• Qasim H et al. Impact of Electronic Cigarettes on Cardiovascular System. Journal of American Heart Association. September 2017

• Many journals have editorials indicating the need for more studies. I the coming years, more information regarding effects of e-cigarettes will be available


• 2014 Eurobaromter study

• Negative effect on smoking cessation

• Rigotti NA et al. Annals of Internal Medicine 2018

• Associated with less tobacco abstinence in hospital discharged patients

• Bhatnagar A et al. Journal of American Heart Association June 2019

• Unclear evidence of any effectiveness

• Walker N et al. Lancet Respiratory Medicine September 2019

• E-cigarettes + Patch IS effective but not much known on E-cigarettes alone

• Hajek P et al. New England Journal of Medicine February 2019

• E-cigarettes ARE effective at smoking cessation

RECOMMENDATIONS

• National Academies of Science, Engineering, and Medicine conclude there is ‘substantial evidence’ that if a youth/young adult uses an E-cigarette, they are at increased risk of using traditional cigarettes

• National Academies of Science, Engineering, and Medicine reported that using E-cigarettes causes health risk. E-cigarettes contain and emit a number of potentially toxic substances.

• The Food and Drug Administration has not found any E-cigarette to be safe and effective in helping smokers quit.

REGULATION

REGULATIONS

• September 2019, there was an announcement regarding a possible ban on electronic cigarettes in the US. Since that announcement, no progress has been made in passing any federal legislation. Remains a state regulated issue


• IT IS THE OPINION OF THIS PHYSICIAN THAT E-CIGARETTES ARE EXPOSING A YOUNGER POPULATION BASE TO THE ADDICTIVE QUALITY OF NICOTINE.

• PLEASE EDUCATE YOUR YOUNG ADULTS IN THE DANGERS OF E-CIGARETTES

MARIJUANAIS IT REALLY BAD FOR

YOU?

MARIJUANA

• 11 states have decriminalized marijuana use

• Alaska, California, Colorado, Illinois, Massachusetts, Michigan, Nevada, Oregon, Vermont, Washington

• 33 states have legalized medical marijuana use

MARIJUANA

• 2nd most commonly smoked substance worldwide

• Contains similar chemical properties and constituents as tobacco smoke

• Histologically, tissue from marijuana-exposed lungs are consistent with chronic bronchitis

• Causes similar mucosal injury pattern and airway inflammation

• No increase incidence of pneumonia

• Based on PFTs, noted increase in FVC in those who smoke marijuana

• Possibly due to marijuana users maintain inhalation for prolonged periods

• Less obstruction noted

• No direct evidence to suggest risk for lung cancer

Nobotny M et al. Journal of Chromatography. 1982

Roth MD et al. American Journal of Respiratory and Critical Care Medicine 1998.

MARIJUANA

• CARDIA TRIAL

• Began in 1985 in efforts to examine the development and determinants of clinical and subclinical cardiovascular disease and their risk factors

• Did not demonstrate substantial relationship with marijuana use and atherosclerosis.

• Noted improvements in FEV1 and FVC

• As exposure increased, this improvement in FEV1 and FVC began to level off.

• Study able to assess marijuana exposure and pulmonary function testing over a 20+ year span

MARIJUANA

• Accumulated weight of evidence implies far lower risks for pulmonary complications of regular marijuana use when compared to pulmonary complications of tobacco use

• No direct link to COPD/Emphysema

• No direct link to pneumothorax

• No direct link to lung cancer

• No direct link to pneumonia

• Unclear why marijuana smoking differs from tobacco smoking

Taskin D. Marijuana and Lung Disease. Chest Septemeber 2018

“Laughing is also good for your respiratory system.”

Allen Klein

Thank you for your time and attention

Documents

VAPING. LET’S CLEAR THE AIR...• Current cigarette smokers, 10.8% usage • Former smokers, 4.8% usage • Never smokers,