Clinician Alert: respiratory illness associated with vaping

September 20, 2019

Federal, state and local health officials continue to work together to identify the risk factors for a multi-state outbreak of severe respiratory illness associated with vaping. Cases were first reported in April 2019. 

As of September 19, CDC reported 530 cases from 38 states and 1 territory, including 7 deaths. In Oregon, there have been 4 cases, including one death.

Patients have presented with respiratory symptoms including shortness of breath, cough, and pleuritic chest pain. Other patients present with symptoms including fatigue, fever, nausea, and diarrhea, and worsening respiratory status. 

All confirmed cases have required hospitalization, and some have required mechanical ventilation. The condition is not thought to be caused by an infection. Symptoms have not improved with antibiotics, but many cases have responded well to corticosteroids.

All cases have reported vaping, and many have reported vaping cannabis products, including THC and CBD oils. However, no single product or additive has been associated with these illnesses and both nicotine and cannabis products have been involved. 

Information for all clinicians

Recommendations for those who care for patients with severe lung disease

  1. Report to Oregon Health Authority Public Health Division (971-673-1111, option 3) immediately any case of illness meeting ALL of the following criteria

    • Hospitalized patient AND

    • History of vaping of any substance in the preceding 90 days AND

    • Radiographic finding of pulmonary infiltrates (opacities on chest x-ray or ground-glass appearance on chest CT)

    • OHA is collecting leftover used vaping products and devices from patients who are willing to turn them over for FDA testing. OHA will coordinate pickup and transfer of products for FDA testing.

  2. If you see cases of severe pulmonary illness without an alternate explanation, please ask about vaping of any substance in the 90 days before illness onset

  3. If e-cigarette or vaping product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain a detailed history regarding:

    • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances

    • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids

    • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)

    • Where the product(s) were purchased

    • Method of substance use: aerosolization, dabbing, or dripping

    • Other potential cases: sharing e-cigarette products (devices, liquids, refill pods, or cartridges) with others

  4. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and of e-cigarette product use. Evaluate and treat for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as appropriate.

  5. Clinical improvement of patients with severe pulmonary disease associated with e-cigarette use has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.

  6. Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.

  7. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during a pathologic examination and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.

  8. Patients who have received treatment for severe pulmonary disease related to e-cigarette or vaping product use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.

Health Warning — Avoid Vaping (English) (609.52 KB)

Health Warning — Avoid Vaping (Spanish) (620.2 KB)

Paul Lewis, MD, ​​Tri-County Health Officer

Christina Baumann, MD, Washington County Health Officer

Sarah Present, MD, MPH, Clackamas County Health Officer

Jennifer Vines, MD, MPH, Deputy Multnomah County Health Officer