What You Need to Know about Vape-Associated Pulmonary Illness (VAPI)

Massachusetts made headlines in late September when the state announced a four-month ban on the sale of all THC and nicotine vape products. The Department of Public Health (DPH) noticed a drastic increase in the number of suspected vape-associated pulmonary illness (VAPI) cases seen in the state, prompting Governor Charlie Baker to take action.

On September 11, the DPH made it mandatory for physicians to report cases of suspected “vaping-related disease” to the state. Since then, more than 150 cases have been reported.

Of those, 10 cases have been confirmed to be related to vaping, and on October 7, the DPH announced the first vape-related death in the state.

With so many sensational headlines and so much speculation being thrown around, it’s important to separate what we know from what we don’t know.

Vape-associated pulmonary illness is not an infection

If you were to ask the average person to name a lung illness, you’d probably get an answer like bronchitis or pneumonia, both of which are infections. VAPI may even resemble an infection in terms of symptoms (fever, cough), laboratory studies (elevated white cell count), and on x-rays.

However, while the etiology of VAPI is not yet known, it does not appear to be infection mediated. So…what are these injuries?

The clinical term for them is inflammatory non-infections. This means that the lungs are inflamed, but not due to bacteria or a virus.

The difference may seem minor, but it’s an important distinction when it comes to treatment: for the most part, VAPI is being treated with steroids, not antibiotics.

There’s no clear pattern among the cases

In trying to determine what’s causing these illnesses, the Centers for Disease Control (CDC) is attempting to find a link between the cases. If, for example, cases could be traced back to a single brand of e-cigarette, type of device, or cartridge it would make discovering a cause much easier.

However, there’s currently no clear, common thread between the various VAPI cases being seen in states across the country.

Furthermore, in patients with VAPI who have had lung biopsies, the patterns of lung injury can differ, raising the question of whether there is a single or multiple different substances causing the damage.

Thus far, researchers haven’t been able to zero in on specific vape brands, flavors, or countries of origin as being the cause. While it’s true that the majority of the cases reviewed and confirmed by the CDC have stemmed from using THC vape products, a percentage of patients with confirmed cases of VAPI have reported vaping nicotine exclusively.

Identifying the root cause of cases of VAPI will be a key step in figuring out how to prevent them. As a result, the CDC is looking into the illnesses on a larger scale, and will continue to work toward determining the cause.

The patient population is diverse

As of October 17, the CDC reported that it had received reports of potential VAPI from all but one state, totaling more than 1,400 cases. With a patient population that large, it makes sense to try to identify demographic trends to see if any one group is being disproportionately impacted.

However, there has been no clear link between age, gender, or other demographic factors and the development of VAPI.

As a group, vape users tend to be younger and male, so it makes sense that a large number of the reported cases fall into those categories — according to the CDC, 80% of the patients with confirmed VAPI are under the age of 35, and 70% are male.

But it’s worth noting that people of all walks of life have been affected by the illness, from young women in high school to men beyond retirement age.

Vape-associated pulmonary illness is a serious condition

Unfortunately, the CDC reported 33 deaths from VAPI as of mid-October. That statistic is a sobering reminder that these lung injuries are to be taken extremely seriously.

Most of the confirmed cases have required hospitalization, and many have ended up in the ICU. Approximately one-third of the cases have been severe enough to require intubation.

More research is needed to determine the next steps

Until the CDC can determine the root cause of these illnesses, it will continue to gather data from cases reported by individual states.

The increased awareness of VAPI could lead to an increase in the number of cases reported to the CDC, which could in turn help identify trends more quickly.

Once the CDC is able to determine what, specifically, is causing these lung injuries, further legislative or regulatory steps may be taken.

What can the public do now?

In a recent Interim Guidance update for managing VAPI, the CDC reiterated several recommendations for the public at large, which are summarized below:

1. E-cigarettes or vaping products should never be used by youths, young adults, or pregnant women.
2. Since THC-containing products have been linked to many cases, particularly those obtained from informal sources, the CDC recommends that persons should not use vaping products containing THC.
3. Since some cases have been reported in nicotine-only use, the CDC continues to recommend that persons consider refraining from vaping products containing nicotine.
4. If individuals have used vaping products to quit cigarette smoking, they should not return to smoking cigarettes, but rather seek out well-established treatments, including behavioral counseling and FDA-approved medications.
5. Persons who continue to use these products should carefully monitor themselves for symptoms, including fever, cough, vomiting, diarrhea, chest pain, and shortness of breath. Should any of those symptoms develop, they should see a healthcare provider.

Dr. Frank Schembri is a Staff Physician, Intensive Care and Pulmonology, at South Shore Hospital, and Adjunct Assistant Professor of Medicine at Boston University School of Medicine.