Latest Guidance on Vaping Distress Syndrome

Ingrid Hein

February 21, 2020

Some people who vape become critically ill, but there is currently no way to tell who is at highest risk for vaping-associated respiratory distress syndrome (VARDS), critical care experts say.

"Our contribution is to give critical care clinicians the tools they need to identify, triage, treat, and monitor patients exposed to vaping in a practical, achievable way," said Craig Lilly, MD, from the University of Massachusetts Medical School in Worcester.

He presented step-by-step guidance to help critical care professionals identify and care for affected patients during the late-breaker session at the Society of Critical Care Medicine 2020 Critical Care Congress in Orlando. The protocol, developed by the UMass Memorial Medical Center VARDS task force, was also published in Critical Care Explorations.

"This is a transition document," Lilly told Medscape Medical News. "There isn't enough evidence to create clinical guidelines."

Other reports have focused on how specific single cases were handled, but the protocol is based on opinion and real-world experience, he explained.

Three Steps to Stratify Patients

With the three-step protocol, clinicians can stratify patients into one of three groups.

Step 1: Define Vaping Exposure

The first step is to find out if your patient has had exposure in the past 90 days. And know the lingo," Lilly advised. Ask patients if they "vape, JUUL, dab, or drip."

You need to create a trusting environment to determine if a patient has been exposed. "Your clinical skills matter; taking the time to sit down and talk to people is important," he added.

Step 2: Determine if a Patient Has Symptoms

Once exposure is established, the second step is to look for respiratory-related symptoms. "Look for clinical clues; if patients complain that it's hard to swallow, they are nauseous, that's a sign it's from vaping and not the flu."

Clinical judgment is needed to determine if a symptom is caused by vaping, Lilly explained. Use standard clinical questioning: "Did the vaping come first or shortness of breath?" Is there some plausible cause other than vaping?"

If a patient has recently been exposed to vaping fumes and symptoms are not attributable to other causes, order chest imaging and screening oximetry.

Saturation of arterial blood should be at least 95%, or similar to the patient's baseline oxygen level. "Walk the patient. If, with a short walk, the oxygen goes below 88%, it's an indication that oxygen is not normal," he said.

Use information gathered about infiltrates, vaping-associated symptoms, and oxygen saturation levels to triage patients into one of the three groups defined in the Worcester Vaping Clinical Classification System, the protocol recommends.

Group 1 involves patients who do not have VARDS symptoms, group 2 involves patients who have symptoms, and group 3 involves patients whose pulse oximetry test is abnormal.

"We offer this classification scheme as a clinically actionable expert-opinion-based starting point for validation studies," Lilly said.

Step 3: Evaluation and Monitoring

Patients in group 1 should be asked if they are interested in help with quitting. If they are, they should be referred to a nicotine- or THC-focused addiction medicine program.

Patients in group 2 should have a chest x-ray and noninvasive pulse oximetry test to determine if their blood oxygen levels are normal (that is, 95% at rest or 88% during exercise). If the results are normal, these patients can be evaluated and managed on an outpatient basis.

"They should be advised to cut out the vaping," Lilly added. And hypoxic patients with normal pulmonary imaging studies should be evaluated for alternative explanations; "pulmonary or fat embolism should be considered." Those whose x-rays are abnormal are at higher risk for respiratory failure.

Patients in group 3, with low oxygen levels, are at high risk for respiratory failure and should be monitored in an inpatient unit, he explained. "Patients with abnormal x-rays should be evaluated for infectious causes, including influenza."

All the recommendations outlined in the protocol are consistent with the e-cigarette or vaping product use-associated lung injury (EVALI) case definition developed by the Centers for Disease Control and Prevention. These include symptoms of cough, chest pain, weight loss, fatigue, and dyspnea of any severity not explained by other conditions.

Epidemic Slow Down

"It's a relief that the vaping epidemic we thought we might face has not materialized," Lilly said. Most practicing physicians likely won't even see a case a year, so it's becoming even more important to know when to order an x-ray and to identify patients at risk.

But "we still see people coming in with vaping-related illnesses," he reported. "It's a low-frequency, high-impact event. It requires vigilance."

Vitamin E and other contaminants are now known to increase the risk for lung injury, but that "doesn't explain all the cases," he said. "We're finding other things — such as allergic reaction and lung inflammation possibly caused by heavy metals in vaping devices — that also can cause lung injury. Ultimately, no form of vaping is safe."

We will continue to see cases, even with commercial-grade products, he predicted. New outbreaks will emerge and we will continue to learn about vaping practices. "This is going to be an uncommon but important-to-recognize cause of respiratory failure," he said.

In January, he treated two VARDS patients who became critically ill. "We need better vigilance and screening," Lilly said.

It's a low-frequency, high-impact event. It requires vigilance.

"In the handful of patients I've treated, some did not answer questions in a truthful way," said Steven Greenberg, MD, from Northshore University Health Systems in Chicago.

"That can lead to personal and professional negative outcomes," he told Medscape Medical News. Patients can be guarded when asked to talk about vaping, worried about insurance or other penalization. "They have to feel comfortable divulging and not have punishment-associated repercussions. We need a way to safeguard them from outside punishment, like increased insurance rates."

Health providers need to share information so that VARDS is better understood. This will help identify illicit forms of solvents, which is how the Drug Enforcement Administration has slowed the epidemic. "That never would have happened without public-health groups getting info from providers," he pointed out.

The protocol Lilly presented is "extensive and thorough," said Greenberg. "It shows us how we should look at these patients in terms of stratification, the next steps for their diagnosis, care, and follow-up."

Clinical providers who manage these patients can take a deep breath because they now have some guidance on what to do "when the next wave comes through," he pointed out.

However, "the actual treatment is still very much up in the air," he acknowledged.

The protocol "refers to eosinophilic pneumonia, hypersensitivity pneumonia, and lipoid pneumonia. Patients may benefit from steroids, but we don't know dose duration," he explained.

On the front line, steroids are given empirically. But "would the patients have gotten better without them? Later or sooner? With a higher or lower dose? That has to be clarified," Greenberg said. "There's more to be done, but it's great that this first document has come out."

Crit Care Explor. 2020;2:e0081. Full text

Society of Critical Care Medicine (SCCM) 2020 Critical Care Congress. Presented February 16, 2020.

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