5 Things We Still Don’t Know About Those Vaping-Related Hospitalizations

Sarah Jacoby

Update:

Health officials seem to be getting closer to figuring out the root cause of the vaping-related lung illness and hospitalizations. In a report from the Centers for Disease Control (CDC) published on Friday, researchers revealed the results of an analysis of lung health data from 29 patients across 10 states. Their results showed that vitamin E acetate—an oil that can be dangerous when inhaled—was present in all 29 samples, leading officials to conclude that vitamin E acetate is likely a “very strong culprit” in the outbreak.

Previous testing revealed the presence of vitamin E acetate in illegal vape cartridges containing THC. So finding it in these patients’ lungs is not entirely surprising. These findings also don’t completely solve the mystery because they don’t conclusively show that vitamin E acetate caused the symptoms these—or any—patients have been dealing with. Of course, it’s possible that more than one compound could be responsible for the illness, the report says.

But it is another important piece of the puzzle and bolsters the argument that illicit THC-containing vapes are likely the culprit here, not necessarily nicotine e-cigarettes.

Update (September 6, 2019):

Today, officials from the CDC and other health agencies confirmed that there have been 215 confirmed cases and as many as 450 possible cases in 33 states that could be linked to the recent outbreak of vaping-related hospitalizations. Additionally, the CDC confirmed there have been three deaths associated with the outbreak of mysterious lung illnesses and one other death is currently being investigated to see if it’s related.

It’s still not clear exactly what’s causing these illnesses, but the Food and Drug Administration (FDA) has been testing samples from vaping devices that patients reported using. So far they’ve found the presence of vitamin E acetate, an oil derivative of vitamin E that can be dangerous to the lungs, in 10 out of 18 samples of THC-containing vape cartridges, the Washington Post reports. But, again, there is no clear cause that all cases have in common. And officials say they are not ruling out a potential issue with nicotine vape cartridges.

For now, the CDC recommends that anyone who vapes anything (including nicotine and THC products) should seriously consider not vaping for the time being. If you do use them, it’s important to monitor yourself for any symptoms that could turn into a serious lung illness, including shortness of breath, coughing, chest pain, nausea, and fever.

Continue to our original story below to learn more about the outbreak and what experts think may be going on.

Original report (August 28, 2019):

With the news that health officials are now looking into nearly 200 cases of vaping-related hospitalizations (including one death), it’s understandable that anyone who vapes would be at least a little on edge. But the truth is that we are still just beginning to put the facts of these cases together—and there are a ton of pieces missing.

What do we know? Well, we know that the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) are now investigating 193 confirmed cases of lung illnesses. All of the cases were reported between June 28 and August 20 of this year and occurred across the country in 22 states. Although no one has identified the cause of these symptoms, all the patients have a reported history of vaping, so that’s where the investigative focus has been so far.

But there’s still a lot to be uncovered. Below, we spoke to a few experts about the news and why this is such a challenging medical mystery to figure out.

1. We still don’t know the root cause—or causes—of the symptoms.

The main symptoms that patients in these cases have presented with include coughing, a shortness of breath, trouble breathing, and fatigue, which are unfortunately pretty common symptoms to see in the E.R., Enid Rose Neptune, M.D., pulmonologist and associate professor of medicine at Johns Hopkins University School of Medicine, tells SELF.

In most situations, doctors can reconstruct what the likely cause of those symptoms is, she says. “But the challenge with the cases that have come up with vaping is that the inciting injury is really unclear.”

Although vaping seems to be the common factor among all the cases, it’s not clear exactly how vaping is involved—or even if it is for sure the cause. And as the CDC points out, even if the symptoms are very similar between patients, we don’t know if they’re symptoms of exactly the same condition. So we could be dealing with a few similar conditions rather than just one.

2. What was actually in those vapes, anyway?

The CDC says that no one product—vape or cartridge or filling—has been implicated in all the cases. But one issue that keeps coming up is that vaping could mean a lot of different things, Mallory Loflin, Ph.D., a researcher at University of California San Diego who has studied cannabis vaporizers, tells SELF.

Although it seems like most are assuming that vaping here means using e-cigarettes, the CDC says that many patients have reported using products containing tetrahydrocannabinol (THC), a major compound in cannabis. That could mean using vaporizers that take a liquid cannabis extract or the actual plant material, but Loflin says that she and her colleagues have sort of assumed that if cannabis vapes are to blame, they are likely to be the vapes that take liquid. “We’ve been concerned about those for a while,” she says, and we know that they don’t always contain what they claim.

“We did a study a couple years ago where we tested all the CBD products on the market to see if they were accurately labeled,” Loflin says. Her team looked at oils, tinctures, and vape liquids containing CBD (another major cannabinoid) and found that the liquids were the most inaccurate—”by a lot,” she says, meaning that they didn’t contain the amount of cannabinoids the product labels said they did.

“It makes you think twice about how those are being produced and makes you raise your eyebrows at the companies producing them,” Loflin says. However, she also notes that she and a few other colleagues have all assumed that the cannabis vapes implicated in these cases are not those that use the actual plant material (to be clear, this is a guess, not a fact—something else we still don’t actually know).

Even within the category of e-cigarettes, there’s a ton of variation, Dr. Neptune says. “We’re now on the third or fourth or fifth incarnation of these devices,” and we don’t know how exactly they’re composed, how they’re heated, or what the exact effects are of delivering these heated ingredients to the lungs.

Essentially an e-cigarette contains a liquid solvent (such as propylene glycol or vegetable glycerin), nicotine, and some sort of flavoring, Humberto Choi, M.D., a pulmonologist and critical care specialist at Cleveland Clinic, tells SELF. But because the FDA hasn’t identified the exact products patients were using, we don’t know exactly what ingredients they contained. Plus the fact that many vapes allow consumers to mix or refill their own e-liquids adds another level of risk and complexity.

And we don’t know much about the potential toxicity of the ingredients that could be in there, Dr. Neptune says. For the most part what we know about the flavorings in e-cigarettes comes from studies in which those ingredients are ingested. “So we have no idea what happens when these flavorings are heated and then delivered to the lungs,” Dr. Neptune says.

One thing we do know about is diacetyl, a chemical used to give foods a buttery flavor. Back in 2002, health officials in Missouri contacted the CDC to investigate a mysterious outbreak of a rare obstructive lung illness called broncholiolitis obliterans (sometimes called “popcorn lung”), which stemmed from a microwave popcorn factory. At the factory, officials noted that “soybean oil, salt, and flavorings are mixed into a large heated tank in a process that produces visible dust, aerosols, and vapors with a strong buttery odor.” They concluded that the workers with lung issues had been repeatedly exposed to high amounts of diacetyl in the air, which likely caused their symptoms.

Today there are specific recommendations for workers in environments where they might breathe in flavorings such as diacetyl. But the truth is that we don’t have much data for the respiratory effects of most chemical flavorings.

Unfortunately, research has shown that many e-cigarettes contain diacetyl and other flavorings that could have ill effects on the lungs if inhaled in large enough amounts. The effects of inhaling those chemicals at the levels in vapes isn’t clear, but these are exactly the kind of findings that make experts nervous: “Lungs were made to breathe clean air,” Dr. Choi says. “When we inhale anything that is not that, we should expect a problem.”

3. Are the symptoms confined to the lungs? And if so, what part of the lungs?

“When you inhale a heated vapor, much of it lands in the upper airway (in the back of the throat through the voice box and into the trachea),” Dr. Neptune explains. “But then a significant amount, depending on the size of the vapor droplets, will wind up in the more distal portions—the nether regions—of the lungs where we have these very delicate structures called alveoli.”

When the alveoli are injured—as they have been in some of the vaping-related cases—that can lead to conditions like acute respiratory distress syndrome (in which fluids build up in the alveoli) and acute lung injury (in which inflammation in the area disrupts the way the lungs work). And unfortunately these diseases are usually challenging to treat and often require measures like mechanical ventilation, Dr. Neptune explains.

In fact, imaging tests like X-rays and CT scans are showing that these patients have signs of serious inflammation in their lungs, explains Dr. Choi. Although these conditions in and of themselves aren’t new, the association with vaping is: “We don’t have even a diagnostic code for it,” Dr. Choi says, which makes the spread of the cases more difficult to track.

One major question that investigators will have is whether the damage to the lungs is confined to the upper airway or if it reached those deeper parts of the lungs, Dr. Neptune says, which would require a much more serious level of treatment.

But another issue—one that’s “probably the most critical in trying to pull the whole situation together,” Dr. Neptune says—is knowing whether or not any other major organs are affected. If they are, that would suggest a more systemic issue, like an infection possibly due to some sort of contamination rather than just an injury to the lungs. So far, though, an infectious disease does not seem to be the issue, the CDC says.

4. How many cases are there, really?

A history of vaping isn’t necessarily something that doctors ask about when they talk to a patient, so it’s possible that previous cases could have been missed if hospital staff didn’t think to connect it to vaping.

“We may have an incredibly higher number of similar cases that might be related to vaping, [but] we simply don’t have that information on the charts when they’re admitted to the hospital or transferred to an ICU,” Dr. Neptune says. “That is the unknown factor here.”

It’s also possible that the cases doctors are seeing in emergency rooms are only the most severe, while those who have milder symptoms may not seek medical attention and would, therefore, be overlooked, Dr. Choi says. “There’s probably a spectrum of lung problems that vaping can cause,” he explains, which could range from a mild cough to shortness of breath to breathing issues so severe that they require mechanical ventilation.

So the actual number of cases out there could be higher than what the CDC has confirmed so far.

5. Is there something else all of these patients have in common?

Considering how challenging it is to pinpoint the specific role that vaping may have played in these illnesses (and how common vaping is in general), it’s worth wondering if maybe there’s something else that these patients have in common that’s more directly the cause of their symptoms.

“We don’t know what it means to say it’s ‘associated with vaping’ because that could mean so many different things,” Dr. Neptune says. “It could mean some commonality in terms of an ingredient that they’re all using, it could mean that the device is delivering different substances with a certain heating pattern or delivery pattern that makes it especially harmful to the lungs, it could mean these are all people who have some other commonality that hasn’t yet been determined.”

So far most of the patients seem to be young adults without any other major health issues, Dr. Choi says. “If there’s any inherent factor related to them that makes them a higher risk [for severe symptoms], I don’t think that’s clear yet.” That’s why it’s so important for hospital staff to report any possible cases to the CDC, he says, noting that he’s reported a few potential cases himself.

The bottom line: Experts have been waiting for some sort of vaping-related issue like this.

And none of the experts we spoke to were surprised to see these cases. “We’re looking at a series of cases that were to some extent entirely predictable,” Dr. Neptune says.

“I don’t think anyone in the medical field is surprised with what’s going on,” Dr. Choi agrees. “The number of people—especially teenagers and young adults—who are vaping is so high that it was just a matter of time before we saw some short-term complications from [vaping].”

But at the same time, the way these cases were discovered and tracked is a great example of how public health is supposed to work. “The fact that they were able to tie these cases together with the fact that they vaped but they vaped different things is a really important finding,” Dr. Neptune says, “because it tells us what we don’t know about this vaping epidemic and why we’re so far behind the ball.”

Finally, as officials continue to investigate these cases, the experts we spoke to say that we need better regulations about how e-cigarettes are made and how they process liquid ingredients, not just how they’re sold and marketed. And tighter regulations around cannabis-related vapes—especially those containing CBD—would be welcome too.

“What the public has to do is demand that as long as these things are available and on the market, we need to get them regulated,” Dr. Neptune says. “We don’t have time to just wait and see what the next medical emergency is—right now is the emergency situation.”

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Originally Appeared on SELF