Vaping / E-Cigarette Lung Illness Diagnosis & Treatment


Okay so let’s sum up if you have a
patient that comes in with respiratory symptoms GI symptoms and constitutional
symptoms and respiratory symptoms remember is chest pain Disney on
exertion shortness of breath GI symptoms could be nausea vomiting or diarrhea
abdominal pain constitutional symptoms will be fevers night sweats or chills
and on x-ray the patient has infiltrates and on CT ground-glass opacification or
dense infiltrates bilaterally dependently and they vaped in the last
90 days then you’ve got to be thinking about this possible situation with the
epidemic that we’ve been talking about and then the question is is this
confirmed versus probable so what you really have to do at that point is
you’ve got to rule out pulmonary infection and the way you would do that
of course is by getting some of your lab tests that you would normally get you
want to get a respiratory viral panel these are panels where you can check for
very small amounts of the viral DNA in the patient’s nasal swab that’ll also
check for the influenza PCR this is particularly important if you’re looking
at cases between October and April because that’s when the flu is rampant
you also want to get a urine antigen for strep and a urine antigen for Legionella
also as we mentioned sputum cultures blood cultures also check for HIV
remember though it’s good to be a little bit problematic because your WBC is in
the study 87% of them had greater than 11,000 some of them were as high as
20,000 and there was definitely a neutrophil yet which would lead you to
believe that perhaps these patients actually have bacterial infections
what’s even more problematic is that the procalcitonin levels in these patients
on average were 0.58 and depending on where those tests are being done for the
most part anything less than 0.1 is negative so you’re going to have a
positive procalcitonin in a lot of these patients you’re gonna have neutrophilia
and your white counts going to be elevated and so you’re going to suspect
that this patients has a pneumonia so even if they do have a pneumonia but you
don’t feel like the patient’s pneumonia adequately explains the severity of
their illness you could consider that as a probable case but if all of this is
all negative and you have everything over here on the left hand side the CDC
and also for the intended purposes of the study considered this as a confirmed
case and now finally we come to treatment which is problematic because
we have no randomized control trials this is a new epidemic this is a new
problem we don’t know what’s really working here and so there are no
official guidelines and so this is an important point that I want to make is
that we really can’t have any recommendations and that was not the
purpose of this paper that was published in the New England Journal of Medicine
however they were able to see what treatments were used and also the fact
that only one person died in the study so that was about 2% of the study so in
looking over what they did for these patients and if you look at the study
you’ll see that of course supportive care is big right so the patient stops
vaping they stop using e-cigarettes and you support them during this process
with supplemental oxygen with sometimes even ventilators so they have to be
intubated and for those people who are mechanically ventilated it was seen in
some of the case studies in that report that they were treated as if they had a
RDS and because some of them actually met the criteria the Berlin criteria for
a RDS which is a severe a RDS which would be APF ratio of less than 100
moderate would be less than 200 and then mild would be less than 300 and so the
treatment in those situations would be low tidal volumes and so you’re looking
at starting out at 8 MLS per kilogram ideal body weight and then going down to
a target of 6 in some of these cases proning them I think there’s a study out
of France that showed that if the if ratio was less than 150 that the
patient benefited from proning also paralysis some studies have shown that
paralysis early on can improve in survival and so treating the patients
like we would normally treat them regardless of the cause is still
something that is worthwhile doing the interesting point though is what a lot
of people have been finding some success with although it’s anecdotal and again
let me reintroduce steroids and with high-dose steroids we’re talking for
instance solu-medrol 125 milligrams IV Q 6 or the usual dose that you might do in
someone with diffuse alveolar hemorrhage is up to one gram of solu-medrol a day
in which case it would be 250 milligrams IV q 6 the problem of course with giving
high-dose steroids indiscriminately is that you’ve got to really make sure and
be confident that the patient doesn’t have an overwhelming infection and that
is sometimes problematic in a patient who has a high white count and maybe has
a band amia or maybe has a neutrophilia so this is something that has to be
entertained with some thought before you just go rushing in there with high-dose
steroids nevertheless these patients who did well we’re started on high-dose
steroids and that’s something that is notable and you can check that out in
the article then the other question is whether or not to give antibiotics and
of course you’ve got to be pretty confident that there is no infection but
if you are gonna start antibiotics because you might think that there’s an
infection of course follow the guidelines for your area again
remembering that you want to start broad-spectrum antibiotics that we’ll
cover for the most likely causes of pneumonia in your patient population so
this is something that is evolving and hopefully we’ll be able to get more
information about this epidemic of e cigarettes and vaping currently thanks
for joining us