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CME

Vaping

General Information

Description

  • inhalation of an aerosol ("vapor") produced by heating a solution containing nicotine, cannabis, or other substances1
  • devices used for vaping vary in design and are referred to by a range of terms such as electronic cigarette (e-cigarette), vape, and JUUL1
  • solutions used in e-cigarettes are typically marketed as containing nicotine with or without flavorings; however solutions and the aerosols emitted have been found to contain other toxins, ultrafine particles, and carcinogens1
  • vaping is associated with an outbreak of severe lung injury (e-cigarette or vaping product use associated lung injury [EVALI]) for which specific causative agent(s) have not been identified.2

Also called

  • electronic cigarettes and vaping devices also called
    • e-cigarette
    • e-cig
    • e-pipes
    • vaporizer
    • vapes
    • vape pen
    • e-hookah
    • hookah pen
    • tank system
    • mod
    • JUUL (e-cigarette brand name)
  • solutions used in e-cigarettes and vaping devices also called
    • e-liquid
    • e-juice
    • vape juice

Definitions

Centers for Disease Control and Prevention lung injury surveillance case definitions

  • Centers for Disease Control and Prevention (CDC) 2019 case definitions for e-cigarette or vaping product use associated lung Injury (EVALI) are intended for surveillance purposes, not clinical diagnosis or forensics
  • primary case definitions
    • primary case definitions are as of September 18, 2019, but may change as more information becomes available (see CDC.gov for updates)
    • confirmed case must meet all of the following criteria
      • use of electronic device or dabbing to inhale substances (for example nicotine, tetrahydrocannabinol [THC]-containing products, flavorings, or other substances) in 90 days preceding symptom onset
      • pulmonary infiltrate on imaging (for example, opacities on chest x-ray or ground-glass opacities on chest computed tomography [CT])
      • absence of pulmonary infection on initial evaluation consisting of, at minimum, all of the following
        • negative respiratory viral panel
        • negative influenza polymerase chain reaction (PCR) or rapid test if local epidemiology supports influenza testing
        • negative results on all other clinically-indicated respiratory infectious disease testing, for example
          • urine antigen for Streptococcus pneumoniae and Legionella
          • testing for HIV-related opportunistic respiratory infections
          • sputum culture if productive cough
          • bronchoalveolar lavage (BAL) culture
          • blood culture
        • no evidence in medical record of plausible alternative diagnoses (for example, cardiac, rheumatologic, or neoplastic disorders)
    • probable case must meet the following criteria
      • use of electronic device or dabbing to inhale substances in 90 days preceding symptom onset
      • pulmonary infiltrate on imaging
      • either of
        • infection identified by culture or PCR, but clinical team believes this is not the sole cause of underlying lung injury
        • minimum criteria to exclude pulmonary infection not met (testing not performed) but clinical team believes infection is not the sole cause of underlying lung injury
      • no evidence in medical record of plausible alternative diagnoses
  • case definitions for out-of-hospital deaths
    • definitions are as of October 4, 2019
    • applicable only to deaths outside hospital or prior to hospital admission (for example in emergency department) in which chest imaging and clinical evaluation outlined in primary case definitions have not been done
    • confirmed case must meet all of the following criteria
      • use of electronic device or dabbing to inhale substances in 90 days preceding death
      • pathologic evidence of acute lung injury, for example
        • diffuse alveolar damage
        • acute fibrinous pneumonitis or bronchiolitis
        • organizing pneumonia, possibly with vacuolated or foamy macrophages and/or pneumocytes
      • absence of pulmonary infection as evidenced by microscopy, immunohistology, microbiology, or molecular testing
        • consider influenza, S. pneumoniae, Legionella, HIV-related infections as appropriate, as well as other infectious diseases
        • recommended microbiologic testing includes
          • nasopharyngeal and/or lung swab for influenza
          • lung swab for respiratory viruses
          • postmortem cultures of lung tissue and blood
        • exclude positive results from postmortem microbiologic testing thought to represent normal viral or bacterial colonization of nasopharynx, or postmortem bacterial overgrowth of lung tissues or blood
      • no evidence of plausible alternative diagnoses in medical record or at autopsy
    • probable case must meet the following criteria
      • use of electronic device or dabbing to inhale substances in 90 days preceding death
      • pathologic evidence of acute lung injury
      • positive result on testing for pulmonary infection, however medical examiner or other forensic pathologist believes infection is not the sole cause of underlying lung injury
        • testing may include microscopy, immunohistology, microbiology, or molecular testing
        • do not include positive results from postmortem microbiologic testing thought to represent normal viral or bacterial colonization of nasopharynx, or postmortem bacterial overgrowth of lung tissues or blood
      • no evidence of plausible alternative diagnoses in medical record or at autopsy
  • Reference - CDC 2019 Oct 17

Vaping methods

  • aerosolization - solution containing e-cigarette or vaping product located in chamber or tank of vaping device is heated to produce aerosol (vapor) which is inhaled through mouthpiece1
  • dripping
    • application of a couple of drops of e-cigarette or vaping product (e-liquid) directly onto device's heating coil then immediately inhaling vapor produced
    • vaping devices designed for dripping are commercially available, or vaping devices can be modified to enable access to heating coil
    • reported to produce thicker cloud of vapor, stronger throat hit, and improved flavor compared to other vaping methods
    • PubMed28167512PediatricsPediatrics201703011393Reference - Pediatrics 2017 Mar;139(3):doi:10.1542/peds.2016-3224
  • dabbing
    • application of cannabis concentrate on a preheated device then inhaling vapor produced in a single breath
    • device often composed of metal, quartz, or ceramics, and referred to as a "nail"
    • blowtorch typically used to heat device
    • PubMed30464676Substance abuse and rehabilitationSubst Abuse Rehabil20181102991-10191Reference - Subst Abuse Rehabil 2018;9:91

Types

Types of vaping devices

  • most devices include1
    • reservoir or tank for vaping solution (e-liquid)
    • heating coil or atomizer to heat solution
    • button to manually activate heating coil, or sensor to activate coil when user inhales
    • mouthpiece
    • battery
  • first generation devices1
    • appear similar to cigarettes
    • may be disposable or may have a cartridge that can be reloaded for repeat use
    • often called cigalikes
  • second generation devices
    • has refillable reservoir for e-cigarette or vaping product1
    • often called vape pens or vapes1
      Electronic vape pen vaporizer
      Image 1 of 3

      Electronic vape pen vaporizer

  • third generation devices
    • voltage and wattage can be modified1
    • often called mods or tank systems1
      Power supply
      Image 2 of 3

      Power supply

      Lost Vape Modefined Sirius 200W TC and vaporizer Geek Vape Ammit MTL RTA

  • fourth generation devices
    • brand names include JUUL, Suorin, and SMPO1
    • JUUL appears similar to a flash drive1
      • popular with adolescents
      • size and shape facilitate surreptitious use
      • uses prefilled replaceable cartridges (pods) containing solutions with variety of flavors and nicotine concentrations
      • can be recharged via USB port
      E-Cigarette
      Image 3 of 3

      E-Cigarette

      A Juul electronic cigarette, with four 'pods' (one loaded and three next to it).

Types of e-cigarette or vaping products

  • products may be commercially available or obtained from illicit sources2
  • e-cigarette solutions (e-liquids) may be modified, for example by adding substances not intended by the manufacturer2
  • common solutions are marketed as containing nicotine, humectants, and flavorings1
    • nicotine content labeled as ranging from 0%-5% (0-59 mg/mL)
    • propylene glycol and vegetable glycerin are the most common humectants (carrier solvents used to produce aerosol when heated)
    • compounds used in flavorings include menthol, glucose, fructose, sucrose, and caffeine
    • JUUL pods are prefilled with 0.7 mL of solution which contains
      • nicotine (available as 3% [35 mg/mL] or 5% concentration)
      • propylene glycol
      • glycerol
      • benzoic acid
      • flavoring such as mango, mint, fruit medley
  • other products may include

References

General References Used

  1. Walley SC, Wilson KM, Winickoff JP, et al. A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics. 2019 Jun;143(6):doi:10.1542/peds.2018-2741
  2. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019 MMWR Morb Mortal Wkly Rep. 2019 Oct 18; 68:919–927

Recommendation grading systems used

  • National Academies of Sciences, Engineering, and Medicine (NASEM) grading system for recommendations
    • levels of evidence
      • Conclusive evidence - based on supportive findings from good-quality controlled studies (randomized and nonrandomized trials) with no credible opposing findings; firm conclusions can be made, and limitations to evidence (chance, bias, and confounding factors) can be ruled out with reasonable confidence
      • Substantial evidence - based on supportive findings from good-quality observational studies or controlled studies with few or no credible opposing findings; firm conclusion can be made, but minor limitations (chance, bias, and confounding factors) cannot be ruled with reasonable confidence
      • Moderate evidence - based on several supportive finds from fair-quality studies with few or no credible opposing findings; general conclusion can be made but limitations (chance, bias, and confounding factors) cannot be ruled out with reasonable confidence
      • Limited evidence - based on supportive findings from fair-quality studies or mixed findings with most favoring one conclusion; conclusion can be made but there is significant uncertainty due to chance, bias, and confounding factors
      • Insufficient evidence - based on mixed findings or a single poor study; no conclusion can be made due to chance, bias, and confounding factors
      • No available evidence - no available studies; health endpoint has not been studied; no conclusion can be made
    • PubMed2989411820180123Reference - NASEM Public health consequences of e-cigarettes (NASEM 2018 Jan 23full-text)

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How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T1568994420333, Vaping; [updated 2019 Nov 16, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T1568994420333. Registration and login required.

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