How doctors diagnose and treat vape pen lung disease

Published on September 26, 2019 · Last updated July 28, 2020
VAPI is often misdiagnosed as infectious pneumonia, which can cost patients precious weeks. Steroids, not antibiotics, seem to clear it up. (ilbusca/iStock)

Vaping-Associated Pulmonary Injury (VAPI) has become the official term that national public health authorities have given to clusters of sickened patients found across the US, beginning in Wisconsin this past spring.

VAPI often presents as common pneumonia. It's not, and antibiotics won't clear it up.

As of Sept. 26, the US Centers for Disease Control and Prevention (CDC) reported 805 confirmed and probable cases of lung injury “associated with the use of e-cigarette or vaping products” in 48 states. There have been at least 12 confirmed deaths across the United States linked to vaping.

The most common symptoms of VAPI—shortness of breath, dry cough, tiredness, chest pain, and coughing up blood—can often be found in other respiratory ailments like pneumonia. That makes it particularly difficult to diagnose and can result in critical time being lost, as doctors prescribe drugs that don’t work. The one thing that appears to help with VAPI, according to multiple reports, is rounds of steroid treatment applied over several weeks.

Patients are going public

State and federal officials have been consistent about updating the statistics about VAPI cases and suspected deaths tied to the syndrome. But it’s been difficult to get information about how VAPI presents in patients themselves. Because of the federal HIPAA medical privacy law, it can be hard for doctors to speak publicly about specific VAPI patients. Fortunately, some patients are going public with their own symptoms and experiences.

There’s also the sudden recognition that a national health issue is emerging, without a clear, consistent product being used, or specific source of toxin in every case. So easy answers about symptoms and treatments are not yet available.

Dr. Steve Feagins is a vice-president of medical affairs for the Mercy Health Hospitals network of 23 hospitals in Cincinnati, and medical director for Ohio’s Hamilton County Public Health. He’s also struck by how new this crisis is.

“We are one month into what we know,” he tells Leafly. “The biggest thing is finding cases that we can confirm.” 

What are the symptoms of VAPI?

On Sept. 13, the federal Centers for Disease Control issued a national advisory letter regarding the VAPI outbreak. That guidance took note of these symptoms, which may present individually or in some combination in VAPI patients: 

  • Shortness of breath
  • Nonproductive cough
  • Pleuritic chest pain 
  • Rapid heart beat (regular or irregular)
  • Fever
  • Chills
  • Fatigue
  • Gastrointestinal distress: nausea, vomiting, abdominal pain, diarrhea
  • Hypoxemia (abnormally low blood-oxygen level)
  • Acute or subacute respiratory failure 

A key feature to look out for is hypoxia, not enough oxygen in the blood. This is because the lungs are failing to transfer oxygen into the bloodstream. Hypoxia shows up as feeling tired, nauseous, sick, and dizzy. Suddenly you can’t climb the stairs anymore, or walk the dog, or play catch.

Patients are showing up at the hospital with blood oxygen levels so low (as low as 35%) that they should be dead. 

Healthcare professionals say the damage done by vaping comes under the category of “Bronchiolitis obliterans.” That’s a condition defined by the National Institutes of Health as a chemically-induced inflammatory condition “that affects the lung’s tiniest airways, the bronchioles” and results the obstruction of oxygen into the body. 

Often misdiagnosed as infectious pneumonia

The CDC noted that many healthcare professionals initially misdiagnosed the patient’s condition as pneumonia, for which they prescribed antibiotics—with no improvement in the lung condition. 

Feagins listed some of the symptoms he and his colleagues have seen in VAPI patients: “Fever, night sweats, possibly even weight loss depending on how long this has been going on.” 

They also have seen diarrhea or stomach ache accompany those symptoms. 

“All of those symptoms would very much be consistent with pneumonia,” he says. “Also: elevated white blood cell count, sometimes very high; some indication of inflammation and infection.” 

VAPI not infectious disease-related

A key component of a VAPI diagnosis is the lack of an infectious disease. Lung cell cultures must come back negative for bacteria or viruses associated with pneumonia. 

This pulmonary syndrome is different: It’s a lung injury from a toxin that manifests itself as pneumonia symptoms.

What do x-rays show?

X-rays can help diagnose the problem. 

Sickened lungs show up as cloudy on the left x-ray, and clear after treatment of one suspected VAPI patient in Utah. (Courtesy University of Utah)

Sickened lungs show up as cloudy on the left x-ray, and clear after treatment of one suspected VAPI patient in Utah. (Courtesy University of Utah)

“All patients described in these reports to date have had abnormal radiographic findings,” reported the CDC, “including infiltrates on chest radiograph and ground glass opacities” on a chest CT scan.

With VAPI patients, “when you look at a chest X-ray or a CT or a CAT scan of the chest, there is stuff all over the place,” says Feagins. 

“Those lungs have what they call whiteout infiltrates, obvious irritation, very similar to a lung injury,” he adds. “And even as individuals seem to feel better they continue to use the oxygen. Some may need to be ventilated on a breathing machine for some time. But it takes longer than usual to get off oxygen to go home.” 

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Fat in lung immune cells

A major cause of VAPI appears to be inhaled oil. Since late 2018, street-market vape cartridge manufacturers have been cutting THC cartridges with larger and larger amounts of a product known as a “thickener,” which consists mainly of a form of vitamin E oil known as tocopheryl-acetate. 

VAPI symptoms are generally consistent with what’s called lipoid pneumonia. Doctors can confirm it by taking a sample of fluid from the lung, and looking for oil in immune cells.

“If you go down with the bronchoscope and you actually look at the cells, more often than not they seemed to be filled with fat, which suggests oil inhalation,” says Feagins. “The actual cause and effect, we don’t know yet.”

Pulmonoligists will tell you inhaling oil can injure your lungs. A pharmaceutical chemist told Leafly that inhaled vitamin E oil can block the fluid lining of the lungs, preventing gas transfer. You suffocate in your own body.

Honest patient info is key

Honest conversations are crucial in these situations. Feagins notes that hospitals in southwest Ohio have had vaping as a question on their patient intake forms since 2016. Including that question, and verbally asking about vaping, can save a patient’s life.

Answering honestly can save a patient’s life. But medical professionals should know that both young and old patients may initially deny using vape devices, both because of social stigma and because the major source of VAPI cases—street-market THC vape cartridges—are illegal. 

Patients may say they only vaped nicotine when in fact they were vaping THC street carts as well. Patients don’t like to admit to federally illegal activity, especially to authority figures like doctors and nurses. They worry they’ll get in trouble with the law, their parents, a spouse—or simply suffer a judgmental frown from the doctor. In recent cases of VAPI, some doctors report having to move patients to a private space, ask them alone, and assure them no personal criminal charges will ever be filed. Here’s a too-common phrase: “We just need to know what you’ve inhaled lately so we can save your life.”

Correct terminology matters

Electronic drug delivery devices (e-cigarettes) are so new that confusion in vocabulary has slowed down treatment in many cases. 

Patients have told doctors, “I don’t vape.” But when doctors ask them, “Do you JUUL?” they’ve said “Yes.” 

Doctors should press patients to describe the type of JUUL pods. “Just nicotine? Other types? From where?” These poisonings are emanating out of the street market for THC pods that are compatible with JUUL devices.

Doctors also need to ask about the use of new cartridges, amount of use, and where exactly they were purchased. 

Pay special attention to demographics. The median age of VAPI poisoning is 19 years old. Around 75% of patients are male. This demographic generally overlaps with the peak age and gender for illicit drug use.

Treatment: Success with steroids

What can help treat VAPI? Doctors can’t say for sure. But so far, steroid treatment has resulted in the most success. 

The CDC reports that “many of the patients who were treated with corticosteroids improved.” 

In a study of Wisconsin patients, four patients who got quick steroid treatment lived. The fifth patient who did not get steroids until 50 days into his symptoms died.

Pulmonologists say steroids are a common treatment with lung inflammation. Steroids dampen the overreaction of the immune system, which can do more damage than the toxin itself.   

A study of five VAPI patients in North Carolina found: “All five patients improved clinically within 24–72 hours after initiation of intravenous methylprednisone (120 mg–500 mg daily). All five patients survived and were discharged home on a taper of oral prednisone.”

And in the largest study, of 53 patients in Wisconsin: “Documentation by the clinical team that the respiratory improvement was due to the use of glucocorticoids was found in the majority of patient notes (65%). All patients who began receiving systemic glucocorticoids were treated with at least 7 days of glucocorticoid therapy.”

While information remains scarce, some patients have come forward of their own accord in order to spread critically needed information and help others who may be fighting for their lives.  

Case history #1: The Ohio delivery driver

In early August 2019, Ohio resident Cody Slagle became horribly ill. 

“I couldn’t eat or go to bathroom,” he later recounted. “My breathing and heart rate were messed up. I could feel my body aching, getting weaker, and wanting to give up.”

'My breathing and heart rate were messed up. I could feel my body aching, getting weaker, and wanting to give up.'

On Aug. 12, officials at a local hospital diagnosed pneumonia and sent the 25-year-old delivery driver home with a prescription for antibiotics. But when his condition worsened, Slagle went to The Jewish Hospital–Mercy Health in Cincinnati, a larger medical center. Doctors there admitted him on Aug. 22. 

Imran Naqvi, MD, VP of Medical Affairs at The Jewish Hospital, recalled the staff’s reaction recently in an article for the hospital’s website. “I presented Cody’s case in morning report,” Naqvi said. “We discussed what it could and couldn’t be. Most of the team thought it was pneumonia. But with the health issues that have started coming to light around vaping, this thought was in the back of my mind.”

Naqvi’s care team asked Slagle if he vaped. Slagle said yes. Three years ago he’d quit smoking by turning to e-cigarettes. The team soon diagnosed Slagle as the first Cincinnati-area patient with a vaping-related lung illness. He was treated with steroids and soon released.

Naqvi’s lessons learned could be critical for patients and caregivers around the nation: 

“The treatment for this issue is different than that for pneumonia,” he said. “Cody’s oxygen levels were at 50 percent, which merits a breathing tube. Fortunately, the steroids kicked in and he avoided a ventilator. This condition can cause permanent lung injury and scarring that can hurt lung oxygenation. Time is of the essence. If we had continued to treat this as pneumonia, the outcome could have been different.” 

Case history #2: The California welder

This case comes to us via WebMD writer Kathleen Doheny, who documented the illness and recovery of Lincoln Rennie, a 23-year-old welder from Orange, CA. 

Doctors first suspected a urinary tract infection. Two days later, they diagnosed acute respiratory distress syndrome, related to vaping.

Rennie woke up in late August feeling ill, with a stomach ache and fever. He took to bed, but the fever kept rising, eventually hitting 104 degrees. His fiancé, Viri Alvarado, insisted he go with her to the hospital on Aug. 31. At the emergency room, doctors first suspected a urinary tract infection. It wasn’t until the third day that medical staff settled on a diagnosis of acute respiratory distress syndrome, related to vaping. 

Ultimately, Rennie recovered with a combination of oxygen (eight days) and corticosteroids. 

Looking back, it may have been a switch to cheaper cannabis vaping cartridges that put him in the hospital. Rennie told WebMD that he’d been using medical cannabis vape cartridges for about ten years to help him sleep. In June 2019, he decided to start buying street-market cartridges, because they were far cheaper ($25) than carts sold in legal, state-licensed stores ($50).

“’I was too trusting,” Rennie told WebMD.” I believe there are safe options,” and regulating the industry more would make it safer

“The scariest part of the bootleg [market] is, they look the same. They will take a brand-name cart, refill it, and say it’s the same brand.”

Case history #3: The New York traveler

Jon Doneson, a 52-year-old operations manager at a startup apparel company, first felt the symptoms after arriving home on Long Island from a business trip to China. In June, he fell ill after working out rather than resting after his flight—so he blamed the sickness on fatigue and jet lag. 

Jon and Susan Doneson. (Courtesy of Jon Doneson)

In subsequent weeks, a strange cough kept dogging him. On Aug. 12, the cough turned painful. He broke out in a fever. His doctor diagnosed bronchitis, but the prescription failed to dent the symptoms. A follow-up X-ray indicated double pneumonia. The doctor put him on a round of doxycycline, a common antibiotic.

Ten days later, Doneson felt so ill he went to Manhasset’s North Shore University Hospital. Staff there suspected a virus picked up in China, so they quarantined the patient and tested him for a variety of ailments. All came back negative.

His condition worsened. Doctors asked his wife Susan to fill out a ‘Do Not Resuscitate’ form. 

Then a pulmonologist noticed a small detail on Doneson’s medical history: He said that a few months ago he’d started using a THC vape pen.

Doctors switched Doneson to a cocktail of antibiotics and steroids. His condition improved within a day. Soon after, he was discharged and is now recovering at home. (Doneson’s story was featured in the Leafly investigative report, Journey of a Tainted Vape Cartridge: From China’s Labs to Your Lungs.) 

Case history #4: Redditor ‘Thulle’ of Fresno

This Fresno, CA-area patient has chosen to remain anonymous, so we’ll identify him as Thulle, which is part of his reddit handle. While recovering in a Fresno hospital, he hosted a reddit AMA about his experience battling and recovering from VAPI. 

'It will feel like your lungs want to give up.'

Thulle reports that he regularly vaped illicit-market THC cartridges under the Heavy Hitters brand. Heavy Hitters is a legal, state-licensed California cannabis brand. Like other popular brands (Cookies, STIIZY, Kingpen), Heavy Hitters has fallen victim to counterfeit package makers who sell fake branded boxes in the hundreds of thousands. At the time, Thulle thought he was buying real Heavy Hitters products, but he now believes they were, “100% black market carts.” 

“They were so well done you wouldn’t be able to tell,” he wrote. Thulle bought them from a friend, “most trustful dude ever, he got fooled too they were such good fakes.” 

One telling detail: According to Thulle, “the cartridge did not give the user a real, lasting high. The high was about 20 [minutes] long and fleeting, required six rips every half hour to keep it going.” 

When illicit THC vape carts are cut heavily with thickening agents like Honey Cut, it’s a double-whammy for the consumer: Less THC means more pulls on the vape, which sends more toxic vitamin E oil into their lungs. 

In late August, Thulle began experiencing chest pains, dry coughing fits, and extreme shortness of breath. “I could only take half ‘max’ breaths,” he recalled. “It will feel like your lungs want to just give up.”

A pulmonologist, aware of the national VAPI outbreak, diagnosed Thulle with lipoid pneumonia, which is essentially pneumonia caused by oil in the lungs.

Doctors ultimately prescribed a four-week steroid treatment, one week of hospital recovery, and possibly home bed rest after that. A second four-week cycle of steroids might be necessary if his lungs don’t clear up entirely. 

“You will need steroids to clear the tainted particles from your lungs,” Thulle said. “It will not go away on its own.” 

“I’m in a lot of chest pain but I didn’t die so I stopped minding the pain so much,” he wrote. “It does hurt like hell though.” 

Case history #5: California pest control technician

This case was also reported by Kathleen Doheny at WebMD. Nathan Fagundez is a 28-year-old agricultural pest control technician living in Hanford, CA, an agricultural hub between Fresno and Bakersfield. Hanford, CA is the first place a California physician identified VAPI in the state.

A regular cannabis consumer, Fagundez started vaping about a year ago in order to cut down on the odor generated by smoking flower. 

He bought about two grams a week, always on the street market. Fagundez estimated that his street carts cost $40, versus $100 for a tested one from a state-licensed California retailer.

Earlier this summer, he told WedMD, “I went with a buddy to pick up carts from LA,” and discovered that the seller “had a whole lab in his garage.” 

Soon after, Fagundez experienced extreme shortness of breath. He’d seen reports about vaping and lung damage on TV and so he checked himself into the hospital. On Aug. 13, medical staff at Adventist Health hospital in Hanford found his blood oxygen levels so low “they couldn’t believe I was still breathing.” 

Fagundez spent 16 days in the hospital, where he was put on oxygen and received steroid treatments. 

After his hospital discharge Fagundez recovered at home, which required the use of a portable oxygen tank. “I bring it for emergencies, if I exert too much,” he told WebMD.

Medical professionals can report incidents of suspected VAPI through the CDC’s emergency reporting system.

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Bruce Kennedy, David Downs, Bruce Barcott, and Dave Howard
Bruce Kennedy, David Downs, Bruce Barcott, and Dave Howard
Bruce Kennedy is an award-winning reporter, editor, and producer based in Colorado. He has covered the legal cannabis industry since 2010, and is a regular contributor to Leafly. David Downs covers cannabis news and culture as Leafly's California Bureau Chief. He's written for WIRED, Rolling Stone and Billboard, and is the former cannabis editor of the San Francisco Chronicle. TW: @davidrdowns | IG @daviddowns Leafly Senior Editor Bruce Barcott oversees the site's news coverage and feature investigations. He is the author of 'Weed the People: The Future of Legal Marijuana in America,' and has written for Time, Rolling Stone, the New York Times Magazine, National Geographic, and other national publications. Dave Howard is a national magazine editor and award-winning author. His most recent book is 'Chasing Phil: The Adventures of Two Undercover Agents With the World's Most Charming Con Man.'
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