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Update on E-cigarette Vaping Associated Lung Disease.

States with Reported Cases of EVALI

Disclaimer: The information contained in this post is up to date as of this writing. For the latest information, visit the CDC website on outbreak of ecigarette related vaping associated lung injury.

In September of 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health published the results of their investigation into a new clinical syndrome. This initial series involved a cluster of 53 cases of ecigarette vaping associated lung injury (EVALI). Since the initial study, the syndrome was found to be a national epidemic. Nearly 1900 people have been affected by vaping associated lung disease, there have been 37 deaths. Cases have been reported in all states except Alaska.

Case Definition: The first step in evaluating a new disease is determining the characteristics that make up that disease. In the case of EVALI, CDC has issued this publication to define cases of Confirmed or Probable EVALI for surveillance purposes. In general, this involves the presence of pulmonary infiltrates in the presence of vaping in the past 90 days and in the absence of infection or other plausible causes.

Presenting Symptoms: Interestingly, patients with EVALI appear to present in a number of ways. These include not only respiratory symptoms, but also with constitutional symptoms and gastrointestinal symptoms. In the initial series of patients in Wisconsin and Illinois, all patients had constitutional symptoms at presentation, most commonly subjective fever. Nearly all (98%) had respiratory symptoms at presentation, and 81% had gastrointestinal symptoms, of which nausea and vomiting were most common.

Exposures: While the particular vaping component that leads to EVALI is not yet known, there are a few common factors. 87% of patients with EVALI reported vaping THC, while only a small minority (<15%) reported vaping nicotine without any THC. However as many have pointed out, vaping THC in most states is illegal. In addition many of these patients are under the age of 18, thus it is reasonable to think that many who claimed not to have used THC use simply did not want to divulge that they had. So why would vaping THC lead to EVALI, when people have been smoking THC for decades? Vape liquids contain several chemicals including propylene glycol, terpenoids, cutting agents, and flavorings. These solvents are used to keep THC and other components, such as flavoring agents in solution. These solutions are prepared in different ways in back yards, garages, and back seats, often cut with unknown substances to reduce their cost. They are then sold as cartridges to people who use them in a variety of different vaping devices which themselves which may heat the fluid at different temperatures and for a different duration.

Radiologic Findings: Ct findings are often heterogenous in EVALI. They can include mild infiltrates to diffuse findings suggestive of ARDS/DAD.

Spectrum of radiological findings in EVALI. Presented by Dr. Kevin Davidson M.D. at CHEST2019.
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What do Asthma and COPD inhalers have in common with Mexican food fast food?

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A 67 year old man came to see me recently, he had COPD, and found that it was getting harder to breathe. “I wanted to make sure that I’m on the right inhaler. My doctor switched me from Advair to Breo– is that better?

GSK would certainly say so, in fact their reps often do. Speaking with drug reps about their inhalers often makes me think of food. Actually I think of food quite often, but that’s more of a personal issue. Thinking of inhalers for COPD and asthma make me think of cheap Mexican food, specifically of the fast food variety. I think it has less to do with my poor dietary habits than the fact that I believe expensive inhalers have quite a lot in common with cheap Mexican food. 

Thinking about that patient’s question from the perspective of cheap Mexican fast food, switching from advair to Breo would be like ordering  one beefy rice burrito, only to be provided with two; but they would keep you full all day. Surely that’s an upgrade if there ever was one, and one which I endorsed. The problem though, and the real reason why he was asking, was not because he doubted the expertise of the prescribing physician but something else entirely. “It’s costing me $450 for 3 months. That’s more than triple what  the other one was. I guess I’ll pay for it if you think it’s worth it”

This was an especially unexpected twist, and not of the tasty cinnamon kind. No, that kind of dough busts straight out of the fast food genre into those fancy big-city restaurants, where it’s been said that they don’t even serve french fries. Like, you can’t even order them.  Continue reading “What do Asthma and COPD inhalers have in common with Mexican food fast food?”

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The IMPACT trial; What do we do about inhaled steroids in COPD?

 

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“B” is for Bias!

Pity inhaled steroids. Once a favored drug in the treatment of COPD, they were initially advocated to be used in combination LABA’s (long acting beta agonists) to have a “protective” effect against the harms of LABA’s which were,, back  in the day, proposed to have existed in the SMART trial. Things of course have change quite a bit since then. The black box warning for combination inhalers has since been dropped. Ironically it’s now the inhaled steroids that we worry about in the treatment of COPD, as mounting evidence implicates inhaled steroids as increasing the risk of pneumonia.

In the most recent GOLD update, steroids have been relegated as add on therapy to LABA for patients with an exacerbation. However GOLD recommends LABA/LAMA combination as preferred due to evidence that the combination reduces exacerbations better than LABA/ICS, as demonstrated in the FLAME trial. In fact ICS is recommended only as add-on therapy to LABA/LAMA in patients who are highly symptomatic and at high risk of exacerbations.

The Impact trial may be changing that. It compared a single inhaler triple therapy LABA/LAMA/ICS to dual combinations of LABA/LAMA and LABA/ICS. Interestingly, and also quite confusingly, the triple therapy group had reduced exacerbations and reduced COPD related hospitalizations. These results are of course in conflict with the results of the Wisdom Trial, which saw no significant difference in the rate of exacerbations between LABA/LAMA combination vs. triple therapy with LAMA/LAMA/ICS. GSK, of course, has wasted no time telling us this,  touting the results of their newest inhaler far and wide. Continue reading “The IMPACT trial; What do we do about inhaled steroids in COPD?”

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Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.

Study Shows That Bariatric Surgery Reduced COPD Exacerbations by More Than Half

I often tell my patients with COPD that quitting smoking can have a greater effect on their respiratory health than any inhaler that I could prescribe them. Should I now also extend that advice to include weight loss for obese patients with COPD? In this journal CHEST® study, researchers used registry data to look at COPD exacerbations for patients both before and after bariatric surgery. In the year before bariatric surgery, risk of COPD exacerbations was 31%. Looking at the rate of COPD exacerbations during the year after bariatric surgery, that rate dropped to 12%, an astounding change.

The accompanying editorial proposes mechanisms explaining why this might be so and postulates whether obesity could be a modifiable risk factor in COPD. While these results are certainly exciting, we look forward to future investigation into whether bariatric surgery, or other weight loss means, could further help reduce risk of COPD exacerbation.

Pneumonia: If You Can’t See It, Does It Still Exist?

The diagnosis of pneumonia requires the radiographic presence of infiltrates on imaging. However, with its greater resolution, CT scanning can often demonstrate infiltrates when none are seen on chest roentgenogram. Do we treat these the same as a regular pneumonia? This study sought to quantify differences between patients with pneumonia as seen on a chest radiograph vs CT scanning. The differences between the two groups appeared to be minor, with procalcitonin levels appearing to be lower in the CT group. Otherwise, it would appear that patients with pneumonia seen only on CT scanning should be managed like other groups.

The accompanying editorial raises the question of what to do with patients who are suspected of pneumonia but have negative chest radiographs. Certainly, exposing them all to CT scanning can’t be the right answer. Perhaps we should err on the side of caution and treat these patients for pneumonia when clinical suspicion is high. Conversely, we should consider CT scanning in this group only if suspicion is low and the presence of an infiltrate would change management. Continue reading “Pulmonary Medicine Update: Bariatric surgery for COPD exacerbations & The Mortality Indicator that Won’t Die.”

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Stem Cells and COPD: What You Need to Know.

I enjoy fielding questions from patients. Yes, I sense you’re rolling your eyes, but really, anything that I can answer that helps keep them out of the hospital is, I feel, time well spent. Recently though,  I’ve been fielding a number of questions that have me concerned. These questions often have a leading tenor about them like, “are you using stem cells for COPD yet?” The questions imply that stem cells are the de rigeur treatment for COPD. Now I may not be at the leading edge of any fashion, but being unfashionable in my treatment regimens? Never!

I can’t blame anyone for wanting to seek out treatments for COPD. It is after all, a leading cause of death and illness in the U.S. And it’s widely regarded that the changes caused by COPD/emphysema in the lungs are permanent. While there are now several different treatment options for emphysema/COPD, very few can prolong life. So if I had a family member with emphysema, I might naturally seek out treatments for COPD that go beyond the usual treatments, and with all the hype surrounding stem cells, why not take a look?

What people find when they google “stem cells and COPD” is in a word, distressing. It’s a fantasy world full of promises of health, healing, and better breathing. Equally distressing are the things that people who visit these sites aren’t recognizing: the greed, lies, lack of ethics, illusions, and misleading claims. Continue reading “Stem Cells and COPD: What You Need to Know.”

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Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?

Press Release: Annual Conference of the Universal College of Chest Physicians October 2085; New Chicago, Mars.

The annual conference enjoyed another record attendance today as attendees flocked to Dr. Ramachandran III’rds keynote address reviewing exploits of physicians in the early part of the century. Dr. Ramachandran highlighted some key decisions and their consequences, such as the ACGME’s decree in 2032 that all residents should be swaddled before their scheduled hourly nap times. This of course led to the now infamous Great Hospital Apocalypses of 2033, 2034, and 2035.

Perhaps nearly as intriguing was the plight of inhaled corticosteroids for the treatment of respiratory diseases like asthma and COPD in the beginning of the 21st century. The period began with greater awareness and concern regarding the use of long acting beta agonist (LABA) bronchodilators such salmeterol. That risk was highlighted by findings published in the SMART trial (access through Chest archives here). There was increased concern regarding the potential harm caused by LABA which culminated in the placement of warnings on medications which contained LABA bronchodilators. These medications, experts said, were to be prescribed with extreme caution because of the possible increase in harm, particularly among children.

Scholars of the early 21st century thus highly recommended that asthmatics, especially children, be started on steroid inhalers before having to resort to using inhaled LABAs. Many also theorized that inhaled steroids had a protective effect when combined with LABA’s, possibly ameliorating their potential danger. Thus many at the time recommended a strategy of not using LABA inhalers at all, unless also simultaneously prescribing an inhaled steroid.

However, problems with this approach started to appear late in the first decade of the century. The TORCH study, a trial using combined inhaled LABA/inhaled steroids in adults with COPD suggested that there was an increased incidence of pneumonia among those treated with inhaled steroids. Early in the second decade a pivotal study then demonstrated that asthmatic children treated with inhaled steroids ended up being about half an inch shorter than they might have otherwise been (interestingly, a later study in 2035  correlated the reduced height with a statistically significant decrease in NBA dunking). Continue reading “Remember When We Used to Prescribe Inhaled Steroids for Asthma and COPD?”

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End of Life Conversations are Becoming End of Life Confrontations

“How Dare You!”

Life can change in a heartbeat. Most of us believe that our lives, our loves and all the that things that make us who we are is a gift from a higher power. One that can be taken away as swiftly as it is given. But somewhere in the shuffle of taking kids to practice, catching up on emails, worrying about bills, and the search for the perfect barbecue, it’s all too easy to forget the truth of life. The one truth. The one single thing that life guarantees each and every one of us. From the moment we take our first breath,  life makes to us but one promise. The promise that our life will someday end.

“Who do you think you are?”

For some of us, death comes after a lifetime of achievement, for others all too soon. For many it will be feared, for others it will be welcomed as their bodies wither away. But for more and more of us in our increasingly sterile and safe society, it is simply not to be thought of at all. An unwelcome stepchild locked tightly away in the attics of our consciousness. Like a demon in waiting, we reshape it, remake it, remold it, until it becomes an ever distant sunset that bookends a romantic dream of a life full of love, accomplishment, achievement.

“You have no right to say that!”

Until finally, that inevitable day approaches. A man or woman in a white coat tells you the terrible news that your loved one is passing away. That yes,  they are alive and can be kept alive, but there is practically no chance that they could recover. They will never go back to the person they were before.

“Where’s my regular doctor?” Continue reading “End of Life Conversations are Becoming End of Life Confrontations”

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Smartphone App Allows COPD Patients to Individualize Their Care.

Health-care technology advocates have long been preaching about the potential of smartphones and other types of disruptive technology to improve health-care delivery. We in organized medicine have been slow to answer the call. Studies that showcase the ability of these tools in major medical journals are rare.  However, in a recent issue of CHEST, we see a welcome addition to the medical literature.

In this study,  researchers taught patients with COPD to create daily symptom diaries on smartphones (BlackBerry 8700s).  The results were uploaded to a research server and the program alerted staff when certain predetermined criteria were met. Using the data, researchers were able to accurately and quickly identify patients who were having an exacerbation of their COPD. They were also able to collect data on both the timing and length of the exacerbation.

This has exciting implications. Perhaps this kind of patient centered  data could be used to identify patients with severe symptoms and prevent hospitalizations, or to serve as a measure of response in clinical trials to various interterventions. The possible applications are numerous.

Though there is one aspect of this study that, as a tech geek, leaves me ambivalent. Should I be excited that even an obsolete smartphone could prove to be so useful? Or depressed that even an obsolete smartphone is so far ahead of current medical technology?

How do you feel about patient-centered smartphone apps that allow patients to individualize their care?

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This article is also posted at the ACCP Thought Leaders Blog.