Intermountain creates new guidelines for treating vaping-related illness

(Rick Egan | The Salt Lake Tribune) Dixie Harris from Intermountain Pulmonary Division talks about the results of Intermountain Health Care study about treatment guidelines for patients for e-cigarette or vaping-associated lung injuries, Friday, Nov. 8, 2019.

Doctors at Intermountain Healthcare have drafted the first guidelines to treat vaping-related illnesses, after studying 60 patients — the largest number treated by any health care system in the nation, they said.

“We’ve been able to act as a system and really capture all the patients we’re seeing and gather all the clinical experiences together,” said Denitza Blagev, a pulmonologist and one of the authors of the guidelines and study of patient outcomes, published Friday in the medical journal The Lancet.

The findings will help doctors differentiate between treatments for severe and milder cases, and care for patients who may be suffering from multiple ailments, Blagev said.

More than 2,000 patients nationwide have developed the mysterious illness, which often starts with flu-like symptoms and progresses into severe respiratory distress and gastrointestinal problems. The vomiting and diarrhea initially made it hard for some patients to realize the illness may be tied to their vaping, said Dixie Harris, one of the first doctors to recognize a pattern among Intermountain’s patients.

That was in August, early in the nationwide outbreak, when doctors on Intermountain's TeleHealth Critical Care system saw similarities among cases during remote consultations.

“Doctors had no idea what was wrong with this patient,” Harris said of one of the early patients. Bronchoscopies showed no signs of infections — but x-rays and CT scans showed severe inflammation, especially in the more severe cases, Harris said.

She showed images of one patient’s lungs, where spaces that should appear empty and black instead were filled with fluid and tissue.

(Photo courtesy of Intermountain Healthcare) An x-ray of the lungs of a person suffering from vaping-related illnesses, released as part of a new study published Friday, Nov. 8, 2019, in the journal The Lancet and backed by Intermountain Healthcare. The foggy, white areas — which would appear black in healthy lungs — indicate severe inflammation similar to an infection. Telling the difference, doctors said, is key to devising treatments.

“I’ve never seen anything like this ... [in a case] not related to an infection,” Harris said.

As more patients in the system’s 24 hospitals and 160 clinics appeared with similar symptoms, doctors connected the dots.

“We have kind of an eye in the sky and are able to see things from a very broad, systems level,” David Guidrey, an Intermountain Healthcare pulmonologist, said at a news conference Friday.

As a result, doctors in the system were quick to identify a lot of patients. In fact, Blagev said, that may explain why Utah has had more diagnoses of vaping-related illness than other states have. It may not be more prevalent here, she said; there may be more diagnoses because so much of Utah's population is under Intermountain's umbrella.

With 60 patients, doctors at Intermountain had a large pool of cases from which to draw observations.

“If we were just isolated hospitals in Utah, I don’t think we would be able to put together this story the way we put it together, in the time we put it together,” said Colin Grissom, another pulmonologist on Intermountain’s team.

The remote consultations especially helped doctors “understand who patients are and standardize treatment,” Blagev said.

The guidelines help doctors decide which cases are most serious and recommend differing doses of steroids based on the severity of the patient. That also helps to avoid unnecessary hospitalizations for patients who turn up early in the illness, or with milder symptoms.

Researchers still haven’t isolated a single cause of the outbreak, but the Centers for Disease Control and Prevention on Friday announced that a common thickening agent in vape juice, vitamin E acetate, may be a possible culprit. CDC officials said this is the first time they’ve found a common suspect in the damaged lungs of patients, the Associated Press reported.

But Intermountain’s patients have reported vaping an array of products — and 17 percent used only nicotine products, the study reported. Vitamin E acetate is mostly used in black-market cartridges containing THC.

There wasn’t a big enough sample of nicotine-only vapers to draw conclusions contrasting their cases to those of THC vapers, Blagev said. But she reiterated warnings against all vaping.

“The best way to prevent this is not to vape anything. There is nothing that has been shown to be safe to vape,” she said.

Another challenge doctors have encountered is distinguishing vaping-related lung injury from other illnesses, which a patient may also have, Harris said. Steroids alone have been effective in treating vaping illness; antibiotics may be necessary if the patient also has an infection, Blagev said.

Patients with the most mild cases of vaping illnesses recovered quickly and completely, the study found. But of 26 patients who returned for follow-up examinations, two-thirds “had some residual abnormalities on x-rays ... and in lung testing,” Blagev said.

“If you are critically ill when you present, you can relapse and have complications,” she said.

The team of pulmonologists said their goal now is to keep the public and doctors aware of the symptoms so they don’t write off the illness as an infection, allergies, or a run-of-the-mill bug — especially as flu season begins.

“This does present in a very similar manner to influenza,” Guidrey said.

People who vape should keep the possibility of this serious illness in mind and seek help immediately if they feel unwell — even if they are only vaping nicotine, Blagev said. Some patients only went to a hospital because of family pressure, and most didn’t bring up vaping right away; some only mentioned it after multiple conversations with doctors, Harris said. Others said they believed they weren’t part of the outbreak because they and their friends vape the same products, but their friends didn’t get sick.

“There’s individual variability in susceptibility to this,” Harris said.

Intermountain’s study and the CDC’s breakthrough come on the heels of two other studies related to vaping that were published this week. One, in the Journal of the American Medical Association, found that more than one in four high-school students — and one in 10 middle-schoolers — use e-cigarettes. The other, in the journal Cardiovascular Research, showed growing evidence that vaping may damage the heart.