The federal government’s investigation into vaping-related illness, formally known as “e-cigarette or vaping product use associated lung injury,” or EVALI, has been fast-moving — but not fast enough. As of December 3rd, 2,291 people have been hospitalized due to EVALI, and 48 people have died, according to the Centers for Disease Control and Prevention.

Below are the latest important findings about the condition you should be aware of while administering everyday care.

The CDC Has Identified the Most Popular E-Cigarette Brands Among EVALI Patients

According to the CDC, 80% of EVALI patients reported using THC-containing vaping products, and the organization recently gathered its first national data set on their popularity. It found that the brand Dank Vapes is most common in the Northeast and South, but in the West, TKO and Smart Cart have dominated. The brand Rove is the most popular in the Midwest.

The CDC stresses that providers should tell patients to stay away from all e-cigarette products, not just these brands.

Researchers Linked Vaping to a Type of Pneumonia Associated With Metal Workers

A patient with a rare lung disease called hard-metal pneumoconiosis, also known as “cobalt lung,” likely developed the condition from vaping. According to the case report published in the European Respiratory Journal, it’s the first known instance of a connection between the two.

When testing the vapor of the patient’s device used to vape cannabis, researchers found cobalt and other toxic metals, including nickel, aluminum, manganese, lead, and chromium. They speculated that the metals came from the e-cigarette’s heating coils, not the vaping liquid.

“This is the first known case of a metal-induced toxicity in the lung that has followed from vaping, and it has resulted in long-term, probably permanent, scarring of the patient’s lungs,” said study author Rupal Shah MD, Assistant Professor of Medicine in the Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, at the University of California, San Francisco, in a statement.

Dr. Shah also expressed concern that the symptoms of hard-metal pneumoconiosis only become noticeable once the scarring to the lung is permanent. The condition causes damaged lung cells to engulf other cells and form ‘giant’ cells visible under a microscope. It can cause breathing difficulties and chronic coughing. Improvement is possible if patients stop their exposure and providers treat them with steroids.

Legal THC Products Can Also Cause EVALI

At least six EVALI patients in Massachusetts purchased THC-containing vaping liquid at legal dispensaries, according to a report from the state’s public health department. According to NBC News, A similar incident occurred in Oregon in September. A woman became ill and died after purchasing a device from a legal cannabis dispensary. That said, experts still believe vapes sold and purchased illegally are causing most illnesses.

A Canadian Teen Has Developed a Different Version of Vaping Illness Than American Patients

According to a recent report in the Canadian Medical Association Journal, a Canadian teen has developed a lung illness that resembles “popcorn lung,” or bronchiolitis obliterans. It’s distinct from American patients who’ve been diagnosed with EVALI. NBC News reports that the 17-year-old had been vaping nicotine and THC products for several months and became ill in the spring.

His injuries were slightly different, while he presented with similar symptoms to Americans, such as coughing and dyspnea. “Computed tomography of the chest showed diffuse centrilobular ‘tree-in-bud’ nodularity, consistent with acute bronchiolitis,” the study authors wrote. His cultures from two bronchoalveolar lavage samples and biopsy stains were negative for infection.

The teen required intubation and almost needed a double lung transplant. The CMAJ reports the teen had been inhaling diacetyl, a chemical in butter-flavoring that sickened workers in a microwave popcorn packaging factory. In the US, vaping-related illness primarily affects the alveoli, unlike popcorn lung, which inflames and obstructs the bronchioles.

Experts Suspect Vitamin E Acetate Is the Primary Chemical Causing the Illnesses

Health officials reported Friday, November 8th, that vitamin E acetate is a “potential toxin of concern” based on biological samples from 29 patients, including two who died. In all patients, researchers found vitamin E acetate at the primary injury site of the lungs, likely because patients inhaled it and the sticky substance clung to the lung tissue. Vitamin E acetate is a common additive in the production of vaping liquids because it resembles THC oil.

But They Caution There Are Other Possibilities, Too

While most cases of vaping illness have occurred in patients who’ve vaped THC, some have said they only used nicotine. The investigation is ongoing. “Based on these data from 29 patients, it appears that vitamin E acetate is associated with EVALI,” the CDC wrote in Friday’s statement. “However, it is possible that more than one compound or ingredient could cause lung injury, and evidence is insufficient to rule out the contribution of other toxicants to EVALI.”

E-Cigarettes May Harm the Heart More Than Regular Cigarettes

Two recent studies examining the effect of e-cigarette use on the heart could add another set of symptoms for providers to assess in possible EVALI patients. The first study compared cholesterol levels of e-cigarette users, regular smokers, people who used both, and those who used neither. It found that vapers had higher levels of (unhealthy) LDL cholesterol and lower levels of (healthy) HDL cholesterol on average than nonsmokers. The second study found that e-cigarette use may diminish the heart’s ability to pump blood during exercise and at rest.

Independent Researchers Have Developed New Guidelines for Treating EVALI, Relying Primarily on Steroids

Clinicians at Intermountain Healthcare in Salt Lake City, Utah — which has seen more than 60 EVALI patients since June 2019 — have offered their expertise on treating the condition, published in The Lancet.

The guidelines recommend “shorter courses of moderate-dose steroids for patients who are either treated as outpatients, or admitted to hospitals, and higher doses of intravenous steroids that are tapered more slowly for patients who are critically ill on admission,” the study authors noted in a statement. “Clinicians also recommend close outpatient follow-up, as complications after initial recovery are recognized.”

Follow the CDC’s Recommendations for Assessing, Treating, and Following Up if You Believe You’ve Encountered a Case of EVALI

The CDC also has its guidelines for recognizing and treating EVALI. Some important points to note:

• When taking a patient’s history, ask about respiratory and constitutional symptoms and e-cigarette use, including types of substances, source, product, time of last use, and method.

• Assess vital signs and oxygen saturation via pulse oximetry. (Pulmonary findings on auscultation have often been unremarkable.)

• Consider complete blood count with differential, liver transaminases, inflammatory markers, and urine toxicology testing.

• Conduct infectious disease evaluations to rule out other etiologies.

• Consider admitting patients with potential lung injury, especially if patients have respiratory distress and comorbidities that compromise pulmonary reserve or decreased (below 95%) O2.

• Consider initiation of corticosteroids except for in patients with possible fungal pneumonia, which might worsen with corticosteroid treatment.

• During flu season, healthcare providers should consider flu in all patients with suspected EVALI. Antivirals should be considered in accordance with established guidelines.