VAPING AND INHALANTS Flashcards
VAPING OR E-CIGARETTES
§ Known by different names e-cigs, ehookahs, mods, vape pens, vapes,
tank systems, electronic nicotine
delivery systems
§ Produce an aerosol by heating a liquid
– usually nicotine and flavorings
§ Inhale aerosol, bystanders can also
breathe aerosol
NOTE: No vapors actually involved in ecigarettes
Vapor – gas phase of a substance
Aerosol – suspension of particles of a
liquid, solid or both within a gas
HOW DO THEY WORK?
- Hacking or Modifying Devices
- Dripping
E-LIQUIDS
- Typically mixture of water, food grade flavoring,
nicotine, cannabis (THC, CBD), propylene
glycol (PG) or vegetable glycerin (VG) - PG and VG used as humectants
- Effects of nicotine well known
- Toxic effects of aerosol flavoring chemicals,
solvents and other products largely unknown
Nicotine: Newer Mods use nicotine salts - Lower pH than free base nicotine
- Allow for high levels to be inhaled more easily
with less irritation on throat
MARKETING AND ADVERTISING
- Pediatric exposure is a serious concern, notably, nicotine toxicity and addiction
issues - TV ads for cigarettes were banned 1971 but in a 2016 US study, it was found >75%
of grade school and high school students had seen TV ads for e-cigarettes
VAPING USAGE
Canadian Tobacco and Nicotine Survey (2019)
Ø 2019, ~16% (5 million) Canadians had vaped
Ø Most commonly used tobacco product in youth (~36%)
Ø Individuals >45 years tended to be previous smokers
Ø ~40% of 18-24 year old reported never being regular
cigarette smokers
E-CIGARETTES VS. REGULAR CIGARETTES?
Ø Not approved as a ‘quit’ smoking aid but may assist
Ø Generally have fewer toxic chemicals (regular smoking ~7000 chemicals)
Ø E-cigarette aerosols contain many harmful substances
- Nicotine
- Cannabinoids (THC, CBD)
- Volatile organics
- Ultrafine particles
- Heavy metals such as Cr, Ni, Pb, Sn
- Carcinogenic substances (formaldehyde, acetaldehyde)
- Flavoring – diacetyl (ie., ‘popcorn’ lung)
Ø Unintended injuries (exploding)
Ø Synthetic Cannabinoids –
Ø K2, Spice, Black Mamba, Kronic
AEROSOL COMPOSITION
Ø Over 250 e-cigarette brands and >8000 flavorings (Note: besides methanol all flavoring
banned in cigarettes)
Ø Full evidence of the impact on heating these substances is unknown
Ø Formation is linked to device characteristics (ie., coil temperature, metals used)
Ø Vaping requires user to more puffs both harder/longer than regular cigarettes
Carbonyl Compounds
§ Thermal degradation of 1,2-propylene glycol and glycerin produces
§ Acetaldehyde, acrolein and formaldehyde
Diacetyl and 2,3-pentanedione
§ Found in the majority of e-cigarettes
§ Flavoring agent (‘butter-flavored’ popcorn), but can create a variety of flavors
§ Previously linked to bronchiolitis obliterans (‘popcorn lung’)
§ Evidence they impair production and function of cilia in human airway
Volatile Organic Compounds
§ Benzene, toluene, ethylbenzene, xylene
Metals
§ Many types predominant include aluminum, iron, chromium, nickel, tin, copper, lead
VAPING ASSOCIATED PULMONARY INJURY (VAPI)
(EVALI – E-CIGARETTE OR VAPING ASSOCIATED LUNG INJURY)
§ ’New’ disease associated with vaping,
>2800 cases, 68 deaths (US)
§ USA reported an outbreak (Peak Aug 2019
- Feb 2020)
§ An acute or subacute chemical pneumonitis
§ Predominately young males (<35 in 80%
cases) and healthy individuals
§ Patients cough, dyspnea, chest pain
§ Common nausea, abdominal pain, diarrhea
§ Used e-cig within 90d of onset
§ Pulmonary infiltrates on chest radiography
(atypical pneumonia)
§ Many patients required ICU and ventilator
support
§ Some developed acute respiratory distress
syndrome (ARDS)
VAPING ASSOCIATED PULMONARY INJURY (VAPI)
(EVALI – E-CIGARETTE OR VAPING ASSOCIATED LUNG INJURY)
§ Pathogenesis largely unknown
§ Products that contained THC and/or
vitamin E acetate were associated with
disease
Study assessing bronchoalveolar lavage
fluid (BAL) in 51 patients with EVALI
§ 48 of 51 patients had vitamin E acetate
and 40 of 47 patients had THC
§ Used to thicken or dilute the THC in
vaping liquids
§ Not found with nicotine products (too
viscous)
§ MOA for pulmonary toxicity not known
§ Interfere with membrane function
§ Heating may produce ketenes (reactive
compound)
BRONCHIOLITIS OBLITERANS (POPCORN LUNG)
Toxic substances associated with developing popcorn lung
* Acetaldehyde
* Ammonia
* Chlorine
* Diacetyl
* Formaldehyde
* Fumes from metal oxides
* Hydrochloric acid
* Mustard gas or sulfur mustard
* Nitrogen oxides
* Sulfur dioxide
CHOLINERGIC TOXIDROME?
§ Cholinergic toxidrome represents acute phase of cholinesterase inhibitor poisoning
§ Accumulation of excessive levels of acetylcholine
§ Pathology depends upon receptors (nicotinic and muscarinic) differ in function, location, physiology
DUMBELS, Killer B’s Days of the week
SLUDGE
NICOTINE POISONING
- Nicotine binds to nicotinic cholinergic
receptors (mimics acetylcholine) - Absorbed rapidly by all routes, enters brain
quickly, volume of distribution ~2.6-3L/kg,
rapidly metabolized (CYP2A6 and
CYP2D6), - Urinary excretion, t½ 120min
- Increased incident in children (< 5years old)
~1000% (lethal dose <50mg), severe
toxicity ~6mg - 2.6X odds severe outcomes, highly
concentrated e-Liquid - Ex. 1x cigarette (10-30mg), 30mL eLiquid
(36mg/ml) (adult lethal doses 30-500mg)
NICOTINE POISONING
-Dose- and time-dependent effects (Biphasic response)
Early (0.25–1 h)
Late (0.5–4 h)
Gastrointestinal Respiratory Cardiovascular Neurologic
Cannabis - How safe is it?
Bill C-45 was approved by Parliament and given royal assent on June 1, 2018.
New status came into effect October 17, 2018.
1. USA legal cannabis market worth $7.97 billion
2. Dramatic increase in potency (from ~2-3% to 20%) over last 10years
3. Key constituents: Δ9-tetrahydrocannabinol (THC) vs cannabidiol (CBD)
4. Key receptors: CB1R versus CB2R
Cannabinoid Receptors - CB1R vs CB2R
Cannabinoid-related products can contain >60 chemicals, Δ9-
tetrahydrocannabinol
(THC) primary psychoactive compound
§ Cannabinoid receptors (CB1 and CB2) found throughout body but brain has stimulant,
sedative or hallucinogenic actions
§ Trigger both catecholamine release and inhibition of sympathetic reflexes
§ Acute effects – decreased coordination, muscle strength, lethargy, decrease
concentration, psychomotor activity
§ Non-classical effects (agitation and seizures) – synthetic or ‘spice’ blends ‘incense
packaging’ (Zombie)
Cannabinoid Receptors - CB1R vs CB2R
Cannabinoid-related products can contain >60 chemicals, Δ9-
tetrahydrocannabinol
(THC) primary psychoactive compound
§ Cannabinoid receptors (CB1 and CB2) found throughout body but brain has stimulant,
sedative or hallucinogenic actions
§ Trigger both catecholamine release and inhibition of sympathetic reflexes
§ Acute effects – decreased coordination, muscle strength, lethargy, decrease
concentration, psychomotor activity
§ Non-classical effects (agitation and seizures) – synthetic or ‘spice’ blends ‘incense
packaging’ (Zombie)
Case - Marijuana Lollipop-Induced Myocardial Infarction
A 70-year-old man with known coronary artery disease presented with crushing chest
pain, diaphoresis and pallor after consuming a marijuana lollipop; the pain began within
30 minutes of consumption. His troponin T increased from 94 ng/L to 216 ng/L, with
slight ST changes but no gross ST elevations. Discharge diagnosis was non-STelevation myocardial infarction, and subsequent nuclear medicine wall motion studies
showed worsening ejection fraction (40% to 31%).
Patient history
- CAD, no angina past 2 yrs, 4x CABG in 2015, hypertension, T2D, obese, 30 pack year
history of smoking, family history, painful osteoarthritis
Patient Medication
- Aspirin 81 mg daily, perindopril 8 mg daily, rosuvastatin 20 mg daily, metoprolol 100
mg twice daily, metformin 500 mg twice daily, glyburide 5 mg three times daily,
pantoprazole 40 mg daily, and zopiclone 7.5 mg nightly.
- Consumed marijuana lollipop (contained 90mg THC, consumed 75%) for pain/ sleep
- Recommended starting dose of dronabinol (synthetic nausea/vomiting) 2.5mg for
older patients with max daily dose 20mg
Case - Marijuana Lollipop-Induced
Myocardial Infarction
Can J Cardiol. (2019) 35 Issue 2.Pages 229.e1-229.e3
What happened?
What does this mean?
What happened?
1. Sudden and unexpected strain on the
body with fearful hallucinations
2. Stimulated SNS (increased tachycardia,
HTN, catecholamine)
3. THC primarily responsible (90mg vs.
~7mg average joint)
What does this mean?
* New legislation - misconceptions
* There is concern and evidence for
increased usage (notably in older
populations)
* Need more information on formulations
and effects
SYNTHETIC CANNABINOIDS (AMB-FUBINACA)
Drug 85 Times as Potent as Marijuana Caused a
‘Zombielike’ State in Brooklyn
Mass intoxication of 33 persons, 18 hospitalized
- Herbal incense product containing synthetic cannabinoid AMB-FUBINACA (85x more
potent)
- Different from cannabinoids found in cannabis plant ( Δ9-THC)
- Patients blank stare, slow response, normal vital signs, lethargic, arousable, normal
reflexes, normal pupils, groaning sounds, slow mechanical movements - ‘zombie-like’
description, discharged from hospital
- Unusual from known effects of synthetic cannabinoids – ie., no cardiotoxicity or acute
kidney injury
- Collaboration between clinicians, lab staff, public health, law enforcement, toxicology
library – difficulty with diagnosis
BAGGING/HUFFING/SNIFFING/SPRAYING
Inhalants
§ Refers to the various substances that individuals typically take only by inhaling (ie., volatile substances)
Abuse
§ Common among teenagers
§ Legal and easy to obtain products
Effects
§ Intoxicating effects - immediately
§ Plethora of chemicals readily absorbed through the lungs and distribute rapidly
§ Initially stimulating, then less inhibited and less in control
§ Chemicals prevent/limit breathing in oxygen
§ Lot of long-term toxicity
INHALANTS
MeOH - toxicity
DFE - Sudden sniffing death syndrome
Toluene - hypokalemia, metabolic acidosis,
leukoencephalopathy, renal injury, rhabdomyolysis
Methylene chloride - metabolized to CO
‘Poppers’ - methemoglobinemia, hemolysis
INHALANTS
Short term effects
Long term effects
Short term effects
q Headaches, nausea, vomiting
q Loss of balance
q Dizziness
q Slurred and slow speech
q Mood changes
q Hallucinations
Long term effects
q Cardiotoxicity (ie., inflammation, CHF, sudden cardiac death)
q Respiratory damage
q Anoxic brain damage
q Liver and kidney damage
q Progressive neurological injury (ie., hearing loss, muscle spasms, loss of coordination)
q Loss of concentration, short term memory loss
Causes of death
q Asphyxia
q Choking
q Suffocation
q Injuries
q Suicides
q Cardiac arrest
SUDDEN SNIFFING DEATH SYNDROME
Sudden sniffing death - abrupt cardiovascular collapse due to an irregular heartbeat
- est’d ~50% of inhalant-related deaths
1,1 difluoroethane (DFE)
q Organic hydrocarbon, colorless, odorless gas used as refrigerant chemical
component of canned air
q Can cause symptoms of inebriation, frostbite or blisters
q CNS depression (drowsiness, nausea, headache, fatigue, weakness)
q Asphyxiant (displace oxygen), heavier than air
q Flammable
Pathophysiology (DFE)
q Cardiac dysrhythmias
q Sensitization of myocardium to catecholamines
q Blocking potassium and calcium channels and sodium current -> prolong
repolarization or increase QT dispersion
q Effects are often unpredictable and occur in first-time users
q Startled by being caught (ie., police, parents) sudden release of catacholamines
Management
q CPR, defibrillation
q Avoid epinephrine, use beta blockers
SUMMARY
Ø ‘Vaping’ predominant among youth
Ø Heating of compounds producing aerosols
Ø Less toxic than ‘traditional’ smoking but still toxic products
Ø VAPI – strong correlation with vitamin E acetate
Ø Nicotine toxicity – seeing increase in children under 5 yrs old
Ø Cannabinoid usage can induce myocardial infarctions
Ø Inhalants - easy access, significant effects, sudden sniffing death
