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Official websites use. Share sensitive information only on official, secure websites. Email: dr. This article is distributed under the terms of the Creative Commons Attribution 4. The use of cannabis for recreational as well as medicinal use is on the rise recently with more states legalizing it. We conducted a review analysis of the literature published on acute respiratory failure from vaping cannabis oil. We have also summarized the clinical details age, length of stay, mode of ventilation, common clinical findings, and steroid use along with common laboratory abnormalities. This article aims to educate health care providers on the clinical manifestations and management strategies for vaping-induced acute respiratory failure. We also discussed the different available formulations of cannabis oil and key ingredients responsible for the vaping-associated lung injury. Keywords: cannabis, cannabidiol, tetrahydrocannabinol, terpenes, acute respiratory failure, acute respiratory distress syndrome, cannabinoid hyperemesis syndrome. The recreational use of cannabis is increasingly prevalent in the United States, with more states legalizing its recreational and medicinal use. While cannabis has over a active ingredients, most attention is drawn toward 2 main ingredients: cannabidiol CBD and tetrahydrocannabinol THC. THC is mainly responsible for the psychoactive symptoms, while CBD is increasingly used to treat chronic medical comorbidities. CBD is widely available for public usage in various forms as no current regulations exist to dictate usage as it does not cause any psychoactive symptoms. One form, which has picked up significantly, especially among teenagers and millennials is the vaping of cannabis. Vaping cannabis oil is convenient; it is discrete, affordable, and delivers the most amount of the compound compared with other routes of cannabis oil use. We, in this case series, shed light on recent data collected from 7 cases who presented with vaping-associated lung injury VALI after vaping cannabis oil. A year-old Hispanic female college student with no significant past medical history presented to the emergency room with fever, chills, productive cough with dark phlegm, rhinorrhea, headaches along with abdominal pain, and shortness of breath for 2 days. Physical examination was unremarkable except for diminished breath sounds with rales bilaterally. Chest X-ray CXR revealed right lung base infiltrate. The patient was diagnosed with community-acquired pneumonia and was discharged on oral azithromycin, ondansetron, and ibuprofen. She returned to the emergency room the following day with progressively worsening shortness of breath. Computed tomography angiogram CTA of the chest with and without contrast revealed bilateral patchy ground glass opacities within the bronchovascular distribution Figure 1. She never smoked cigarettes. She denied having any pets, recent travel history, or exposure to any sick contacts. Airway examination was normal on bronchoscopy and bronchoalveolar lavage BAL gram stain showed mixed respiratory flora and cultures were negative bacterial, fungal, and viral pathogens. Antibiotics were escalated to ceftriaxone and azithromycin for 5 days. Her symptoms significantly improved and was discharged home 7 days later without the need for supplemental oxygen. Case Series Analysis Table a. A year-old Caucasian male college student with medical history of depression and anxiety presented with subjective fevers, shortness of breath, productive cough, nausea, vomiting, and epigastric pain for 4 days. Patient admits experiencing similar symptoms 2 months prior to this presentation and was treated with oral antibiotics for 10 days as an outpatient. Denies having any pets, recent travel, or exposure to sick contacts. Physical examination was significant for respiratory distress and decreased breath sounds on both lung bases. Extensive infectious workup including sputum studies, urine, and serum studies were negative Table 1. CXR showed bilateral air space disease and CT of the chest without contrast showed bilateral upper lobe ground glass opacities and lower lobe dense consolidations Figure 2. Ultrasound of the abdomen was unremarkable. He was discharged home with 2 L of supplemental oxygen via nasal cannula on prednisone 40 mg daily with a 3-week steroid taper regimen. A year-old old Hispanic male with medical history of anxiety presented to the emergency room complaining of fever, shortness of breath, productive cough with green phlegm, and body aches for 2-day duration. He denies any sick contacts or recent travel. Vitals signs on presentation were temperature Physical examination was remarkable for respiratory distress and bilateral coarse breath sounds on auscultation. Initial CXR showed bilateral infiltrates and CT chest without contrast showed bilateral patchy glass patchy opacities with subpleural sparing and small right pleural effusion Figure 3. He was started on IV methylprednisone 60 mg daily for 2 days and then converted to oral prednisone 40 mg daily. He clinically improved and was discharged on room air with steroid taper to be completed in 2 weeks. Bilateral ground glass patchy infiltrates with subpleural sparing and small right pleural effusion. A year-old Hispanic female with no significant past medical history presented with fever, chills, shortness of breath, and productive cough with whitish phlegm for 4 days. She also admits decreased appetite with a pound weight loss since the last month. Denies any recent travel history or exposure to sick contacts. Vital signs on presentation were temperature of Lungs were clear to auscultation and the rest of the physical examination was also unremarkable. Initial CXR showed left basilar infiltrate and she was started on levofloxacin for presumed pneumonia. Her respiratory status declined over the next few days and CTA of chest later showed bilateral upper lobe ground glass opacities Figure 4. Airway examination was normal on bronchoscopy and BAL gram stain showed mixed respiratory flora and cultures were negative for bacterial, fungal, and viral pathogens. Her symptoms subsequently resolved, and she was sent home on room air with a tapering steroid course over 2 weeks. A year-old Caucasian female waitress at a local restaurant presented with complaints of worsening dyspnea, productive cough with yellow phlegm, nausea, vomiting, generalized weakness, and diarrhea for 2 weeks duration. She was prescribed azithromycin 10 days prior to this presentation without any improvement in her symptoms. She denied any sick contacts or travel abroad. On physical examination, the patient was in respiratory distress with vital signs of temperature Physical examination was significant for decreased breath sounds throughout the lung fields. Extensive infectious workup including sputum studies urine and serum studies were negative Table 1. CXR showed bilateral interstitial infiltrates and CTA of the chest with and without contrast confirmed bilateral upper lobe ground glass patchy infiltrates Figure 5 a. The patient was started on IV methylprednisolone 60 mg daily and then transitioned to oral prednisone 40 mg daily. A repeat CT chest with contrast 6 days after steroid initiation showed interval improvement of patchy bilateral infiltrates with a small residual superior segment of right lower lobe ground glass opacity Figure 5 b. She was discharged home with a tapering course of steroids for a total to 2 weeks. Bilateral pleural effusions with peribronchovascular ground glass infiltrates with septal thickening, nodular pattern. A year-old Hispanic female with no significant past medical history presented with progressively worsening dyspnea, nonproductive cough, subjective fevers, nausea, decreased appetite, and fatigue for 10 days. She was alert and oriented on physical examination and in mild respiratory distress, noted to have diffuse bilateral wheezing with rhonchi on auscultation. CTA of the chest showed bilateral diffuse ground glass opacities with septal thickening, tree in bud opacities, and bilateral pleural effusions Figure 6. She was diagnosed with community-acquired pneumonia and was started on azithromycin and ceftriaxone. As the hypoxia did not improve with antibiotics, she was later started on IV methylprednisolone 60 mg daily for 3 days, changed to oral prednisone 40 mg daily for presumed VALI. She received azithromycin and ceftriaxone for a total of 5 days during her hospital stay. Repeat CXR showed an improvement, and the patient was discharged home with a steroid taper for a total of 2 weeks. A year-old Hispanic male presented to the urgent care with complaints of fatigue and generalized body aches for 2 weeks with fever CXR at that time showed basilar interstitial infiltrates and was sent home with doxycycline for presumed pneumonia. Subsequent follow-up with primary care provider 3 days later showed worsening dyspnea and a new left side pleuritic chest pain. The patient was advised to complete his prescribed antibiotic course and also given a prescription for albuterol, fluticasone-salmeterol inhalers. The following day, the patient presented to the emergency room with worsening respiratory symptoms and is concerned that he is having vaping lung injury after seeing a local news report about the possible lung problems associated with vaping. The patient admitted vaping THC daily. He complained of worsening shortness of breath on exertion along with decreased appetite. He denied any nausea and vomiting. On physical examination, the patient was in respiratory distress with temperature of Auscultation of the lungs revealed diminished coarse breath sounds throughout the lung fields. Pertinent abnormal laboratory workup was mentioned in Table 1. CXR showed bilateral patchy opacities and CTA of the chest showed diffuse ground-glass opacities with crazy paving pattern with subpleural sparing Figure 7. Extensive infectious and autoimmune workup was negative. He was started on high dose of methylprednisone 60 mg IV every 12 hours for 2 days then transitioned to oral prednisone. He decompensated after switching to oral steroids, hence IV methylprednisone 60 mg IV q12 hours was restarted for 5 more days, then again tapered to oral steroids. He was discharged home on 2 L of oxygen via nasal cannula along with steroid taper over the next 3 weeks. Cannabis sativa is a flowering plant indigenous to eastern Asia but now is cultivated throughout the world due to its widespread industrial uses. Cannabinoids are being consumed in varied formulations, and vaping is one such delivery method that has been increasingly used in the recent times. Vaping device consists of a vape cartridge containing the desired material in the liquid formulation nicotine or cannabinoids along with a mouthpiece, battery, and a heating component that converts the liquid formulation in the cartridge to a vapor form facilitating inhalation. Vitamin E acetate is another additive commonly added to THC-based cigarettes or vaping products. Though benign with oral intake, inhalation of vitamin E acetate aerosols was associated with an increase in the markers of lung injury by analyzing bronchoalveolar lavage fluid. With the increasing use of cannabis-based products and vaping devices in the United States, vaping cannabis has emerged as a major route of cannabis consumption. These cartridges can then be used with vaping devices that are commercially available in the market. The series of cases we presented above suggest a possible etiological link between vaping cannabis and respiratory failure. Along with respiratory distress, our cases also experienced flu-like symptoms, fatigue, fevers, and gastrointestinal symptoms like nausea, vomiting, and abdominal cramps. A high index of clinical suspicion combined with detailed history, supported by imaging studies, and the absence of an alternative etiology for respiratory failure is the key to diagnose VALI. It should be highly suspected among cases who develop respiratory distress after vaping along with a positive drug screen, consistent laboratory, and imaging findings after ruling out other alternative etiologies including infections. Apart from supportive care by providing oxygen supplementation, initiation of steroids or antibiotics depend on the initial clinical presentation and subsequent clinical course. Routine use of steroids is not advisable, and the decision on steroid initiation is based on individual clinical assessment. While early initiation among cases with severe respiratory distress and withholding steroids among cases with alternative diagnosis is universally accepted, early initiation versus conservative management among less severe cases is still a topic of debate. Recommended dose includes methylprednisolone equivalent of 0. Empiric antibiotics should be initiated in those cases for possible pneumonia awaiting results of infectious workup and clinical improvement. After documenting clinical stability for 1 to 2 days, patients can be safely discharged but a close follow-up is required owing to the increased risk of worsening and readmission among cases with VALI. Patients should also be educated to stay away from vaping strictly. High clinical suspicion along with early diagnosis and appropriate clinical intervention is crucial and has led to the successful recovery in our patients. Vaping cannabis oil can lead to acute respiratory failure. A high index of suspicion among treating physicians is needed to facilitate prompt diagnosis and treatment initiation. Our case series and above discussion should help increase physician awareness on the clinical presentation of these cases, to aid in the early diagnosis and prompt management, thus decreasing the morbidity, mortality, and prolonged hospital course. Ethics Approval: Our institution does not require ethical approval for reporting individual cases or case series. Informed Consent: Verbal informed consent was obtained from the patient s for their anonymized information to be published in this article. As a library, NLM provides access to scientific literature. Find articles by Sreedhar Adapa. 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Buying hash Wuhan