One night at the hospital, I learned that a critically ill patient was being flown in on a helicopter.

His lungs were severely injured, dangerously limiting the amount of oxygen delivered to the brain and the rest of the body. The damage to his heart was already evident. His blood pressure was falling rapidly. He would need to be placed on the heart-lung machine as soon as he arrived.

“Apparently, he suddenly complained of having trouble breathing,” a colleague explained to me. “Then he just collapsed.”

“But something must have injured his lungs. Does he have pneumonia?” I asked.

My colleague shook his head.

“Did he have a massive heart attack? Does he have severe asthma? How about a clot in his lungs? COPD? Pancreatitis?” I was nearing the bottom of my list of differential diagnoses.

None of these was correct.

“Well, how old is the patient? Does he have any other illness?” I asked, hoping to find a clue in his story.

Before I had a chance to process it all and express my confusion, the doors opened, revealing a teenager who was barely old enough to begin shaving. He already had a breathing tube inserted into his trachea by paramedics. The alarms blared continuously because so little oxygen was getting in his body.

We immediately placed him on the heart-lung machine. To our relief, his blood pressure and oxygen status stabilized.

However, we also knew that this was only the beginning of the hourglass. This machine, while a powerful substitute for his heart and lungs for the time being, was not a cure. We had gained only a little more time to figure out what could possibly be going on in this young and previously healthy patient’s lungs.

Solution

Electronic cigarettes, also known as e-cigarettes, e-hookahs, or vapes, are devices people use to inhale an aerosol containing primarily nicotine and other chemicals. These devices — heavily advertised to youth in the United States — often have a sleek design, resembling a pen or a USB drive. They have become extraordinarily popular, especially among young consumers. A recent study estimated that more than a third of high school students were vaping in 2018.

However, with its rise in popularity, the medical profession also began to observe the dangerous consequences of vaping. As of Nov 5., more than 2,000 cases of e-cigarette or vaping associated lung injury (EVALI) have been reported in the United States. The symptoms may vary from being mild to life-threatening, requiring invasive rescue therapies such as heart-lung machines. It has already claimed the lives of more than 30 people.

The U.S. Centers for Disease Control and Prevention recommends against the use of vaping products at this time. Most serious injury cases have detected THC, the psychoactive component of marijuana, in the aerosol.

Just last week, health officials announced a “breakthrough” in the investigation, the identification of Vitamin E acetate as a “very strong culprit” in lung injuries. The substance is sometimes added to THC-based vaping products. That’s not the end of the story, though; other chemicals or toxins from vaping could be causing the illnesses, officials said.

There is much more we do not know. We don’t know what made the young man who arrived in our ER by helicopter more vulnerable to EVALI than the other millions of people who use vaping products. We don’t know how long it will take for this boy to recover. We don’t know if his lungs will ever return to being normal again.

What we do know is that millions of people, especially young adults who have become addicted to vaping, are at risk of falling severely ill. Most of them are probably unaware of the danger — after all, e-cigarettes have also been marketed heavily as a good way to quit cigarettes, implying that they must be safe. But by the time users have trouble getting air, it’s too late to prevent injury.

Our patient’s lungs did recover enough while being supported on the heart-lung machine to transition to a ventilator. He is making incremental progress daily. But again, as with most cases that have been reported so far, we don’t yet know what his quality of life will be in the long term.

Jason Han is a resident in cardiothoracic surgery in the Perelman School of Medicine at the University of Pennsylvania.