Telemedicine article published in Inspirations (the California Thoracic Society newsletter):
Pulmonologist Dr. Ni-Cheng Liang discusses vaping, including what it is, why it’s bad for you and more.
In recent years, cigarette smoking has been on the decline. However, another method of inhaling nicotine — as well as many other chemicals — is on the rise. It’s known as vaping, e-cigarettes or e-cigs. Is vaping safe? According to the Centers for Disease Control and Prevention (CDC), vaping has been linked to more than 40 deaths and thousands of cases of lung disease across the United States.
What is vaping?
Vaping is the process of inhaling a liquid that has been heated into a vapor. Vaping devices contain a cartridge that holds liquid. When someone inhales on the mouthpiece of the device, it triggers a battery-powered heating element that converts the liquid into vapor, which is then inhaled into the lungs. Depending on the ingredients in the liquid, the vapor may contain a variety of compounds, including nicotine, marijuana derivatives, such as THC and CBD, and countless flavorings, ranging from mint and menthol to fruit and candy.
Initially, vaping was viewed as a potential aid to quit smoking, but the FDA has not recognized it as a valid form of nicotine replacement therapy. Research shows that while vaping has helped some quit smoking cigarettes, some users are now addicted to it.
Moreover, vaping has become a popular behavior with nonsmokers, especially among young users. The National Institutes of Health reports that about 37 percent of 12th graders reported vaping in 2018, compared with 28 percent in 2017.
“Vaping has turned into somewhat of a fad among adolescents,” says Dr. Liang. “The e-cigarette user age is much younger than that of smokers, and the flavorings unfortunately attract a younger population.”
Often, parents have no idea their children are using e-cigarettes. Vaping devices come in many shapes and forms, ranging from easily recognizable cylinders and pipes to devices cleverly disguised as USB drives, pens and lip balms.
In addition, vaping is bad for you. Nicotine is addictive, but most worrisome is the damage vaping may do to the lungs. As of December, the CDC reports more than 2,400 cases of lung disease and 52 deaths associated with vaping,
“Vaping contains so many different additives, and one possible culprit in these lung injuries is vitamin E acetate, which dilutes the e-liquid,” explains Dr. Liang. “In many of those patients, vitamin E acetate was found in their lungs.”
Dr. Liang compares vitamin E acetate to honey coating the delicate lining of the lungs and airways, which interferes with normal lung function. Symptoms of vaping-related lung injury have included coughing, shortness of breath, chest pain and coughing up blood.
“The lung injury is partially reversible and steroids are the mainstay of treatment,” Dr. Liang says. “But we don’t even know what vitamin E acetate does to the lungs as this has never come up before. We think it might cause a severe and rapid airway obstruction and it can also induce lung injury from damaging the air sacs within the lungs themselves.”
While vitamin E acetate seems to be more prevalent in black market and homemade e-cartridges, trace amounts have been found in commercial products as well. What’s more, other potentially deadly additives, including cyanide and pesticides, have been identified in some black market products.
There is no “safe” vaping
Is there a way to vape safely? The answer is no. At this time there is no oversight as to what goes into vaping cartridges, so you have no real control over what you breathe into your lungs. “Flavorings” may contain a mix of toxic chemicals. Even substances that are safe to use on skin, such as glycerin, are known to irritate the lungs when inhaled.
“I’ve treated people who have almost died from this type of lung injury and it’s been a huge wake-up call for them,” says Dr. Liang. “It’s not worth your lung health or your life to vape, or even try e-cigarettes.”
If you are trying to quit smoking, talk to your physician about safe, proven methods, including FDA-approved nicotine replacement products and cessation programs. Many workplaces offer programs for their employees and families.
For over fifteen years, the San Diego County Medical Society has collaborated with San Diego Magazine to recognize physicians who are held in the highest regard by their peers. Votes and nominations are open to all physicians in San Diego. They are asked to vote for those within and outside of their specialty to whom they would refer their friends and family. Through this process, 776 physicians in 90 specialties were identified.
Coastal Pulmonary Dr. Eisman, Dr. Hooper, Dr. Hsing, Dr. Liang, Dr. Magana, Dr. Makani, Dr. Shaw, and Dr. Tran were named as Top Doctors in the 2019 edition.
Taught by Dr. Ni-Cheng Liang, Director of Pulmonary Integrative Medicine
2019 American Lung Association San Diego Lung Health Provider of the Year and Outstanding Mother Awardee
Top Doctor San Diego for Pulmonary Medicine 2017 and 2019
Join us Sundays from 9:30am-Noon
Scripps Memorial Hospital Encinitas Conference Center
354 Santa Fe Dr, Encinitas, CA 92024
September 22nd-November 17th, 2019 with a Day of Mindfulness from 9am-4pm on Nov. 3rd
Learn to develop a healthier relationship with stress and other challenges in your life including chronic health conditions. You are innately able to reconnect and strengthen your ability to pay attention, on purpose, and non-judgmentally to the present moment.
Investment for yourself and others.
Special discounted rate for current Coastal Pulmonary Associates patients and care-givers: $99
General Public $399
For more information and to register visit www.ncliangmd.com
Dr. Ni-Cheng Liang is a mother of two, wife, sister, daughter, cancer survivor, and physician. Dr. Liang is the Director of Pulmonary Integrative Medicine at Coastal Pulmonary Associates affiliated with the Scripps Health Network. She also serves as a Voluntary Assistant Professor of Medicine appointment at the University of California San Diego School of Medicine while continuing to volunteer as a pulmonary attending for the UCSD Medical Student Free Clinic for undocumented and underserved patients.
Dr. Liang is passionate about improving the care of patients with chronic lung disease, particularly those with COPD. She was part of the UCSD COPD Readmissions Reduction Committee. Dr. Liang’s experience on this subject has been invaluable to all of California, as she has held a position on the planning committee for the California Thoracic Society since 2016. In 2017, Dr. Liang was recognized as one of San Diego Magazine’s Top Doctors in Pulmonary Medicine. Dr. Liang previously served as the Medical Director of Pulmonary Services at the UCSD Center for Pulmonary and Sleep Medicine.
In 2012, Dr. Liang returned to her practice as a cancer survivor. It was then she became very passionate about incorporating evidence based integrative modalities into her practice of medicine for her patients, as well as mindfulness for optimizing physician well-being and reducing burnout. She attributes allopathic medicine for saving her life, but integrative medicine approaches such as mindfulness and yoga for maximizing her quality of life as a cancer survivor.
Her newfound outlook on life led Dr. Liang to advocate for mindfulness in medicine. She is the immediate past American Thoracic Society (ATS) Integrative Therapies Interest Group Co-Chair, having co-authored the only Patient Education Series document on Integrative Therapies in Pulmonary Patients, published in the American Journal of Respiratory and Critical Care Medicine. She is a committee member of the ATS Wellness and Burnout Collaborative. She has presented and led over 20 experiential workshops and retreats locally and nationally on mindfulness, physician well-being, and integrative medicine to a variety of audiences inclusive of all levels of medical trainees, faculty physicians, healthcare administrators, and patients. She was awarded the UCSD Academy of Clinician Scholars Kaiser Teaching Award twice, and developed a mindfulness-based internal medicine residency wellness curriculum, as well as a mobile wellness program that included short videos of mindfulness practices for healthcare providers. Dr. Liang was also Course Director for the Mindfulness in Medicine medical student course at UCSD between 2013 and 2018.
Dr. Liang began her career at UCSD as an Internal Medicine resident and Pulmonary fellow, and served as a Chief Medical Resident. Dr. Liang and her husband, Gerald, enjoy caring for their two daughters, ages 9 and 14 months. In her free time, Dr. Liang enjoys reading, yoga, meditation, paddle boarding, writing, hiking, and teaching art to her daughter’s third grade class.
When Dr. Scott Eisman started working nights in the Scripps Memorial Hospital Encinitas emergency room during the 1980s, patients were few and far between. With two or three nightly visitors, there was even enough down time to play catch at a baseball field across the street.
Not any more.
“Now it is full almost 24 hours a day,” said Eisman, currently the hospital’s chief of staff. “There has been a tremendous growth in the community.”
To better accommodate increased demand for emergency-room beds in coastal North County from a rising population and the aging baby-boomer set, Scripps Encinitas plans to open a $94 million critical-care building today. The structure includes a new 26-bed emergency department — more than double the size of its predecessor.
North County’s population swelled by about 20 percent over the past decade, according to the San Diego Association of Governments. The hospital’s former emergency room, which hadn’t been expanded since 1991, couldn’t keep up.
Since 2000, the number of people visiting Scripps Encinitas’ emergency room soared more than 50 percent. Last year alone, the emergency department served just over 40,000 patients, compared with almost 27,000 patients in 2003.
“They were overbooked like a hotel that sold too many rooms,” said Tom Grant, 82, of Encinitas. He has visited the Scripps Encinitas emergency room several times and found an overflow crowd on each occasion. Grant said he and his wife, Mary Ellen, donated $1 million toward the new emergency department after seeing the need for a revamped facility.
In past years, the small emergency room forced doctors and nurses to place patients in different locations throughout the hospital — an inefficient system, Eisman said.
The new facility consolidates beds and equipment. Upon entering the waiting room, with its modern wood paneling and blue-and-gray stone walls, nurses take patients into rooms designed to assess the severity and urgency of an injury or illness, and then to private rooms for further care. Eisman expects the upgraded system to shorten treatment times.
For easy access, a CT scanner, an MRI scanner and digital diagnostic X-ray units are housed in the emergency department.
On the second floor, the new facility has 36 private surgical impatient rooms — including twelve that can be used for intensive care.
“It is very flexible,” Eisman said. “It really serves the different needs of the area.”
Scripps Encinitas is one of several medical centers in San Diego County to renovate or reconstruct its facilities in recent years. Palomar Health completed a 740,000-square-foot Palomar Medical Center in Escondido in 2012, while Kaiser Permanente in San Diego broke ground on its new hospital in February.
Hospitals must regularly remodel their infrastructure to keep up with changing technology and regulations, said Nate Kaufman, the managing director for Kaufman Strategic Advisors, a health-care consulting firm.
Many health providers are renovating or building new facilities in part to comply with a California law that requires hospitals to meet certain earthquake safety standards, Kaufman added.
Chris Van Gorder, chief executive for the Scripps Health network, said the state mandate to update facilities has not come without pain.
“This is probably the largest unfunded liability in the history of the state,” Van Gorder said. “It has been a huge burden for us and for hospitals throughout California.”
The new critical-care building at Scripps Encinitas is part of an expansion project financed by philanthropic donations, operational income and debt financing.
Scripps Health has worked to secure donations to help defray the cost of the Encinitas project, collecting about $40 million to date — including a $10 million contribution from the Leichtag Family Foundation, the network said.
Van Gorder hopes the public continues to donate toward the $58 million fundraising goal.
“We have found that people tend to donate after they can see what they’re donating for,” he said.
Staff writer Paul Sisson contributed to this report.
The medical staff at Scripps Memorial Hospital Encinitas has voted local resident Dr. Scott Eisman to a two-year term as the facility’s chief of staff.
Eisman is board certified in internal medicine, critical care medicine and pulmonary disease. In addition to his chief of staff duties, he serves as medical director of the hospital’s intensive care unit and hospitalist program. Previously, he chaired Scripps Encinitas’ pulmonary and internal medicine divisions.
As chief of staff, Eisman will be responsible for setting the agenda for and presiding at all meetings of the medical staff. He will also serve as the primary liaison between the hospital’s medical staff of more than 650 physicians and Scripps Health’s executive leadership and board of trustees. Visit www.scripps.org.