As the number of people reported to be experiencing lung injury as a result of vaping or using e-cigarettes grows to more than 1,200, the Centers for Disease Control and Prevention have revised its recommendations for clinicians treating vaping-related lung injury.
In a Morbidity and Mortality Weekly Report released Friday, the CDC announced that it is providing “a framework for healthcare providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms of e-cigarette, or vaping, product use associated lung injury (EVALI).”
The most noteworthy addition is that flu season is setting in. Therefore, the CDC urges that, when evaluating any patients presenting with lung symptoms, providers consider “multiple etiologies, including the possibility of EVALI and concomitant infection.”
Below are important experts from the CDC’s most recent guidance:
- When evaluating patients for EVALI, ask about: the use of e-cigarettes, products and types of substances used, product source, specific product name, duration and frequency of use, time of last use, product delivery system, and method of use.
- Be empathetic, nonjudgmental, and guarantee confidentiality.
- Rely on standard guidelines for interviewing adolescents about substance use.
- Physical exams should include vital signs and pulse-oximetry.
- Let clinical findings guide lab testing. The CDC advises a respiratory virus panel, including influenza testing during influenza season, and that any additional testing should be based on published guidelines for evaluation of community-acquired pneumonia.
- Obtain a CXR. A CT chest scan might also be useful, depending on clinical circumstances.
- Consider consulting a pulmonologist.
Treating patients with suspected vaping-related lung injury (EVALI)
- Patients with suspected EVALI should be admitted to the hospital if they have decreased O2 saturation (<95%) on room air, are in respiratory distress, or have comorbidities that compromise pulmonary reserve.
- Outpatient management may be appropriate for patients who are available for follow-up within 48 hours, have normal O2 saturation (≥95%), reliable access to care, and strong social support systems. For these patients, consider antimicrobials, including antivirals.
- Corticosteroids might be helpful in treating this injury, but consider withholding them until after evaluation for infectious etiologies, such as fungal pneumonia, which might worsen with corticosteroids.
- Ideally, consult a specialist before initiating or changing any treatment.
- Follow up with patients hospitalized for EVALI 1-2 weeks after discharge. Conduct pulse-oximetry and consider repeating the CXR. Two months after discharge, consider follow-up testing including spirometry, diffusion capacity testing, and CXR.
- Advise patients to discontinue vaping. Recommend therapy and FDA-approved cessation products.
- Keep in mind that older patients and those who are pregnant or with a history of cardiac or lung disease are at higher risk for more severe outcomes.
- The long-term effects and risk of recurrence of EVALI are unknown.
Public health guidance
- Report cases of suspected EVALI to state, local, territorial, or tribal health departments. When possible, obtain products patients had been using and send them for testing.
- At this time, FDA and CDC have not identified the cause(s) of lung injuries among EVALI cases. The only commonality is that patients report the use of e-cigarettes.
- Data suggest that THC products containing THC, particularly those obtained from informal sources, are linked to most of the cases.
- That said, agencies cannot exclude the possibility that nicotine products are contributing to the outbreak.
- For patients using e-cigarettes to quit smoking, recommend evidence-based treatments, such as counseling and FDA-approved medications.
- People who continue to vape should monitor themselves carefully for symptoms and see a healthcare provider immediately if symptoms develop.
Update on outbreak spread
As of Friday, October 11, 2019, the CDC reported 1,299 cases of lung injury associated with the use of e-cigarette products. Twenty-six deaths have been reported in 21 states.
“When we first distributed advice for clinicians back in late August, the guidance was based on limited experience clinicians had caring for a relatively small number of patients,” Anne Schuchat, MD, principal deputy director of the CDC, told reporters Friday. “We are not seeing meaningful drop-off in new cases.”
Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019, Centers for Disease Control and Prevention.