For Healthcare Providers

Physician with arms folded holding a stethescope

As this investigation continues, CDC encourages clinicians to report possible cases of e-cigarette, or vaping, product use associated lung injury (EVALI) to their local or state health department for further investigation. CDC and FDA are expanding the range of available laboratory testing to support health departments in evaluating possible cases of EVALI.

If EVALI is suspected, a detailed history of the substances used, the sources of products, duration and frequency of use, and the devices used and how they are used should be obtained, as outlined in

CDC has also developed International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM)-Supplement pdf icon[PDF – 160 KB] coding guidance for healthcare encounters related to EVALI.

What is New

CDC has identified vitamin E acetate as a chemical of concern among people with e-cigarette, or vaping, product use associated lung injury (EVALI). Recent CDC laboratory testing of bronchoalveolar lavage (BAL) fluid samples (fluid samples collected from the lungs) from 29 patients with EVALI submitted to CDC from 10 states found vitamin E acetate in all of the samples. Vitamin E acetate is used as an additive, most notably as a thickening agent in THC-containing e-cigarette, or vaping, products.

CDC recommends that people should not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers. While this investigation is ongoing, vitamin E acetate should not be added to e-cigarette, or vaping, products.

In addition, people should not add any substance to e-cigarette or vaping products that are not intended by the manufacturer, including products purchased through retail establishments. CDC will continue to update guidance, as appropriate, as new data become available from this outbreak investigation.

Clinical Guidance

EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Rapid recognition of EVALI patients by health care providers is critical to reduce severe outcomes.

Patient Interview

  • Ask about the use of e-cigarette, or vaping, products in a confidential and nonjudgmental manner when evaluating patients with respiratory symptoms (e.g., cough, chest pain, and shortness of breath), gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea), or constitutional symptoms (e.g., fever, chills, and weight loss).
  • Ask patients about recent use of e-cigarette, or vaping, products. If confirmed, the types of substances used (e.g., THC and nicotine) and where they were obtained should be ascertained.

Physical Examination

  • Assess vital signs and pulse oximetry.

Laboratory Testing and Imaging

  • Laboratory testing should be guided by clinical findings.
    • A chest radiograph (CXR) should be considered on patients with a history of e-cigarette, or vaping, product use, who have respiratory or gastrointestinal symptoms, particularly when chest pain, dyspnea, or decreased oxygen saturation (<95% while breathing room air) are present.
    • Health care providers should evaluate for causes of community-acquired pneumonia according to established guidelines as indicated by imaging findings.
Consideration of Outpatient Management
  • Some patients with history of e-cigarette, or vaping, product use who are evaluated for respiratory, gastrointestinal, or constitutional symptoms might be candidates for outpatient management.
  • Candidates for outpatient management should have normal oxygen saturation (≥95%), no respiratory distress, no comorbidities that might compromise pulmonary reserve, reliable access to care, strong social support systems, and should be able to ensure follow up within 24–48 hours of initial evaluation and to seek medical care promptly if respiratory symptoms worsen; in some cases, patients who initially had mild symptoms experienced a rapid worsening of symptoms within 48 hours.
  • Hospital admission should be strongly considered for patients with concurrent illness such as influenza and potential EVALI, especially if respiratory distress, comorbidities that compromise pulmonary reserve, or decreased oxygen saturation (<95% while breathing room air) are present.
Flu Season Considerations

Influenza Testing and Empiric Antimicrobial, including Antiviral Treatment

  • Influenza testing should be strongly considered, particularly during influenza season. It might be difficult to differentiate EVALI, a diagnosis of exclusion, from influenza or community-acquired pneumonia on initial assessment, and EVALI might co-occur with respiratory infections.
  • Treatment with empiric antimicrobials, including antivirals, should be considered in accordance with established guidelines and local microbiology and resistance patterns for community-acquired pneumonia.
  • Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk for influenza complications, who is diagnosed with confirmed or suspected influenza, on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset Influenza vaccination
  • Health care providers should emphasize the importance of annual influenza vaccination for all persons aged ≥6 months, including patients who use e-cigarette, or vaping products.
  • It is not known whether patients with EVALI are at higher risk for severe complications of influenza or other respiratory infections. In addition, administration of pneumococcal vaccine should be considered for patients with a history of EVALI according to current guidelines.
  • Check out Key Facts About Seasonal Flu Vaccine for more information.
Treatment and Follow-up

Corticosteroid Treatment

  • Corticosteroids might be helpful in treating EVALI.
  • Use of corticosteroids for the treatment of EVALI in the outpatient setting has not been well studied and should be considered with caution. Corticosteroids might worsen respiratory infections commonly seen in the outpatient setting.
  • In published reports primarily including hospitalized patients, most patients with EVALI who received corticosteroids had rapid improvement; dosages have been previously described.
  • Some patients who have not received corticosteroids have also had clinical improvement with cessation of e-cigarette, or vaping, products, and comparative studies have not been conducted.

Post- Discharge Follow-Up

  • Patients discharged from the hospital after inpatient treatment for EVALI should have a follow-up visit within 1–2 weeks.
    • The follow-up evaluation should include pulse-oximetry and consideration of a repeat CXR.
    • Additional follow-up testing 1–2 months after discharge might include spirometry, diffusion capacity for carbon monoxide, and CXR.
    • Health care providers should also advise patients with a history of EVALI to return as soon as possible if they develop new or worsening respiratory symptoms, with or without fever, for early evaluation with influenza testing and early initiation of antiviral or antibiotic treatment, as indicated.

Considerations at Point of Care

Report cases of EVALI within the past 90 days to state or local health department.

Discontinue E-cigarette, or Vaping, Product Use
  • Advising patients to discontinue use of e-cigarette, or vaping, products should be integral to the care approach.
  • Healthcare providers should offer or connect patients to services to stop using e-cigarette, or vaping, products. Resuming use of these products has the potential to cause slowed recovery, recurrence of symptoms, or further lung injury.
  • Adult patients who are using e-cigarette, or vaping, products for smoking cessation should be advised not to return to smoking cigarettes. They should be provided with evidence-based interventions, including behavioral counseling and FDA-approved cessation medications.
  • Adolescents and young adults might benefit from specialized services, such as addiction treatment services and providers who have experience with counseling and behavioral health follow-up.
  • People who have significant impairment or distress from ongoing problematic use of THC-containing vaping products should seek evidence-based behavioral treatment and recovery services for cannabis use disorder.
Public Health Clinical and Product Sample Testing

Testing Bronchoalveolar Lavage (BAL) Fluid Samples by CDC

Testing Pathologic Specimens by CDC

  • If a lung biopsy or autopsy is performed, consider submission of fixed lung biopsy tissues or autopsy tissues to CDC for evaluation.
  • Testing can include evaluation for lipids on formalin fixed (wet) lung tissues that have not undergone routine processing.
  • Conducting routine tissue processing and histopathologic evaluation is still important. Routine microscopic examination will be performed, as well as infectious disease testing, if indicated, on formalin-fixed (wet) tissues, or formalin-fixed, paraffin-embedded tissue specimens.

Testing Aerosol Emissions from E-cigarette, or Vaping, Products by CDC

  • CDC is offering aerosol emissions testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids.
  • Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquid and will improve our understanding of exposure among case-patients associated with the Lung Injury outbreak. CDC is coordinating e-cigarette, or vaping, product analysis with FDA.
  • If product, including devices and liquids, are available for testing, healthcare providers should coordinate with STLT health departments for sample submission.
    • For information about collection and submission of e-cigarette, or vaping, products and e-liquids associated with confirmed or probable cases for possible aerosol emissions testing by CDC, contact IncidentResponse@cdc.gov.
Resources for Healthcare Providers

Algorithm for Management of Patients with Respiratory, Gastrointestinal, or Constitutional Symptoms and E-cigarette, or Vaping, Product Use pdf icon[PDF – 279 KB]
The purpose of this algorithm is to provide a brief summary of the Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, November 2019.

Lung Injury Associated with E-cigarette Use or Vaping National Case Form pdf icon[PDF – 264 KB]
(also available in Spanish pdf icon[PDF – 304 KB])
The purpose of this document is to provide guidance for local and state health departments to report any probable or confirmed patient case of EVALI and transmit data to CDC using the Data Collection and Integration for Public Health (DCIPHER) platform, or by contacting CDC at eocevent101@cdc.gov.

International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM)-Supplement pdf icon[PDF – 160 KB]
The purpose of this document is to provide official diagnosis coding guidance for healthcare encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI). This guidance is consistent with current clinical knowledge about disorders associated with the use of e-cigarette, or vaping, products.

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
This guidance document provides recommendations for health care providers regarding e-cigarette, or vaping, product use associated lung injury (EVALI). This document provides interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital admission and treatment; 3) patient follow-up; 4) special considerations for high risk groups; and 5) clinical and public health recommendations.

Laboratory Clinical Sample Collection, Storage, and Submission Guidance for Lung Injury Associated with E-Cigarettes, or Vaping Product Use pdf icon[PDF – 198 KB]
(also available in Spanish pdf icon[PDF – 98 KB])
The purpose of this document is to provide general sample collection, storage, and shipping guidance for healthcare providers and public health laboratory personnel involved in the care of patients who meet, or are highly suspected of meeting, the case definition for lung injury related to the use of e-cigarette, or vaping, products. For information on the submission of non-tissue samples, please contact IncidentResponse@cdc.gov.

Specimen Submission Guidance for Pathologic Evaluation of Tissue Specimens from Cases of Lung Injury Associated with E-Cigarette, or Vaping Product Use pdf icon[PDF – 142 KB]
This guidance document will assist health departments, healthcare providers, medical examiners or coroners, and pathologists with submission of tissue specimens that could be collected from cases of EVALI.

Video: E-Cigarette 101

Still image from the E-Cigarette Microlearning Video

The Association of State and Territorial Health Officials (ASTHO) and CDC’s Office on Smoking and Health (OSH) recently developed a video with CDC expert Dr. Brian King giving an ‘e-cigarette 101’ talk for clinicians and public health professionals.

Clinician Outreach and Communication Activity (COCA)

COCA Webinar – Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette or Vaping Product Use Associated Lung Injury
On October 17, 2019, CDC experts described updates to prior interim recommendations for U.S. health care providers caring for patients with suspected or known lung injury associated with e-cigarette or vaping products as published in MMWR on October 11, 2019.

COCA Webinar – Outbreak of Lung Injury Associated with E-cigarette Product Use or Vaping: Information for Clinicians
On September 19, 2019, CDC experts described e-cigarette and vaping terminology related to e-cigarette, or vaping products; summarized frequent Clinical, Laboratory, Radiographic, and Pathologic Findings and Outcomes among cases; and discussed recommendations for clinicians.

Poster for Clinical Settings

Poster: Do You Have Any of These Symptoms?

This Poster for Clinical Settings is available in English and Spanish for use in healthcare settings to encourage conversation between patients and providers about their use of e-cigarette, or vaping, products.

CDC Resources

Surgeon General’s Report on E-Cigarette Use

Substance Abuse and Mental Health Services Administration Resources

Quitting Resources

FDA Resources

National Institute on Drug Abuse for Teens

Publications

Morbidity and Mortality Weekly Report (MMWR)

New England Journal of Medicine

If you have questions about CDC’s investigation into the lung injuries associated with use of e-cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636.