For Healthcare Providers

Physician with arms folded holding a stethescope

As this investigation continues, CDC encourages clinicians to continue 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.

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.

Hospitalized patients should be documented as clinically stable for 24–48 hours prior to discharge. Patients should have a follow-up visit with a primary care provider or pulmonary specialist, optimally within 48 hours of discharge, as outlined in

New tools for physicians include an updated algorithm pdf icon[print-only PDF – 120 KB] for management of patients with suspected EVALI and a Discharge Readiness Checklist pdf icon[PDF – 110 KB].

What is New
  • CDC, FDA, and state health authorities have made progress in identifying substances of concern in EVALI, and in characterizing the outbreak.
  • Emergency department (ED) visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.
  • National and state data from patient reports and product sample testing suggest tetrahydrocannabinol (THC)-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak.
    • 82% of hospitalized patients with data on substance use reported using THC-containing products; 33% reported exclusive use of THC-containing products (as of January 14, 2020).
    • 50% of EVALI patients who reported using THC-containing products provided data on product source (as of January 7, 2020).
      • 16% reported acquiring products only from commercial sources (recreational and/or medical dispensaries, vape or smoke shops, stores, and pop-up shops).
      • 78% reported acquiring products only from informal sources (family/friends, dealers, online, or other sources).
      • 6% reported acquiring products from both commercial and informal sources.
    • CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, family, or in-person or online dealers.
  • In an Illinois study, 14% of 121 interviewed EVALI patients reported using only nicotine-containing e-cigarette, or vaping, products. This is consistent with national findings.
    • Nine of the interviewed EVALI patients had no indication of any THC use.
    • Some EVALI patients report the use of only nicotine-containing e-cigarette, or vaping, products. The contributing cause or causes of EVALI for individuals reporting use of only nicotine-containing products warrants further study.
  • Vitamin E acetate is strongly linked to the EVALI outbreak. Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by CDC from geographically diverse states. Vitamin E acetate has not been found in the lung fluid of people that do not have EVALI.
  • However, evidence is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products, in some of the reported EVALI cases.

CDC will continue to update guidance as we learn more about EVALI.

Evaluation

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 healthcare providers is critical to reduce severe outcomes.

Influenza cannot be distinguished from EVALI by signs, symptoms, clinical features at presentations (medical examination), or testing. Acute respiratory illness in a patient with a history of e-cigarette/vaping and THC exposure could be caused by influenza viruses, other respiratory infections, EVALI, or all of the above.

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, stomach pain, and diarrhea), or nonspecific 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.
  • Learn best practices for the patient interview with Don’t Forget to Ask pdf icon[PDF – 129kb].

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.
    • Healthcare 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% while breathing room air), 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.
  • Healthcare 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, product use, and comparative studies have not been conducted.

Discharge Planning

  • Hospitalized patients should be documented as clinically stable for 24–48 hours prior to discharge.
  • Healthcare providers should assure patients have social support and access to mental health and substance use disorder services.
  • Medication reconciliation and patient counseling should be provided by the inpatient pharmacist to help ensure medication adherence.
  • Healthcare providers should confirm patients have a follow-up appointment with a primary care provider or pulmonology specialist, optimally within 48 hours of discharge.
  • Healthcare providers can use the EVALI Discharge Readiness Checklist pdf icon[PDF – 110 KB] to help plan for safe discharge.

Post- Discharge Follow-Up

  • Patients discharged from the hospital after inpatient treatment for EVALI should have a follow-up visit with a primary care provider or pulmonology specialist, optimally within 48 hours.
    • The follow-up evaluation should include: clinical assessment to confirm that the patient’s respiratory status is stable; ongoing education about EVALI; ensuring adherence with medication regimens such as tapering of corticosteroids (if prescribed at the time of hospital discharge); reinforcing the importance of abstinence from e-cigarette, or vaping, product use; facilitating connection to outpatient care by all providers or services indicated by patients’ medical history or conditions; connecting patients to needed social, mental health, and substance use disorder resources; and establishing connections to necessary services.
  • Longer-term pulmonary follow-up should generally occur within 2–4 weeks after discharge (often at completion of the corticosteroid taper) to assess pulmonary function and resolution of radiographic findings.
  • Additional follow-up testing 1–2 months after discharge might include spirometry, diffusing capacity of the lung for carbon monoxide (DLCO), and CXR.
  • Patients who have experienced prolonged immobilization during hospitalization (particularly those with intensive care unit-related deconditioning and muscle atrophy) might benefit from physical therapy. Ongoing engagement with addiction medicine and mental health services should be considered as indicated.
  • Healthcare 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

  • Consider posting reminders or signage (poster for clinical settings available in Englishpdf icon [print-only PDF – 299 KB] or Spanishpdf icon [print-only PDF – 296 KB]) to encourage conversation between patients and providers about use of e-cigarette, or vaping, products.

Report cases of EVALI within the past 90 days to your 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.
  • The best way for people to ensure that they are not at risk while the investigation continues is to consider refraining from use of all e-cigarette, or vaping, products. Adults using e-cigarettes as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using FDA-approved cessation medicationsexternal icon.
  • People who have significant impairment or distress from ongoing problematic use of THC-containing e-cigarette, or vaping, products should seek evidence-based behavioral treatment and recovery services. Visit Substance Abuse and Mental Health Services Administration’s Treatment Locatorexternal icon to locate treatment in your area or call 1-800-662-HELP (4357).
Public Health Clinical and Product Sample Testing

Testing Bronchoalveolar Lavage (BAL) Fluid Samples by CDC

Testing Pathologic Specimens by CDC

  • CDC can continue to provide technical assistance to state, tribal, local, and territorial (STLT) health departments by evaluating fixed autopsy tissue specimens from individuals with a history of e-cigarette, or vaping, product use who die and for whom EVALI or a possible infectious etiology are suspected.
  • See Specimen Submission Guidance for Pathologic Evaluation of Tissue Specimens from Deaths with Suspected E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI)pdf icon [PDF – 165 KB] for more information.
  • If individuals with a history of e-cigarette, or vaping, product use are identified after death or at autopsy and show microscopic findings consistent with acute lung injury, had antecedent respiratory or gastrointestinal symptoms, or are otherwise suspected of having EVALI, medical examiners, coroners, and other pathologists are encouraged to report the cases to their STLT health departments.
  • Fixed lung biopsy tissue specimens may also be submitted on a limited case-by-case basis if there is a specific suspicion for a possible infectious disease etiology. Please contact pathology@cdc.gov for consultation.
  • CDC will perform routine microscopic examination, as well as infectious disease testing, if indicated, on formalin-fixed (wet) tissues, or formalin-fixed, paraffin-embedded (FFPE) tissue specimens.
  • Pre-approval is required before submission of specimens to CDC. For more information and to obtain pre-approval or consultation regarding specimen submission, please contact pathology@cdc.gov.

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

  • CDC is conducting aerosol emissions testing of case-associated product samples from e-cigarette, or vaping, products and e-liquids paired to BAL fluid samples.
  • Analysis of aerosol emissions will augment FDA’s ongoing work to characterize e-liquids 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.
  • Healthcare providers should coordinate with STLT health departments for product and BAL fluid sample submission.
Resources for Healthcare Providers

Update: Characteristics of a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, August 2019–January 2020
This report updates patient demographic characteristics, self-reported substance use, and hospitalization dates for EVALI patients reported to CDC by states, as well as the distribution of emergency department (ED) visits related to e-cigarette, or vaping, products. Data show that ED visits related to e-cigarette, or vaping, products continue to decline, after sharply increasing in August 2019 and peaking in September.

Characteristics of Persons Who Report Using Only Nicotine-Containing Products Among Interviewed Patients with E-cigarette, or Vaping, Product Use–Associated Lung Injury — Illinois, August–December 2019
This report examines EVALI patients who report using only nicotine-containing e-cigarette, or vaping, products in Illinois. Findings suggest that the contributing cause or causes of EVALI for individuals reporting use of only nicotine-containing products warrants further study.

Update: Product, Substance-Use, and Demographic Characteristics of Hospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, August 2019–January 2020
This report updates patient demographic characteristics, self-reported substance use, and e-cigarette, or vaping, product sources reported to CDC as of January 7, 2020. Findings strengthen the association between EVALI and the use of THC-containing e-cigarette, or vaping, products obtained from informal sources.

Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019
This guidance document provides updates to prior interim guidance for U.S. healthcare providers evaluating and caring for patients with suspected EVALI, with particular considerations for discharge planning and optimized follow-up and case management after discharge.

Algorithm for Management of Patients with Respiratory, Gastrointestinal, or Constitutional Symptoms and E-cigarette, or Vaping, Product Use (12/20/2019) pdf icon[print-only PDF – 120 KB]
The purpose of this algorithm is to provide a brief summary of the Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019.

EVALI Discharge Readiness Checklist pdf icon[PDF – 110 KB]
This checklist can be used to assist with planning towards the safe discharge of patients hospitalized with EVALI.

Characteristics of Patients Experiencing Rehospitalization or Death After Hospital Discharge in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injury Lung Injury — United States, 2019
This is the first report that analyzes factors that may increase risk for rehospitalization and death among EVALI patients following hospital discharge. These findings helped inform updates to clinical guidance for healthcare professionals.

Vitamin E Acetate in Bronchoalveolar-Lavage Fluid Associated with EVALIexternal icon
This study analyzed bronchoalveolar lavage (BAL) fluid samples from EVALI cases and a comparison group of healthy people, demonstrating that vitamin E acetate is closely associated with EVALI.

Syndromic Surveillance for E-Cigarette, or Vaping, Product Use–Associated Lung Injuryexternal icon
This report analyzed syndromic data on emergency department visits associated with possible EVALI. Data suggest that the EVALI outbreak began in June 2019 and cases have been declining since a peak in September.

Don’t Forget to Ask: Assessing the Risk of Lung Injury in Patients Using E-Cigarette, or Vaping, Products pdf icon[PDF – 129kb]
This fact sheet covers best practices for assessing the risk of lung injury in patients using e-cigarette, or vaping, products. Learn how to ask patients about e-cigarette, or vaping, product use.

Case Study: A Teen With Cough: Could This Be Vaping Related?external icon
Early diagnosis of EVALI and appropriate treatment remains critical to improving patient outcomes. Challenge yourself with a Medscape Case Study that illustrates key EVALI evaluation and treatment scenarios.

Update: Demographic, Product, and Substance-Use Characteristics of Hospitalized Patients in a Nationwide Outbreak of E-cigarette, or Vaping, Product Use–Associated Lung Injuries — United States, December 2019
This is the first report that analyzes national data on use of THC-containing product brands by patients with e-cigarette, or vaping, product use-associated lung injury (EVALI).

Characteristics of E-cigarette, or Vaping, Products Used by Patients with Associated Lung Injury and Products Seized by Law Enforcement — Minnesota, 2018 and 2019
This is the first report presenting chemical analytic results on products obtained from EVALI patients and on products intended for the illicit market both before and during the outbreak. These data further support a potential role for vitamin E acetate in the EVALI outbreak.

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
This guidance document provides updates to prior interim recommendations for U.S. healthcare providers evaluating and managing patients with suspected or known lung injury associated with e-cigarette, or vaping, product use, with particular considerations for outpatient management and for influenza season.

Lung Injury Associated with E-cigarette Use or Vaping National Case Formpdf icon [print-only PDF – 264 KB]
(also available in Spanishpdf icon) [print-only 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)-Supplementpdf icon [PDF – 160 KB]
The purpose of this document is to provide official diagnosis coding guidance for healthcare encounters related to the 2019 healthcare 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.

Laboratory Clinical Sample Collection, Storage, and Submission Guidance for Lung Injury Associated with E-Cigarettes, or Vaping Product Usepdf icon [PDF – 198 KB]
(also available in Spanishpdf 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 Deaths with Suspected E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI)pdf icon [PDF – 165 KB]
This guidance document will assist health departments, healthcare providers, medical examiners or coroners, and pathologists with submission of tissue specimens, particularly from autopsy, that could be collected from individuals with suspected 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 Healthcare Providers regarding the Management Approach of Patients with Suspected E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI)
On November 21, 2019, CDC experts described updates to prior interim recommendations for U.S. healthcare providers evaluating and managing patients with suspected or known lung injury associated with e-cigarette, or vaping, product use, with particular considerations for outpatient management and for influenza season, as published in MMWR on November 19, 2019.

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. healthcare 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.