For Healthcare Providers

Physician with arms folded holding a stethescope

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, health care providers should ask about the use of e-cigarette, or vaping, products in a confidential and nonjudgmental manner.   The most critical step in assessing EVALI is to ask patients about recent use of e-cigarette, or vaping, products. If confirmed, the types of substances used (e.g., [tetrahydrocannabinol] THC and nicotine) and where they were obtained.

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].

Overview
  • CDC, FDA, and state health authorities have made progress in identifying the cause of EVALI.
  • 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 show 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.
  • 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.
  • 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 related to EVALI as appropriate.

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 presentation (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.
Influenza 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
  • CDC and FDA recommend that people not use THC-containing e-cigarette, or vaping, products, particularly from informal sources like friends, or family, or in-person or online dealers.
  • Resuming use of e-cigarette, or vaping, products during recovery from EVALI has the potential to cause slowed recovery, recurrence of symptoms, or further lung injury.
  • Adults using nicotine-containing e-cigarette, or vaping, products as an alternative to cigarettes should not go back to smoking; they should weigh all available information and consider using FDA-approved smoking cessation medicationsexternal icon. If they choose to use e-cigarettes as an alternative to cigarettes, they should completely switch from cigarettes to e-cigarettes and not partake in an extended period of dual use of both products that delays quitting smoking completely. They should contact their healthcare professional if they need help quitting tobacco products, including e-cigarettes, as well as if they have concerns about EVALI.
  • 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).

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.