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 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 and Fact Sheet for Evaluating and Caring for Patients with Suspected EVALI pdf icon[PDF – 119 KB] (also available in Spanish pdf icon[PDF – 82 KB]).

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 might be 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 e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers. Until the relationship of vitamin E acetate and lung health is better understood, 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 Evaluation

EVALI is a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis. Health care providers should consider multiple etiologies, including the possibility of EVALI and concomitant infection.

History

  • Ask about respiratory (e.g., cough, chest pain and shortness of breath), gastrointestinal (e.g., abdominal pain, nausea, vomiting and diarrhea), and constitutional symptoms (e.g., fever, chills and weight loss) for patients who report a history of using e-cigarette, or vaping, products. Gastrointestinal symptoms preceded respiratory symptoms in some patients.
  • Ask patients about recent use of e-cigarette, or vaping, products and ideally should ask about types of substances used (e.g., THC, cannabis [oil, dabs], nicotine, modified products or the addition of substances not intended by the manufacturer); product source, specific product brand and name; duration and frequency of use, time of last use; product delivery system, and method of use (aerosolization, dabbing, or dripping).

Physical Examination

  • Assess vital signs and oxygen saturation via pulse oximetry.
  • Pulmonary findings on auscultation have often been unremarkable.

Laboratory Testing

  • Initial laboratory evaluation should be guided by clinical findings.
    • Consider complete blood count with differential, liver transaminases, and inflammatory markers (e.g., erythrocyte sedimentation rate and C-reactive protein), which may be elevated (Layden JE, 2019).
    • Consider conducting urine toxicology testing, with informed consent, including testing for THC.
  • Infectious disease evaluation to rule out other etiologies might include
    • Respiratory viral panel including influenza testing during flu season, Streptococcus pneumoniaeLegionella pneumophilaMycoplasma pneumoniae, endemic mycoses, and opportunistic infections.

Imaging

  • Chest radiograph (CXR).
  • Consider chest computed tomography (CT) for evaluation of severe or worsening disease, complications, other illnesses, or when CXR result does not correlate with clinical findings.
  • Radiographic findings consistent with EVALI include pulmonary infiltrates on CXR and opacities on CT scan.(Henry TS, 2019; Schier JG, 2019)

Other Considerations

  • Further evaluation of patients meeting inpatient admission criteria might include:
    • Consultation with pulmonary, critical care, medical toxicology, infectious disease, psychology, psychiatry, and addiction medicine specialists.
    • Additional testing with bronchoalveolar lavage (BAL) or lung biopsy as clinically indicated, in consultation with pulmonary specialists.
Treatment and Follow-up

Admission Criteria and Outpatient Management

  • Strongly consider admitting patients with potential lung injury, especially if patients have respiratory distress, comorbidities that compromise pulmonary reserve, or decreased (<95%) O2
  • Outpatient management for patients with suspected lung injury might be considered on a case-by-case basis, in particular for patients with less severe injury, lack of comorbidities, and for whom follow-up within 24–48 hours of initial evaluation can be assured.
  • Outpatients should have normal oxygen saturation, reliable access to care and social support systems, and be instructed to promptly seek medical care if respiratory symptoms worsen.

Medical Treatment

  • Consider initiation of corticosteroids except for patients with possible fungal pneumonia, that might worsen with corticosteroid treatment. Among 140 cases reported nationally to CDC that received corticosteroids, 82% of patients improved.
    • In some circumstances, it would be advisable to withhold corticosteroids while evaluating patients for infectious etiologies, such as fungal pneumonia, that might worsen with corticosteroid treatment.
  • Consider influenza antivirals in accordance with established guidelines.
  • Early initiation of antibiotic coverage for community-acquired pneumonia should be strongly considered in accordance with established guidelines.

Patients Not Admitted to Hospital

  • Follow-up within 24–48 hours to re-assess and manage possible worsening lung injury.
  • Consider empiric use of antimicrobials including antivirals.

Post-Hospital Discharge Follow-Up

  • Schedule follow-up visit no later than 1–2 weeks after discharge that includes pulse-oximetry testing.
  • Consider additional follow-up testing including spirometry and diffusion capacity testing and consider repeat CXR in 1–2 months.
  • Consider endocrinology consultation for patients treated with high-dose corticosteroids.

Cessation Services and Preventative Care

  • Strongly advise patients to discontinue use of e-cigarette, or vaping, products.
  • Provide education and cessation assistance for patients to aid nicotine addiction and treatment or referral for patients with marijuana use disorder.
  • Advise adult patients using e-cigarettes, or vaping, products, to quit smoking, and to not to return to smoking cigarettes.
  • Adult patients addicted to nicotine should be provided with evidence-based interventions, including behavioral counseling and FDA-approved medications.
  • Emphasize the importance of routine influenza vaccination and consider pneumococcal vaccination in accordance with established guidelines.

Considerations at Point of Care

Report cases of lung injury associated with use of e-cigarette, or vaping, products within the past 90 days to state or local health department.

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.
Flu Season and Other Considerations

It is unknown if patients with a history of EVALI are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury.

  • Health care providers should emphasize the importance of annual vaccination against influenza for all persons >6 months of age, including patients with a history of EVALI. In addition, administration of pneumococcal vaccine should be considered according to current guidelines.
  • Early initiation of antimicrobial treatment for community-acquired pneumonia in accordance with established guidelines should be strongly considered given the overlap of signs and symptoms in these conditions. During influenza season, health care providers should consider influenza in all patients with suspected EVALI. Antivirals should be considered in accordance with established guidelines. Decisions on initiation or discontinuation of treatment should be based on specific clinical features and, when appropriate, in consultation with specialists.
  • During flu season, health care providers should consider flu in all patients with suspected EVALI. Antivirals should be considered in accordance with established guidelinesexternal icon. Decisions on initiation or discontinuation of treatment should be based on specific clinical features and, when appropriate, in consultation with specialists
  • Check out Key Facts About Seasonal Flu Vaccine for more information.
Resources for Healthcare Providers

Fact Sheet for Evaluating and Caring For Patients with Suspected EVALI pdf icon[PDF – 119 KB]
(also available in Spanish pdf icon[PDF – 82 KB])
The purpose of this fact sheet is to provide a brief summary of  the 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.

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

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.