For Healthcare Providers

Healthcare Provider

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.

If e-cigarette, or vaping, product use associate lung injury is suspected, a detailed history of the substances used, the sources of products, and the devices 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 efforts should be made to collect clinical samples and to determine if any remaining product, devices, and liquids are available for testing.

Recommendations for Clinicians
  1. Report cases of lung injury of unclear etiology and a history of e-cigarette, or vaping, product use within the past 90 days to your state or local health department. Reporting of lung injury cases may help CDC and state, local, territorial, and tribal health departments (SLTT) determine the cause of these lung injuries.
  2. Ask all patients who report e-cigarette, or vaping, product use within the last 90 days about respiratory, gastrointestinal, and constitutional symptoms.
  3. If e-cigarette, or vaping, product use is suspected as a possible etiology of a patient’s lung injury, obtain detailed history regarding the following, using empathetic, non-judgmental private questioning:
  • Substance(s) used: nicotine, cannabinoids (e.g., marijuana, tetrahydrocannabinol [THC], cannabis [oil, dabs], synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
  • Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
  • Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)
  • Where the product(s) were purchased
  • Method of substance use: aerosolization, dabbing, or dripping
  • Other potential cases: sharing e-cigarette, or vaping, products (devices, liquids, refill pods, or cartridges) with others
  1. Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms. Evaluate and treat for other possible causes of illness (e.g., infectious, cardiac, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology, psychology, psychiatry, addiction medicine) as appropriate.
  2. For patients who report use of e-cigarette, or vaping, products, physical examination should include vital signs and pulse oximetry. Pulmonary findings on auscultation exam have often been unremarkable, even among patients with severe lung injury. For more information regarding laboratory and infectious disease testing see 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
  3. Patients with suspected EVALI should be admitted to the hospital if they have decreased oxygen (O2) saturation (<95%) on room air or are in respiratory distress. Outpatient management might be considered on a case-by-case basis for patients with less severe illness; follow-up within 24-48 hours is recommended.
  4. A chest x-ray (CXR) should be obtained on all patients with a history of e-cigarette use, or vaping, and who have respiratory or gastrointestinal symptoms, particularly when accompanied by decreased O2 saturation (<95%). Chest computed tomography (CT) might be useful when the CXR result does not correlate with clinical findings, or to evaluate severe or worsening disease, or complications, or other illnesses in the differential diagnosis.
  • Radiographic findings consistent with EVALI include pulmonary infiltrates on CXR and opacities on chest CT.
  1. Healthcare providers should consider empiric use of a combination of antibiotics, antivirals, or steroids, based upon clinical context. Clinical improvement has been reported with the use of corticosteroids. Early initiation of antibiotic treatment for community-acquired pneumonia in accordance with established guidelines should be strongly considered. During influenza season, health care providers should consider influenza in all patients with suspected of having EVALI. Antivirals should be considered in patients suspected of having influenza in accordance with established guidelines. The decision to use corticosteroids and dosing regimen should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies, and should be made in consultation with a pulmonologist when possible.
  2. Patients discharged from the hospital after inpatient treatment of EVALI should have a follow-up visit no later than 1-2 weeks after hospital discharge. Patients who received care for EVALI on an outpatient basis should have close follow-up within 24-48 hours to assess and manage possible worsening lung injury.
  3. Advising patients with suspected or confirmed EVALI to discontinue use of e-cigarette, or vaping, products is an integral part of the patient’s care for EVALI. Cessation of e-cigarette, or vaping, products might speed recovery; resuming use of e-cigarette, or vaping, products has the potential to cause recurrence of symptoms or lung injury.
  4. Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with SLTT health departments.
  5. Lipid-laden alveolar macrophages have been detected in bronchoalveolar lavage (BAL) fluid by lipid staining methods (e.g., Oil Red O, Sudan Black). The decision about whether to perform a BAL should be based on individual clinical circumstances in consultation with pulmonary specialists.
  1. Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing involves the application of alcohols, which remove lipids, to formalin-fixed tissues. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
  • A spectrum of pathologic findings associated with acute lung injury have been seen, including diffuse alveolar damage, acute fibrinous pneumonitis or bronchiolitis, or organizing pneumonia often with vacuolated or foamy macrophages and/or pneumocytes.

If individuals are identified after death or at autopsy who showed findings consistent with acute lung injury as described above, medical examiners, coroners, and other pathologists are encouraged to report the cases to their SLTT. If a lung biopsy or autopsy is performed on a patient suspected of EVALI, 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. 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. For more information, see Specimen Submission Guidance for Pathologic Evaluation of Tissue Specimens from Cases of Pulmonary Disease Associated with E-Cigarette Product Use pdf icon[PDF – 119 KB].

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

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 pdf icon[PDF – 198 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 Pulmonary Disease Associated with E-Cigarette Product Use 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 that could be collected from cases of lung injury associated with the use of e-cigarette, or vaping, products.

Video

E-Cigarette 101 Video (long form and short form)
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 – Outbreak of Lung Injury Associated with E-cigarette Product Use or Vaping: Information for Clinicians
On September 19, 2019 CDC experts hosted a Clinician Outreach and Communication Activity (COCA) Call. 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.

Outbreak of Lung Injury Associated with E-cigarette Product Use or Vaping: Information for Clinicians Presentation ppt icon[PPTX – 2 MB]
Download presentation in PDF format. pdf icon[PDF – 634 KB]
This PowerPoint presentation is being provided for clinicians to use to review terminology related to e-cigarette, or vaping, products, clinical features reported among cases of lung injury in recent outbreaks, and CDC recommendations for clinicians.

Poster (For Print Only)

This Poster for Clinical Settings pdf icon[print-only PDF – 343 KB] is available in English and Spanish pdf icon[print-only PDF – 340 KB] for use in healthcare settings to encourage conversation between patients and providers about their use of e-cigarette, or vaping, products.

Publications

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 electronic cigarette, or vaping, products, contact CDC-INFO or call 1-800-232-4636.