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

MMWR Early Release/ October 11, 2019

Overview

CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical partners continue to investigating the multistate outbreak of lung injury associated with the use of electronic cigarette (e-cigarette) or vaping products. In late August, CDC released recommendations for health care providers regarding e-cigarette or vaping product use associated lung injury (EVALI) based on limited data from the first reported cases.

Based on the most current data, CDC’s updated interim guidance provides a framework for health care providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms EVALI.

As of October 8, 2019, 49 states, the District of Columbia, and one territorial health department have reported 1,299 cases of EVALI to CDC, with 26 deaths reported from 21 states. Among 573 patients who reported information on substances used in e-cigarette, or vaping products in the 90 days preceding symptom onset, 76% reported using THC-containing products, and 58% reported using nicotine-containing products; 32% reported exclusive use of THC-containing products, and 13% reported exclusive use of nicotine-containing products. No single compound or ingredient has emerged as the cause of these injuries to date, and there might be more than one cause. Available data suggest THC-containing products play a role in this outbreak, but the specific chemical or chemicals responsible for EVALI have not yet been identified, and nicotine-containing products have not been excluded as a possible cause.

Clinical Evaluations for Patients with Suspected EVALI

EVALI is considered 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. In addition, health care providers should evaluate alternative diagnoses as suggested by clinical findings and medical history (e.g., cardiac, gastrointestinal, rheumatologic, and neoplastic processes; environmental or occupational exposures; or causes of acute respiratory distress syndrome).

Patient history

Based upon medical chart abstraction data submitted to CDC, 95% (323/339) of patients diagnosed with EVALI initially experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath), and 77% (262/339) had gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea). Gastrointestinal symptoms preceded respiratory symptoms in some patients (1–3). Respiratory or gastrointestinal symptoms were accompanied by constitutional symptoms such as fever, chills, and weight loss among 85% (289/339) of patients.

All health care providers evaluating patients for EVALI should ask about the 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). Empathetic, nonjudgmental, and private questioning of patients regarding sensitive information to assure confidentiality should be employed. Standardized approaches should be used for interviewing adolescents. Resources exist to guide patient interviews, including those of adolescents. In some situations, asking questions over the course of the hospitalization or during follow-up visits might elicit additional information about exposures, especially as trust is established between the patient and clinicians.

Management of Patients with Suspected EVALI

Admission criteria and outpatient management

Several factors should be considered when deciding whether to admit a patient with potential EVALI to the hospital. Among 1,002 cases reported to CDC with available data as of October 8, 96% of patients were hospitalized. Patients with suspected EVALI should be admitted if they have decreased O2 saturation (<95%) on room air, are in respiratory distress, or have comorbidities that compromise pulmonary reserve. Consider modifying factors such as altitude to guide interpretation of measured O2 saturation.

Outpatient management of suspected EVALI might be considered on a case-by-case basis for patients who are clinically stable, have less severe injury, and for whom follow-up within 24–48 hours of initial evaluation can be assured. Candidates for outpatient management should have normal O2 saturation (≥95%), reliable access to care, and strong social support systems. For these patients, empiric use of antimicrobials, including antivirals, if indicated, should be considered. Some patients who initially had mild symptoms experienced a rapid worsening of symptoms within 48 hours. In Illinois and Wisconsin, 72% of patients had either an outpatient or emergency department visit before seeking additional medical care that resulted in hospital admission. Health care providers should instruct all patients to seek medical care promptly if respiratory symptoms worsen.

Clinical Care and Public Health Recommendations

Reporting cases to state, local, territorial, or tribal health departments is critical for accurate surveillance of EVALI. Reporting cases and obtaining and sending products, devices, and clinical and pathologic specimens for testing, can help health departments and CDC determine the cause or causes of these lung injuries. CDC is developing International Classification of Diseases, Tenth Edition, Clinical Modification coding guidance for health care encounters related to EVALI. Updates, when available, can be found under the CDC Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping page.

Please read the MMWR for more information about Clinical Evaluation for Patients with Suspected EVALI, Management of Patients with Suspected EVALI, and Clinical Care and Public Health Recommendations.

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