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

Abstract

This report summarizes updated CDC guidance for the evaluation, management, and follow-up of people with lung injury related to electronic cigarette or vaping product use. This report summarizes updated CDC guidance for the evaluation, management, and follow-up of people with lung injury related to electronic cigarette or vaping product use. CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical partners are investigating a 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.1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar,2CDCSevere Pulmonary Disease Associated With Using E-Cigarette Products. HAN alert No. 421.. US Department of Health and Human Services, CDC, Health Alert Network, Atlanta, GA2019Google Scholar This report summarizes national surveillance data describing clinical features of more recently reported cases and interim recommendations based on these data for US health care providers caring for patients with suspected or known EVALI. It provides interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital admission and treatment; 3) patient follow-up; 4) special considerations for groups at high risk; and 5) clinical and public health recommendations. Health care providers evaluating patients suspected to have EVALI should ask about the use of e-cigarette, or vaping, products in a nonjudgmental and thorough manner. Patients suspected to have EVALI should have a chest radiograph (CXR), and hospital admission is recommended for patients who have decreased blood oxygen (O2) saturation (<95%) on room air or who are in respiratory distress. Health care providers should consider empiric use of a combination of antibiotics, antivirals, or steroids based upon clinical context. Evidence-based tobacco product cessation strategies, including behavioral counseling, are recommended to help patients discontinue use of e-cigarette, or vaping, products. To reduce the risk of recurrence, patients who have been treated for EVALI should not use e-cigarette, or vaping, products. CDC recommends that persons should not use e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC). At present, CDC recommends persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products. 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 (median age of death = 49 years, range = 17-75 years). Among 1,043 patients with available data on age and sex, 70% were male, and the median age was 24 years (range = 13-75 years); 80% were aged < 35 years, and 15% were aged < 18 years. 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.a 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. Ongoing federal and state investigations have provided information about the clinical characteristics of cases and a surveillance case definition for confirmed and probable cases has been developed1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar; this case definitionb is not intended to guide clinical care. To inform CDC’s updated interim clinical guidance, on October 2, 2019, CDC obtained individual expert perspectives on the evaluation and treatment of patients with suspected EVALI. Discussions occurred with nine national experts in adult and pediatric pulmonary medicine and critical care who were designated by professional medical societies to participate (Lung Injury Response Clinical Working Group). Evidence supporting CDC’s recommendations include data from medical abstractions reported to CDC, previously published case series,3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar, 4Davidson K Brancato A Heetderks P et al.Outbreak of electronic-cigarette–associated acute lipoid pneumonia—North Carolina, July–August 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: 784-786Crossref PubMed Scopus (81) Google Scholar, 5Maddock SD Cirulis MM Callahan SJ et al.Pulmonary lipid-laden macrophages and vaping.N Engl J Med. 2019; 381 (https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491073&dopt=Abstract.): 1488-1489Crossref PubMed Scopus (141) Google Scholar and the aforementioned individual expert opinions. EVALI is considered a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis (Box 1). 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 (eg, cardiac, gastrointestinal, rheumatologic, and neoplastic processes; environmental or occupational exposures; or causes of acute respiratory distress syndrome).6Matthay MA Zemans RL Zimmerman GA et al.Acute respiratory distress syndrome.Nat Rev Dis Primers. 2019; 5: 18Crossref PubMed Scopus (481) Google ScholarBOX 1Clinical evaluation for patients with recent history of use of e-cigarette, or vaping, products and suspected lung injuryHistory•Ask about respiratory, gastrointestinal, and constitutional symptoms (eg, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and fever) for patients who report a history of use of e-cigarette, or vaping, products.•Ask all patients about recent use of e-cigarette, or vaping, products.○Types of substances used (eg, tetrahydrocannabinol [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 exam•Assess vital signs and oxygen saturation via pulse-oximetry.Laboratory testing•Infectious disease evaluation might include○Respiratory viral panel including influenza testing during flu season, Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections.•Initial laboratory evaluation○Consider complete blood count with differential, liver transaminases, and inflammatory markers (eg, erythrocyte sedimentation rate and C-reactive protein).○In all patients, consider conducting urine toxicology testing, with informed consent, including testing for THC.Imaging•Chest radiograph.•Consider chest computed tomography for evaluation of severe or worsening disease, complications, other illnesses, or when chest x-ray result does not correlate with clinical findings.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 or lung biopsy as clinically indicated, in consultation with pulmonary specialists.SummaryWhat is already known about this topic?Forty-nine states, the District of Columbia, and one US territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states.What is added by this report?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 of e-cigarette, or vaping, product use associated lung injury (EVALI).What are the implications for public health practice?Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury. •Ask about respiratory, gastrointestinal, and constitutional symptoms (eg, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and fever) for patients who report a history of use of e-cigarette, or vaping, products.•Ask all patients about recent use of e-cigarette, or vaping, products.○Types of substances used (eg, tetrahydrocannabinol [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). •Assess vital signs and oxygen saturation via pulse-oximetry. •Infectious disease evaluation might include○Respiratory viral panel including influenza testing during flu season, Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections.•Initial laboratory evaluation○Consider complete blood count with differential, liver transaminases, and inflammatory markers (eg, erythrocyte sedimentation rate and C-reactive protein).○In all patients, consider conducting urine toxicology testing, with informed consent, including testing for THC. •Chest radiograph.•Consider chest computed tomography for evaluation of severe or worsening disease, complications, other illnesses, or when chest x-ray result does not correlate with clinical findings. •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 or lung biopsy as clinically indicated, in consultation with pulmonary specialists. What is already known about this topic? Forty-nine states, the District of Columbia, and one US territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states. What is added by this report? 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 of e-cigarette, or vaping, product use associated lung injury (EVALI). What are the implications for public health practice? Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury. Based upon medical chart abstraction data submitted to CDC, 95% (323/339) of patients diagnosed with EVALI initially experienced respiratory symptoms (eg, cough, chest pain, and shortness of breath), and 77% (262/339) had gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea). Gastrointestinal symptoms preceded respiratory symptoms in some patients.1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar, 2CDCSevere Pulmonary Disease Associated With Using E-Cigarette Products. HAN alert No. 421.. US Department of Health and Human Services, CDC, Health Alert Network, Atlanta, GA2019Google Scholar, 3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar or gastrointestinal symptoms were by constitutional symptoms as and of patients of patients = with e-cigarette use, or vaping, product use associated lung injury cases that had medical chart abstraction data from national EVALI surveillance to CDC data October 2019, from the Carolina, and used in with data were excluded from for median and saturation < 95% room rate rate to care or other and or other of hospital = electronic cases that had medical chart abstraction data data October 2019, from the Carolina, and Patients with data were excluded from for and or other in a = electronic health care providers evaluating patients for EVALI should ask about the use of e-cigarette, or vaping, products and should ask about of substances used (eg, 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). and of patients regarding information to should be should be used for to guide patient including of In some the of the or during follow-up might information about as is the patient and patients who report the use of e-cigarette, or vaping, products, should include vital signs and pulse-oximetry. was reported in of patients and in saturation < 95% at on room air was for of patients reported to CDC the for pulse-oximetry. Among patients to date, pulmonary findings on have been patients with severe lung injury Lung Injury Response Clinical Working October 2, testing should be by clinical findings. A respiratory including influenza testing during influenza season, should be testing should be based on published for evaluation of to consider include Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic the of by of these by and patient medical laboratory reported in patients with EVALI include blood inflammatory markers erythrocyte sedimentation rate and liver In a report of initial patients from Illinois and had a and had an of patients had liver or 35 JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar at this these be used to EVALI from infectious In all patients, providers should consider with informed consent, urine toxicology testing, including testing for THC. findings with EVALI include pulmonary on and on chest computed tomography JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google SJ of lung Engl J Med. 2019; PubMed Scopus Google Scholar A should be obtained on all patients with a history of e-cigarette, or vaping, product use who have respiratory or gastrointestinal when by decreased saturation might be when the result does not correlate with clinical findings or to evaluate severe or worsening disease, as or or other in the as or pulmonary In some chest has findings as a or JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar Among patients with findings and a clinical with a chest might not be for to a chest should be on a on the clinical with might be to patient patients for possible should be to consultation with a who help guide evaluation, empiric and the for to and bronchoalveolar lavage to alternative diagnoses as pulmonary should be on a of or lung biopsy for lipid-laden macrophages (eg, using or in the evaluation of EVALI In addition, there should be a for with critical care because, based upon data submitted to CDC, of patients were to an care and and critical care should be to of respiratory with medical toxicology, infectious disease, psychology, psychiatry, addiction and other should be considered as by patient should be considered when to a patient with EVALI to the hospital (Box Among cases reported to CDC with available data as of October 8, of patients were Patients with suspected EVALI should be have decreased saturation (<95%) on room are in respiratory or have that pulmonary as to guide of of patients with suspected e-cigarette, or vaping, product use associated lung injury criteria and consider patients with lung respiratory distress present, have that pulmonary or decreased (<95%) saturation as to guide for patients with suspected lung injury who have severe injury might be considered on a of of for should be considered in with influenza in with not to follow-up to and possible worsening lung should have oxygen to care and and be to medical care respiratory symptoms empiric use of and follow-up no than that follow-up testing including and testing, and consider chest radiograph in consultation for patients treated with and patients to discontinue use of e-cigarette, or vaping, and cessation for patients to addiction and treatment or for patients with of influenza and Health treatment to treatment in or consider patients with lung respiratory distress present, have that pulmonary or decreased (<95%) saturation as to guide for patients with suspected lung injury who have severe injury might be considered on a of of for should be considered in with influenza in with follow-up to and possible worsening lung should have oxygen to care and and be to medical care respiratory symptoms empiric use of and follow-up no than that follow-up testing including and testing, and consider chest radiograph in consultation for patients treated with patients to discontinue use of e-cigarette, or vaping, and cessation for patients to addiction and treatment or for patients with of influenza and Health treatment to treatment in or of suspected EVALI might be considered on a for patients who are clinically have severe and for follow-up of initial evaluation be for should have saturation to care, and these patients, empiric use of including antivirals, indicated, should be patients who initially had symptoms experienced a worsening of symptoms In Illinois and of patients had an or department medical care that in hospital JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar Health care providers should all patients to medical care respiratory symptoms might be in this injury. case with of a of the inflammatory JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar, 4Davidson K Brancato A Heetderks P et al.Outbreak of electronic-cigarette–associated acute lipoid pneumonia—North Carolina, July–August 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: 784-786Crossref PubMed Scopus (81) Google Scholar, 5Maddock SD Cirulis MM Callahan SJ et al.Pulmonary lipid-laden macrophages and vaping.N Engl J Med. 2019; 381 (https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491073&dopt=Abstract.): 1488-1489Crossref PubMed Scopus (141) Google Scholar In a of patients in Illinois and of patients the medical in of patient that was to the use of JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar Among cases reported to CDC that of patients 1). the of this injury is not and is possible that patients might or by use of e-cigarette, or vaping, products. In some be to evaluating patients for infectious etiologies, as that might with the diagnosis one of empiric with and might be for patients with severe A range of and might be considered on a on the use of and should be in consultation with a of treatment for in with should be considered the of signs and symptoms in these influenza season, health care providers should consider influenza in all patients with suspected EVALI. should be considered in with on or of treatment should be based on specific clinical features when in consultation with specialists. Patients from the hospital inpatient treatment for EVALI should have a follow-up no than that and should consider the follow-up testing that might include testing, and should be and the risk of of EVALI are not symptoms report that some patients have during the for follow-up Lung Injury Response Clinical Working October 2, patients have had saturation < oxygen at and might ongoing pulmonary Patients treated with might care from an to It is patients with a history of EVALI are at risk for severe of influenza or other respiratory viral are or from lung injury. Health care providers should the of influenza for all persons of including patients with a history of EVALI. In addition, of should be considered to current patients to discontinue use of e-cigarette, or vaping, products should be an of the care during an inpatient admission and should be during of e-cigarette, or vaping, products might from this use of e-cigarette, or vaping, products has the to cause of symptoms or lung injury. Evidence-based tobacco product cessation include behavioral and cessation patients who have addiction to THC-containing or nicotine-containing products, management, and have been to and consultation with addiction medicine should be Clinical of and for cannabis PubMed Scopus Google Scholar, J in with and in Scopus Google Scholar, et tobacco use and US Department of Health and Human Services, Health for and Scholar Patients with characteristics or including history of or lung disease, or might be at risk for more severe Among reported cases patients aged years experienced the of and and the inpatient first who and not were and not Among with and disease, and 1). might to be to patients aged years, these patients might duration of and have a risk of 1). Rapid of a high of of of and might be in this patient data might other groups at high information about in and help guide clinical care. patients, as and young adults, might from as addiction treatment and providers who have with and behavioral health cases to or health is critical for surveillance of EVALI. cases and and products, and clinical and for testing, help health and CDC the cause or causes of these lung CDC is of Clinical guidance for health care related to EVALI. when be at (Box and Health of e-cigarette, or vaping, product use associated lung injury at of include departments, care, or to patients and providers about use of e-cigarette, or vaping, cases of lung injury associated with use of e-cigarette, or vaping, products the 90 days to state or local health including and is available for be with health is of Clinical guidance for related to EVALI. when be at testing by of including bronchoalveolar or to CDC for of by a lung biopsy or is on a patient suspected of lung injury related to e-cigarette, or vaping, product use, consider of lung biopsy or to CDC for include evaluation for on lung that have not be as as infectious disease testing, indicated, on or include departments, care, or to patients and providers about use of e-cigarette, or vaping, cases of lung injury associated with use of e-cigarette, or vaping, products the 90 days to state or local health including and is available for be with health is of Clinical guidance for related to EVALI. when be at of including bronchoalveolar or to CDC for a lung biopsy or is on a patient suspected of lung injury related to e-cigarette, or vaping, product use, consider of lung biopsy or to CDC for include evaluation for on lung that have not be as as infectious disease testing, indicated, on or At this and CDC have not the cause or causes of the lung injuries EVALI and the all cases is that patients report the use of e-cigarette, or vaping, products. This outbreak might have more than one and substances and product are To date, national and state data suggest that products obtained the or from other (eg, or are to most of the cases and play a role in the et Injury Response of a multistate outbreak of lung injury associated with e-cigarette use, or 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: PubMed Scopus Google Pray et product use, or vaping, persons with associated lung and 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: PubMed Scopus Google Scholar CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. Persons should not of e-cigarette, or vaping, products, the Persons should not or substances to e-cigarette, or vaping, products that are not intended by the including products that the exclusive use of nicotine-containing products has been reported by a of persons with and that persons with EVALI report use of and nicotine-containing products, the possibility that nicotine-containing products play a role in this outbreak be at present, CDC to that persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. are using e-cigarette, or vaping, products to cigarette should not to should use including health care and persons to use these products, should for symptoms and a health care symptoms Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. is no tobacco and the use of tobacco products, including a persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products. 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