Vaping-Related Lung Injury: New CDC Recommendations for Primary Care Physicians

October 24, 2019

Associate Editor of Patient Care Online

The multistate outbreak of vaping-related lung injury is ongoing, but the CDC's updated interim guidance can help physicians navigate the clinical evaluation and management of these patients.

Reported cases of e-cigarette, or vaping, product use associated lung injury (EVALI) has been on the rise across the US with 1479 confirmed and probable cases reported in 49 states and 33 confirmed deaths in 24 states as of October 15. Because this multistate outbreak is ongoing, patient information is still being collected. The cause of the lung injury is still unknown. The US Centers for Disease Control and Prevention (CDC) recently released their updated interim guidance to provide a framework for physicians in their initial clinical evaluation and management of suspected patients with EVALI. Above, we highlight these recommendations.

History:

Ask patients with a reported history of vaping use about respiratory, GI, and constitutional symptoms (eg, fever, chills, weight loss)

Ask ALL patients about types of substances used in the vaping product (eg, cannabis, nicotine); product source, specific product brand and name; duration and frequency of use, time of last use; product delivery system; and method of use (eg, aerosolization, dabbing, or dripping)

Physical Exam: Assess vital signs and O₂saturation via pulse-oximetry. Lab testing: Infectious disease evaluation might include respiratory viral panel (including influenza during flu season), Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections. During initial lab evaluation, consider CBC with differential, ALT/AST, and inflammatory markers. For all patients, a urine toxicology should be conducted (with informed consent) including testing for THC.

Imaging:

Obtain CXR for all patients with history of vaping who have respiratory or GI symptoms

Consider chest CT scan to evaluate severe/worsening disease, complications, other illnesses-or if CXR results do not correlate with clinical findings

CT scan may not be necessary for diagnosis of patients with abnormal CXR results and clinical picture consistent with EVALI

Decide case-by-case whether to obtain chest CT

Other considerations. Further evaluation of patients meeting inpatient admission criteria may include:

Consultation with pulmonary, 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

Consult with critical care physicians to determine optimal management of respiratory failure

Admission criteria and outpatient management. Admit patients for decreased O₂ saturation on room air (consider modifying factors such as altitude to guide interpretation of measured O₂ saturation), respiratory distress, and comorbidities that compromise pulmonary reserve. Consider outpatient management for patients with clinically stable, less severe injury, and for whom follow-up within 24-48 hours of initial evaluation can be assured. Outpatient management for patients with suspected lung injury that is less severe may be considered case-by-case.

Medical treatment:

Consider initiation of corticosteroids

Strongly consider early initiation of antimicrobial coverage for community-acquired pneumonia in accordance with established guidelines

Consider influenza antivirals in accordance with established guidelines

Base decisions on initiation or discontinuation of treatment on specific clinical features and consultation with specialists (when appropriate)

Patients not admitted to hospital:

Recommend follow-up within 24–48 hours to assess and manage possible worsening lung injury

Outpatients should have normal O₂ saturation, have reliable access to care and social support, and be instructed to promptly seek medical care if respiratory symptoms worsen

Consider empiric use of antimicrobials and antivirals

Post-hospital discharge follow-up:

Schedule follow-up visit 1–2 weeks after discharge (includes pulse-oximetry testing)

Consider additional follow-up testing 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 preventive care:

Strongly advise patients to discontinue use of any vaping product

Provide education, cessation assistance to aid nicotine addiction and treatment/referral for patients with marijuana-use disorder

Emphasize importance of routine influenza vaccination in all patients

Consider pneumococcal vaccine

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