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E-cigarette, or vaping, product use associated lung injury (EVALI), previously referred to as vaping-
- Rapid recognition of patients with EVALI, increased understanding of diagnostic and treatment considerations, and timely reporting to public health could reduce morbidity
and mortality associated with this injury. - Healthcare providers should conduct a complete
clinical evaluation for patients
with suspected EVALI including a patient
history, physical examination, laboratory testing, and imaging, and should consider consultation
with specialists. - Healthcare providers of suspect EVALI cases should let patients know public health is interested in speaking with
them and collecting products to test for chemicals
that may be involved
in this national
outbreak.
Background
BPH along with the Centers for Disease
Control and Prevention (CDC), LHDs,
and
clinical partners continue to investigate a multi-state outbreak of e-cigarette, or vaping, product use associated lung injury (EVALI). As of November 5, 2019, 2,051 cases have been reported to CDC from 49 states,
the District of Columbia
and 1 U.S. territory; 39 deaths have been confirmed in 24 states. A total of 8 cases and 0 deaths have been reported
in West Virginia
to date. The
latest national analyses
of bronchoalveolar lavage
(BAL) fluid samples (or samples
of fluid collected
from the lungs) of patients with
EVALI, identified vitamin E acetate, an
additive in some THC- containing products. This is the first time a potential chemical of concern has been detected in biologic samples from patients with these lung injuries. These findings provide direct evidence of vitamin E acetate
at the primary
site of injury within the lungs.
While it appears that
vitamin E acetate is associated with EVALI,
evidence is not yet sufficient to rule out contribution of other chemicals of concern to EVALI. No one compound
or ingredient has emerged as the cause of these illnesses
to date; and it may be that there is more than one cause of this outbreak. Many different substances, brands and product sources are still
under investigation.
Clinical
Evaluation for Patients with
Suspected EVALI
EVALI is considered a diagnosis
of exclusion because at present there is no specific test or marker for its diagnosis. Healthcare providers should consider multiple etiologies, including the possibility of EVALI and concomitant infection. Additionally, 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: All healthcare providers evaluating patients for EVALI should ask about the use of e-cigarette, or vaping, products and should ask about types of substances used, duration and frequency of use, and last time of use.
Physical Examination: For patients who report the use of e-cigarette, or vaping, products, physical examination
should include vital signs and
pulse-oximetry.
Laboratory Testing: Laboratory testing should be guided by clinical findings. A respiratory virus panel including influenza during influenza season, should be conducted. Evaluation of community-acquired pneumonia should
include testing for the following
infectious diseases: Streptococcus pneumoniae, Legionella pneumophila, and opportunistic respiratory infections if appropriate.
Imaging: Radiographic findings consistent with EVALI include pulmonary infiltrates on CXR and opacities on chest computed tomography (CT) scan. A CXR
should be obtained on
all patients with a history of e-cigarette, or vaping, product use who have respiratory or gastrointestinal symptoms, particularly when accompanied by decreased O2 saturation (<95%). Chest CT might be useful when the CXR result
does not correlate with clinical findings or to evaluate
severe or worsening disease, complications such as pneumothorax or pneumomediastinum, or other illnesses in the differential diagnosis, such as pneumonia or pulmonary embolism.
Consultation with Specialists: Consultation with specialists might be necessary to optimize
patient management. For patients being evaluated for possible
EVALI, consideration should be given to consultation with a pulmonologist who can help guide further evaluation, recommend empiric treatment, and review the indications for
bronchoscopy.
For complete guidance
on evaluating
and caring for patients
with suspected EVALI, visit the
CDC’s Evaluating and
Caring for Patients with
EVALI at https://go.usa.gov/xpajC.
Reporting: Report all cases of suspected EVALI within 24 hours to the LHD or to BPH by calling . EVALI is a Category
II reportable condition
under the Reportable Disease
Rule 64-CSR-7.
Let patients know public health is interested in speaking with them and collecting products to test for
chemicals that may
be involved in this national
outbreak.
Patient Education
Individuals should not use e-cigarette, or vaping, products that contain THC. Individuals should not purchase any type of e-cigarette, or vaping, product, particularly those containing THC, off the street and should not modify or add any substance to e-cigarette, or vaping, products that are not intended by the manufacturer, including products purchased through
retail establishments. The
only way to assure individuals are
not
at-risk while the investigation continues, is to refrain
from using all e-cigarette,
or vaping, products. Irrespective of the investigation, e-cigarette, or vaping, products should never be used by youth, young adults or those who are pregnant.
For assistance with quitting tobacco,
the West Virginia Tobacco
Quitline is available and free or
low cost to all residents
over the age of 18. Pregnant
women and those under 18 may participate with physician approval. Call 1-800-QUIT-NOW (1-800-784-8669) or 1-877-966-8784 to speak to a Quitline
representative. In addition,
effective treatments are available, and recovery is possible for those addicted
to marijuana. To locate
treatment in your
area, call 1-800-662-HELP (1-800-662-4357).