CDC issues interim guidance on evaluation, treatment of suspected vaping injuries

Patients in whom injuries from vaping are suspected should undergo chest radiographs, and hospital admission is recommended for those who have blood oxygen saturation less than 95% on room air or who are in respiratory distress, according to new guidance from the CDC.

Clinicians should consider empiric use of antibiotics, antivirals, and/or steroids based on clinical context, the CDC added in the interim guidance published Oct. 11 in MMWR. As of Oct. 15, there have been 1,479 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) reported to the CDC, resulting in 33 deaths. Among patients with available data on age and sex, 70% were male, and the median age was 24 years. Eighty percent were younger than age 35 years, and 15% were younger than age 18 years.

Among patients who reported information about what substances they had vaped in the 90 days before symptom onset, 76% reported using tetrahydrocannabinol (THC)-containing products, and 58% reported using nicotine-containing products. Also, 32% reported exclusively using THC-containing products, and 13% reported exclusively using nicotine-containing products. No single compound or ingredient has emerged as the cause of injuries, and there might be more than one cause, the CDC said. Available data suggest that THC-containing products play a role in this outbreak, but the specific chemical or chemicals responsible for EVALI have not yet been identified, the agency noted. Nicotine-containing products have not been excluded as a possible cause, according to the CDC.

According to data abstracted from medical charts, 95% of patients diagnosed with EVALI initially experienced respiratory symptoms such as cough, chest pain, and shortness of breath, and 77% had gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea. In some patients, gastrointestinal symptoms preceded respiratory symptoms, and respiratory or gastrointestinal symptoms were sometimes accompanied by other symptoms such as fever, chills, and weight loss.

Clinicians should ask about vaping and ideally should ask about types of substances used; product source, specific product brand and name; duration and frequency of use, time of last use; product delivery system, and method of use, such as aerosolization, dabbing, or dripping, the CDC said.

For patients who report vaping, the physical exam should include vital signs and pulse oximetry. Tachycardia was reported in 55% of patients and tachypnea in 45%. Oxygen saturation less than 95% at rest on room air was present for 57% of patients, underscoring the need for routine pulse oximetry, the CDC said. Pulmonary findings on auscultation have often been unremarkable, even among patients with severe lung injury, the agency noted.

Laboratory testing should be guided by clinical findings, according to the CDC. A respiratory virus panel, including influenza testing during flu season, should be strongly considered. Additional testing should be based on published guidelines for evaluation of community-acquired pneumonia. Infectious diseases to consider include Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections, the CDC said.

While chest radiographs should be done on all patients with a history of vaping and EVALI symptoms, the interim guidance added that chest CT might be useful when the chest radiograph does not correlate with clinical findings or there is a need 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.

The most up-to-date, publicly available information on EVALI can be found on the CDC's website. Anyone with questions can contact CDC-INFO at 800-232-4636 or via the CDC's online contact form.