As summer 2019 came to a close, serious pulmonary illnesses associated with e-cigarettes, commonly referred to as vaping, became a national issue. In response, the Centers for Disease Control and Prevention (CDC) issued an interim guidance document which urged health care facilities and clinicians to investigate vaping-use related to serious lung-related illness (EVALI). (See our previous post.)

In November 2019, based upon etiological evidence, CDC updated its guidance with specific clinical recommendations. As EVALI can mimic influenza and pneumonia symptoms, CDC urged clinicians to conduct patient interviews that enquired about e-cigarette use when evaluating patients with respiratory symptoms. As substance use, especially among adolescents and young adults is a sensitive topic, CDC urged empathetic, nonjudgmental, private questioning to confirm the use of these products. The November document provides suggestions for ascertaining an accurate history of use. A detailed physical exam, including laboratory testing and imaging should be considered if product use is confirmed. The November document recommended courses of treatment and patient management options, emphasizing the importance of immediate discontinuation of use.

In December 2019, CDC added recommendations for avoiding EVALI rehospitalizations and death following discharge. Data shows that the patients who were rehospitalized or who died after discharge had a higher rate of comorbidities than the general EVALI population. In light of this, CDC recommends enhanced discharge planning and follow-up. As part of discharge planning, CDC recommends that a patient be clinically stable for 24-48 hours before discharge and that discharge planning include the scheduling of an initial follow-up appointment within 48 hours of discharge and scheduling of an initial pulmonology appointment within 2-4 weeks with a pulmonology follow-up within two months. Additionally, any specialty outpatient follow-up appointment should be scheduled as part of the discharge process. In making these recommendations, CDC acknowledges that while age and cardiovascular health are factors that can contribute to readmission or death, the vast majority of these patients have mental and/or behavioral health issues that must be address in order to maintain a cessation of vaping and reinjury. The December 2019 guidance document contains a detailed algorithm for the management of EVALI patients.

References

For the December 2019 Update:
Evans ME, Twentyman E, Click ES, et al. Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019. MMWR Morb Mortal Wkly Rep 2020;68:1189-1194. DOI: http://dx.doi.org/10.15585/mmwr.mm685152e2external icon.

For the November 2019 Update:
Jatlaoui TC, Wiltz JL, Kabbani S, et al. Update: Interim Guidance for Health Care Providers for Managing Patients with Suspected E-cigarette, or Vaping, Product Use–Associated Lung Injury — United States, November 2019. MMWR Morb Mortal Wkly Rep 2019;68:1081-1086. DOI: http://dx.doi.org/10.15585/mmwr.mm6846e2external icon.

For the original guidance:
CDC (2019). Severe Pulmonary Disease Associated with Using E-Cigarette Products. CDCHAN-00421. Available from: https://emergency.cdc.gov/han/han00421.asp

Schier JG, Meiman JG, Layden J, Mikosz CA, VanFrank B, King BA … Meaney-Delman D (2019). Severe Pulmonary Disease Associated with Electronic-Cigarette-Product Use – Interim Guidance. MMWR Morb Mortal Wkly Rep 2019;68:787–790. Available from: http://dx.doi.org/10.15585/mmwr.mm6836e2 .

Layden J, Ghinai I, Pray I, Kimball A, Layer M, Tenforde M … Meiman J (2019). Pulmonary illness related to e-cigarette use in Illinois and Wisconsin – Preliminary report. N Engl J Med Available from: 10.1056/NEJMoa1911614