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

David A. Siegel, MD; Tara C. Jatlaoui, MD; Emily H. Koumans, MD; Emily A. Kiernan, DO; Mark Layer, MD; Jordan E. Cates, PhD; Anne Kimball, MD; David N. Weissman, MD; Emily E. Petersen, MD; Sarah Reagan-Steiner, MD; Shana Godfred-Cato, DO; Danielle Moulia, MPH; Erin Moritz, PhD; Jonathan D. Lehnert, MPH; Jane Mitchko, MEd; Joel London, MPH; Sherif R. Zaki, MD; Brian A. King, PhD; Christopher M. Jones, PharmD, DrPH; Anita Patel, PharmD; Dana Meaney Delman, MD; Ram Koppaka, MD, PhD


Morbidity and Mortality Weekly Report. 2019;68(41):919-927. 

In This Article

Clinical Evaluation for Patients With Suspected EVALI

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 (e.g., cardiac, gastrointestinal, rheumatologic, and neoplastic processes; environmental or occupational exposures; or causes of acute respiratory distress syndrome).[6]

Patient History

Based upon medical chart abstraction data submitted to CDC, 95% (323/339) of patients diagnosed with EVALI initially experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath), and 77% (262/339) had gastrointestinal symptoms (e.g., abdominal pain, nausea, vomiting, and diarrhea). Gastrointestinal symptoms preceded respiratory symptoms in some patients.[1–3] Respiratory or gastrointestinal symptoms were accompanied by constitutional symptoms such as fever, chills, and weight loss among 85% (289/339) of patients (Table).

All health care providers evaluating patients for EVALI should ask about the use of e-cigarette, or vaping, products and ideally should ask about types of substances used (e.g., 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). Empathetic, nonjudgmental, and private questioning of patients regarding sensitive information to assure confidentiality should be employed. Standardized approaches should be used for interviewing adolescents. Resources exist to guide patient interviews, including those of adolescents.§ In some situations, asking questions over the course of the hospitalization or during follow-up visits might elicit additional information about exposures, especially as trust is established between the patient and clinicians.

Physical Examination

For patients who report the use of e-cigarette, or vaping, products, physical examination should include vital signs and pulse-oximetry. Tachycardia was reported in 55% (169/310) of patients and tachypnea in 45% (77/172); O2 saturation <95% at rest on room air was present for 57% (143/253) of patients reported to CDC (Table), underscoring the need for routine pulse-oximetry. Among patients identified to date, pulmonary findings on auscultation exam have often been unremarkable, even among patients with severe lung injury (personal communication, Lung Injury Response Clinical Working Group, October 2, 2019).

Laboratory Testing

Laboratory testing should be guided by clinical findings. A respiratory virus panel, including influenza testing during influenza 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 likelihood of infection by any of these varies by geographic prevalence and patient medical history. Other abnormal laboratory tests reported in patients with EVALI include elevated white blood cell (WBC) count, serum inflammatory markers (C-reactive protein, erythrocyte sedimentation rate [ESR]), and liver transaminases. In a report of initial patients from Illinois and Wisconsin, 87% had a WBC >11,000/mm[3] and 93% had an ESR >30mm/hr; 50% of patients had elevated liver transaminases (aspartate aminotransferase or alanine aminotransferase >35 U/L).[3] However, at this time, these tests cannot be used to distinguish EVALI from infectious etiologies. In all patients, providers should consider conducting, with informed consent, urine toxicology testing, including testing for THC.


Radiographic findings consistent with EVALI include pulmonary infiltrates on CXR and opacities on chest computed tomography (CT) scan.[1,7] 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. In some cases, chest CT has demonstrated findings such as bilateral ground glass opacities despite a normal or nondiagnostic CXR.[3] Among patients with abnormal CXR findings and a clinical picture consistent with EVALI, a chest CT scan might not be necessary for diagnosis. The decision to obtain a chest CT should be made on a case-by-case basis depending on the clinical circumstances.

Consultation With Specialists

Consultation with several 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. The decision to perform bronchoscopy and bronchoalveolar lavage (BAL) to rule out alternative diagnoses such as pulmonary infection should be made on a case-by-case basis. The value of staining BAL cells or fresh lung biopsy tissue for lipid-laden macrophages (e.g., using oil red O or Sudan Black) in the evaluation of EVALI remains unknown. In addition, there should be a low threshold for consulting with critical care physicians, because, based upon data submitted to CDC, 47% (159/342) of patients were admitted to an intensive care unit and 22% (74/338) required endotracheal intubation and mechanical ventilation (Table); critical care physicians should be consulted to determine optimal management of respiratory failure. Consultation with medical toxicology, infectious disease, psychology, psychiatry, addiction medicine, and other specialists should be considered as warranted by patient circumstances.