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

Management of Patients With Suspected EVALI

Admission Criteria and Outpatient Management

Several factors should be considered when deciding whether to admit a patient with potential EVALI to the hospital (Box 2). Among 1,002 cases reported to CDC with available data as of October 8, 96% of patients were hospitalized. Patients with suspected EVALI should be admitted if they have decreased O2 saturation (<95%) on room air, are in respiratory distress, or have comorbidities that compromise pulmonary reserve. Consider modifying factors such as altitude to guide interpretation of measured O2 saturation.

Outpatient management of suspected EVALI might be considered on a case-by-case basis for patients who are clinically stable, have less severe injury, and for whom follow-up within 24–48 hours of initial evaluation can be assured. Candidates for outpatient management should have normal O2 saturation (≥95%), reliable access to care, and strong social support systems. For these patients, empiric use of antimicrobials, including antivirals, if indicated, should be considered. Some patients who initially had mild symptoms experienced a rapid worsening of symptoms within 48 hours. In Illinois and Wisconsin, 72% of patients had either an outpatient or emergency department visit before seeking additional medical care that resulted in hospital admission.[3] Health care providers should instruct all patients to seek medical care promptly if respiratory symptoms worsen.

Medical Treatment

Corticosteroids might be helpful in treating this injury. Several case reports describe improvement with corticosteroids, likely because of a blunting of the inflammatory response.[3–5] In a series of patients in Illinois and Wisconsin, 92% of 50 patients received corticosteroids; the medical team documented in 65% of 46 patient notes that "respiratory improvement was due to the use of glucocorticoids".[3] Among 140 cases reported nationally to CDC that received corticosteroids, 82% of patients improved (Table). However, the natural progression of this injury is not known, and it is possible that patients might recover without corticosteroids or by avoiding use of e-cigarette, or vaping, products. In some circumstances, it would be advisable to withhold corticosteroids while evaluating patients for infectious etiologies, such as fungal pneumonia, that might worsen with corticosteroid treatment. Nevertheless, because the diagnosis remains one of exclusion, aggressive empiric therapy with corticosteroids, antimicrobial, and antiviral therapy might be warranted for patients with severe illness. A range of corticosteroid doses, durations, and taper plans might be considered on a case-by-case basis. Whenever possible, decisions on the use of corticosteroids and dosing regimen should be made in consultation with a pulmonologist.

Early initiation of antimicrobial treatment for community-acquired pneumonia in accordance with established guidelines** should be strongly considered given the overlapping of signs and symptoms in these conditions. During influenza season, health care providers should consider influenza in all patients with suspected EVALI. Antivirals should be considered in accordance with established guidelines.†† Decisions on initiation or discontinuation of treatment should be based on specific clinical features and, when appropriate, in consultation with specialists.

Follow-up From Hospital Admission

Patients discharged from the hospital after inpatient treatment for EVALI should have a follow-up visit no later than 1–2 weeks after discharge that includes pulse-oximetry, and clinicians should consider repeating the CXR. Additional follow-up testing 1–2 months after discharge that might include spirometry, diffusion capacity testing, and CXR should be considered. Long-term effects and the risk of recurrence of EVALI are not known. Whereas many patients' symptoms resolved, clinicians report that some patients have relapsed during corticosteroid tapers after hospitalization, underscoring the need for close follow-up (personal communication, Lung Injury Response Clinical Working Group, October 2, 2019). Some patients have had persistent hypoxemia (O2 saturation <95%), requiring home oxygen at discharge and might need ongoing pulmonary follow-up. Patients treated with high-dose corticosteroids might require care from an endocrinologist to monitor adrenal function.

It is unknown if patients with a history of EVALI are at higher risk for severe complications of influenza or other respiratory viral infections if they are infected simultaneously or after recovering from lung injury. Health care providers should emphasize the importance of annual vaccination against influenza for all persons >6 months of age, including patients with a history of EVALI. In addition, administration of pneumococcal vaccine should be considered according to current guidelines.§§

Addressing Exposures

Advising patients to discontinue use of e-cigarette, or vaping, products should be an integral part of the care approach during an inpatient admission and should be re-emphasized during outpatient follow-up. Cessation of e-cigarette, or vaping, products might speed recovery from this injury; resuming use of e-cigarette, or vaping, products has the potential to cause recurrence of symptoms or lung injury. Evidence-based tobacco product cessation strategies include behavioral counseling and FDA-approved cessation medications.¶¶ For patients who have addiction to THC-containing or nicotine-containing products, cognitive-behavioral therapy, contingency management, motivational enhancement therapy, and multidimensional family therapy have been shown to help, and consultation with addiction medicine services should be considered.[8–10]

Special Considerations for Groups at High Risk

Patients with certain characteristics or comorbidities, including older age, history of cardiac or lung disease, or pregnancy, might be at higher risk for more severe outcomes. Among reported cases (Table), patients aged >50 years experienced the highest percentage of endotracheal intubation and mechanical ventilation (54%) and the longest mean inpatient stays (15 days). The mean first recorded O2 saturations among those who did and did not require intubation were 87% and 92%, respectively (data not shown). Among those with and without past cardiac disease, 31% and 21%, respectively, required intubation (Table). Special consideration might need to be given to patients aged >50 years, because these patients might require longer duration of hospitalization and have a higher risk of intubation (Figure). Rapid identification of exposure, a high index of suspicion of EVALI, initiation of corticosteroids, and specialist consultations might be lifesaving in this patient population.


Percentage of persons needing intubation (N = 338) and hospitalization (N = 242) among patients with e-cigarette, or vaping, product use associated lung injury (EVALI), by age of patient — United States, February 1–October 3, 2019*,†
Abbreviation: E-cigarette = electronic cigarette.
* Data reported through October 3, 2019, from the following 29 states: Alabama, Delaware, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New Mexico, Oklahoma, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Vermont, Washington, West Virginia, and Wisconsin.
95% confidence intervals indicated by error bars.

Additional data might identify other groups at high risk, provide important information about disparities in outcomes, and help guide clinical care. Certain patients, such as adolescents and young adults, might benefit from specialized services, such as addiction treatment services and providers who have experience with counseling and behavioral health follow-up.