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

Tara C. Jatlaoui, MD; Jennifer L. Wiltz, MD; Sarah Kabbani MD; David A. Siegel, MD; Ram Koppaka, MD, PhD; Michele Montandon, MD; Susan Hocevar Adkins, MD; David N. Weissman, MD; Emily H. Koumans, MD; Michelle O'Hegarty, PhD; Megan C. O'Sullivan, MPH; Matthew D. Ritchey, DPT; Kevin Chatham-Stephens, MD; Emily A. Kiernan, DO; Mark Layer, MD; Sarah Reagan-Steiner, MD; Jaswinder K. Legha, MD; Katherine Shealy, MPH; Brian A. King, PhD; Christopher M. Jones, PharmD, DrPH; Grant T. Baldwin, PhD; Dale A. Rose, PhD; Lisa J. Delaney, MS; Peter Briss, MD; Mary E. Evans, MD


Morbidity and Mortality Weekly Report. 2019;68(44):1081-1086. 

In This Article

Abstract and Introduction


CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical stakeholders are investigating a nationwide outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI).[1] CDC has published recommendations for health care providers regarding EVALI.[2–4] Recently, researchers from Utah and New York published proposed diagnosis and treatment algorithms for EVALI.[5,6] EVALI remains a diagnosis of exclusion because, at present, no specific test or marker exists for its diagnosis, and evaluation should be guided by clinical judgment. Because patients with EVALI can experience symptoms similar to those associated with influenza or other respiratory infections (e.g., fever, cough, headache, myalgias, or fatigue), it might be difficult to differentiate EVALI from influenza or community-acquired pneumonia on initial assessment; EVALI might also co-occur with respiratory infections. This report summarizes recommendations for health care providers managing patients with suspected or known EVALI when respiratory infections such as influenza are more prevalent in the community than they have been in recent months.[7] Recommendations include 1) asking patients with respiratory, gastrointestinal, or constitutional symptoms about the use of e-cigarette, or vaping, products; 2) evaluating those suspected to have EVALI with pulse oximetry and obtaining chest imaging, as clinically indicated; 3) considering outpatient management for clinically stable EVALI patients who meet certain criteria; 4) testing patients for influenza, particularly during influenza season, and administering antimicrobials, including antivirals, in accordance with established guidelines; 5) using caution when considering prescribing corticosteroids for outpatients, because this treatment modality has not been well studied among outpatients, and corticosteroids could worsen respiratory infections; 6) recommending evidence-based treatment strategies, including behavioral counseling, to help patients discontinue using e-cigarette, or vaping, products; and 7) emphasizing the importance of annual influenza vaccination for all persons aged ≥6 months, including patients who use e-cigarette, or vaping products.

As of November 13, 2019, 49 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands) have reported 2,172 EVALI cases to CDC, including 42 (1.9%) EVALI-associated deaths. Based on established definitions,* patients with EVALI require reported use of e-cigarette, or vaping, products within 3 months of symptom onset, positive imaging findings, and an evaluation to rule out infectious causes.

In anticipation of increasing incidence of influenza and other respiratory infections during the winter, CDC, the Council of State and Territorial Epidemiologists, state health departments, and clinical partners assessed the need for additional clinical guidance. CDC obtained individual clinical perspectives on the management of patients with suspected EVALI from nine national experts (Lung Injury Response Clinical Working Group) involved in previously published clinical guidance for EVALI patients[4]