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<a href='/the-exchange/management-of-patients-with-suspected-evali'>Management of Patients with Suspected EVALI</a>

Management of Patients with Suspected EVALI

Over the last several years there has been a dramatic spike in individuals vaping, and we have witnessed the associated injuriesincluding burns and lung impairment. The CDC and other public health officials are currently investigating a multistate outbreak of lung injuries associated with the use of e-cigarette, or vaping, products. The workup is straightforward, but how do we decide when to admit these patients?

Outpatient management of suspected e-cigarette, or vaping, product use associated lung injury (EVALI) should 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 to 48 hours of initial evaluation can be assured. These patients should have normal O2 saturation (≥95%), reliable access to care, and strong social support systems (family/medical provider). 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. You should always instruct patients to seek medical care promptly if respiratory symptoms worsen.

Several factors should be considered when deciding whether to admit a patient with suspected EVALI: they should always be admitted if they have decreased O2 saturation (<95%) on room air, are in respiratory distress, or have comorbidities that compromise pulmonary reserve.

Corticosteroids might be helpful in treating vape-related lung injuries. Several case reports describe improvement with corticosteroids, likely secondary to the blunting of the inflammatory response. However, the natural progression of these injuries is not known, and it is possible that patients might recover without corticosteroids or by avoiding use of vaping products. Whenever possible, decisions regarding the use of corticosteroids and dosing regimen should be made in consultation with a pulmonologist.

Early initiation of antimicrobial treatment for community-acquired pneumonia should be strongly considered given the overlap of signs and symptoms in these conditions. During influenza season, healthcare providers should consider influenza in all patients with suspected EVALI. Antivirals should be considered in accordance with established guidelines.

Advising patients to discontinue use of e-cigarette products should always be a part of the care during an inpatient admission, and should be re-emphasized during outpatient follow-up. Cessation of e-cigarette products might help speed recovery, whereas resuming use of e-cigarette products can potentially cause recurrence of symptoms or lung injury.

References
  • Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. Accessed November 5, 2019.
  • Centers for Disease Control and Prevention. Severe pulmonary disease associated with using e-cigarette products. emergency.cdc.gov/han/han00421.asp. Accessed November 5, 2019.
  • Siegel DA, Jatlaoui TC, Koumans EH, et al. 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. MMWR Morb Mortal Wkly Rep. 2019;68:919-927.

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Found in: Health Policy and Trends, Pulmonary Medicine

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