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Commentary and Observations from
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Managing Patients With Suspected Vape-Related Lung Problems

Managing Patients With Suspected Vape-Related Lung Problems

We have been hearing about more and more cases of lipoid pneumonia linked to marijuana oils in e-cigarettes. According to the CDC, as of November 2019, there have been over 2172 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) and 42 associated deaths. With so many patients coming in complaining of influenza-like symptoms, as healthcare providers we need to always consider EVALI as a possibility. EVALI remains a diagnosis of exclusion because there are no specific tests or markers. Patients may present with complaints of fever, cough, headache, myalgia, fatigue, or respiratory infection.

Recommendations include:
  • Obtaining a focused history and physical exam
    • Inquire if using e-cigarettes or vaping products
      • What type of substance?
        • Nicotine, tetrahydrocannabinol (THC) or cannabis (specify if oil or dabs), modified products or the addition of substances (vitamin E acetate)
        • Product brand and name
      • Duration and frequency?
      • Last time used?
        • Where they were obtained (friends, family, in-person, or online dealer)
  • Obtaining a pulse oximetry (should be >95% on room air) and vital signs
  • Chest imaging (if indicated): CXR or CT (if CXR is normal)
  • Testing patients for influenza (particularly during season) and recommending annual influenza vaccination
  • Administering antimicrobials, antivirals
  • Prescribing corticosteroids (use with caution)
  • Recommending evidence-based treatment strategies, such as behavioral counseling, to help patients with e-cigarette or vaping cessation
  • Recommending cognitive behavioral therapy, motivational enhancement therapy, or family therapy for patients with cannabis use disorder

According to the established definition of EVALI, a patient must report use of e-cigarette or vaping products within 3 months of symptom onset, have a positive image finding, and an evaluation to rule out an infectious cause (negative viral panel and a negative influenza PCR or rapid test).

If EVALI is suspected, follow-up is encouraged. Patients with outpatient management should follow up within 24 to 48 hours. Patients discharged from the hospital should initially follow up within 1 to 2 weeks, at which time a pulse oximetry and repeat CXR should be done. Patients treated with high-dose corticosteroids may need a referral to endocrinologist. Spirometry diffusion capacity for carbon monoxide and CXR should be done at an additional follow-up 1 to 2 months later. All patients should be advised to return as soon as possible if they develop new or worsening respiratory symptoms, with or without fever.

References

Filed under: Infectious Diseases, Public Health, Pulmonary Medicine

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