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
2019; Elsevier BV; Volume: 19; Issue: 12 Linguagem: Inglês
10.1111/ajt.15690
ISSN1600-6143
AutoresDavid A. Siegel, Tara C. Jatlaoui, Emily H. Koumans, Emily Kiernan, Mark Layer, Jordan Cates, Anne Kimball, David N. Weissman, Emily E. Petersen, Sarah Reagan-Steiner, Shana Godfred‐Cato, Danielle Moulia, Erin D. Moritz, Jonathan D. Lehnert, Jane Mitchko, Joel London, Sherif R. Zaki, Brian A. King, Christopher M. Jones, Anita Patel, Dana Meaney‐Delman, Ram Koppaka,
Tópico(s)Smoking Behavior and Cessation
ResumoThis report summarizes updated CDC guidance for the evaluation, management, and follow-up of people with lung injury related to electronic cigarette or vaping product use. This report summarizes updated CDC guidance for the evaluation, management, and follow-up of people with lung injury related to electronic cigarette or vaping product use. CDC, the Food and Drug Administration (FDA), state and local health departments, and public health and clinical partners are investigating a multistate outbreak of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. In late August, CDC released recommendations for health care providers regarding e-cigarette, or vaping, product use associated lung injury (EVALI) based on limited data from the first reported cases.1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar,2CDCSevere Pulmonary Disease Associated With Using E-Cigarette Products. HAN alert No. 421.. US Department of Health and Human Services, CDC, Health Alert Network, Atlanta, GA2019Google Scholar This report summarizes national surveillance data describing clinical features of more recently reported cases and interim recommendations based on these data for US health care providers caring for patients with suspected or known EVALI. It provides interim guidance for 1) initial clinical evaluation; 2) suggested criteria for hospital admission and treatment; 3) patient follow-up; 4) special considerations for groups at high risk; and 5) clinical and public health recommendations. Health care providers evaluating patients suspected to have EVALI should ask about the use of e-cigarette, or vaping, products in a nonjudgmental and thorough manner. Patients suspected to have EVALI should have a chest radiograph (CXR), and hospital admission is recommended for patients who have decreased blood oxygen (O2) saturation (<95%) on room air or who are in respiratory distress. Health care providers should consider empiric use of a combination of antibiotics, antivirals, or steroids based upon clinical context. Evidence-based tobacco product cessation strategies, including behavioral counseling, are recommended to help patients discontinue use of e-cigarette, or vaping, products. To reduce the risk of recurrence, patients who have been treated for EVALI should not use e-cigarette, or vaping, products. CDC recommends that persons should not use e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC). At present, CDC recommends persons consider refraining from using e-cigarette, or vaping, products that contain nicotine. Irrespective of the ongoing investigation, e-cigarette, or vaping, products should never be used by youths, young adults, or women who are pregnant. Persons who do not currently use tobacco products should not start using e-cigarette, or vaping, products. As of October 8, 2019, 49 states, the District of Columbia, and one territorial health department have reported 1,299 cases of EVALI to CDC, with 26 deaths reported from 21 states (median age of death = 49 years, range = 17-75 years). Among 1,043 patients with available data on age and sex, 70% were male, and the median age was 24 years (range = 13-75 years); 80% were aged < 35 years, and 15% were aged < 18 years. Among 573 patients who reported information on substances used in e-cigarette, or vaping, products in the 90 days preceding symptom onset, 76% reported using THC-containing products, and 58% reported using nicotine-containing products; 32% reported exclusive use of THC-containing products, and 13% reported exclusive use of nicotine-containing products.a No single compound or ingredient has emerged as the cause of these injuries to date, and there might be more than one cause. Available data suggest THC-containing products play a role in this outbreak, but the specific chemical or chemicals responsible for EVALI have not yet been identified, and nicotine-containing products have not been excluded as a possible cause. Ongoing federal and state investigations have provided information about the clinical characteristics of cases and a surveillance case definition for confirmed and probable cases has been developed1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar; this case definitionb is not intended to guide clinical care. To inform CDC's updated interim clinical guidance, on October 2, 2019, CDC obtained individual expert perspectives on the evaluation and treatment of patients with suspected EVALI. Discussions occurred with nine national experts in adult and pediatric pulmonary medicine and critical care who were designated by professional medical societies to participate (Lung Injury Response Clinical Working Group). Evidence supporting CDC's recommendations include data from medical abstractions reported to CDC, previously published case series,3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar, 4Davidson K Brancato A Heetderks P et al.Outbreak of electronic-cigarette–associated acute lipoid pneumonia—North Carolina, July–August 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: 784-786Crossref PubMed Scopus (81) Google Scholar, 5Maddock SD Cirulis MM Callahan SJ et al.Pulmonary lipid-laden macrophages and vaping.N Engl J Med. 2019; 381 (https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491073&dopt=Abstract.): 1488-1489Crossref PubMed Scopus (141) Google Scholar and the aforementioned individual expert opinions. 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 (eg, cardiac, gastrointestinal, rheumatologic, and neoplastic processes; environmental or occupational exposures; or causes of acute respiratory distress syndrome).6Matthay MA Zemans RL Zimmerman GA et al.Acute respiratory distress syndrome.Nat Rev Dis Primers. 2019; 5: 18Crossref PubMed Scopus (481) Google ScholarBOX 1Clinical evaluation for patients with recent history of use of e-cigarette, or vaping, products and suspected lung injuryHistory•Ask about respiratory, gastrointestinal, and constitutional symptoms (eg, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and fever) for patients who report a history of use of e-cigarette, or vaping, products.•Ask all patients about recent use of e-cigarette, or vaping, products.○Types of substances used (eg, tetrahydrocannabinol [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).Physical exam•Assess vital signs and oxygen saturation via pulse-oximetry.Laboratory testing•Infectious disease evaluation might include○Respiratory viral panel including influenza testing during flu season, Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections.•Initial laboratory evaluation○Consider complete blood count with differential, liver transaminases, and inflammatory markers (eg, erythrocyte sedimentation rate and C-reactive protein).○In all patients, consider conducting urine toxicology testing, with informed consent, including testing for THC.Imaging•Chest radiograph.•Consider chest computed tomography for evaluation of severe or worsening disease, complications, other illnesses, or when chest x-ray result does not correlate with clinical findings.Other considerations•Further evaluation of patients meeting inpatient admission criteria might include○Consultation with pulmonary, critical care, medical toxicology, infectious disease, psychology, psychiatry, and addiction medicine specialists.○Additional testing with bronchoalveolar lavage or lung biopsy as clinically indicated, in consultation with pulmonary specialists.SummaryWhat is already known about this topic?Forty-nine states, the District of Columbia, and one US territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states.What is added by this report?Based on the most current data, CDC's updated interim guidance provides a framework for health care providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms of e-cigarette, or vaping, product use associated lung injury (EVALI).What are the implications for public health practice?Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury. •Ask about respiratory, gastrointestinal, and constitutional symptoms (eg, cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and fever) for patients who report a history of use of e-cigarette, or vaping, products.•Ask all patients about recent use of e-cigarette, or vaping, products.○Types of substances used (eg, tetrahydrocannabinol [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). •Assess vital signs and oxygen saturation via pulse-oximetry. •Infectious disease evaluation might include○Respiratory viral panel including influenza testing during flu season, Streptococcus pneumoniae, Legionella pneumophila, Mycoplasma pneumoniae, endemic mycoses, and opportunistic infections.•Initial laboratory evaluation○Consider complete blood count with differential, liver transaminases, and inflammatory markers (eg, erythrocyte sedimentation rate and C-reactive protein).○In all patients, consider conducting urine toxicology testing, with informed consent, including testing for THC. •Chest radiograph.•Consider chest computed tomography for evaluation of severe or worsening disease, complications, other illnesses, or when chest x-ray result does not correlate with clinical findings. •Further evaluation of patients meeting inpatient admission criteria might include○Consultation with pulmonary, critical care, medical toxicology, infectious disease, psychology, psychiatry, and addiction medicine specialists.○Additional testing with bronchoalveolar lavage or lung biopsy as clinically indicated, in consultation with pulmonary specialists. What is already known about this topic? Forty-nine states, the District of Columbia, and one US territory have reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products. Twenty-six deaths have been reported from 21 states. What is added by this report? Based on the most current data, CDC's updated interim guidance provides a framework for health care providers in their initial assessment, evaluation, management, and follow-up of persons with symptoms of e-cigarette, or vaping, product use associated lung injury (EVALI). What are the implications for public health practice? Rapid recognition by health care providers of patients with EVALI and an increased understanding of treatment considerations could reduce morbidity and mortality associated with this injury. Based upon medical chart abstraction data submitted to CDC, 95% (323/339) of patients diagnosed with EVALI initially experienced respiratory symptoms (eg, cough, chest pain, and shortness of breath), and 77% (262/339) had gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea). Gastrointestinal symptoms preceded respiratory symptoms in some patients.1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar, 2CDCSevere Pulmonary Disease Associated With Using E-Cigarette Products. HAN alert No. 421.. US Department of Health and Human Services, CDC, Health Alert Network, Atlanta, GA2019Google Scholar, 3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar Respiratory or gastrointestinal symptoms were accompanied by constitutional symptoms such as fever, chills, and weight loss among 85% (289/339) of patients (Table 1).TABLE 1Characteristics of patients (N = 342) with e-cigarette use, or vaping, product use associated lung injury (EVALI),*For cases that had full medical chart abstraction data available. from national EVALI surveillance reports to CDC — United States, 2019†Surveillance data through October 3, 2019, from the following 29 U.S 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.CharacteristicEVALI patientsNo. (%)Total no. used in calculation§Patients with missing data were excluded from denominators for selected characteristics.Age, median (range) (y)22 (13-71)338Symptoms reportedAny respiratory323 (95)339Any gastrointestinal262 (77)339Any constitutional¶Self-reported fever, chills, and unexpected weight loss.289 (85)339Vital signsOxygen saturation < 95% while breathing room air143 (57)253Tachycardia (heart rate > 100 beats/min)169 (55)310Tachypnea (respiratory rate > 20 breaths/min)77 (45)172Clinical courseAdmission to intensive care unit159 (47)342Age group (y)13-1745 (56)8018-2449 (38)13025-5054 (47)115≥519 (69)13Past cardiac disease**Heart failure, heart attack, or other heart conditions.8 (50)16No past cardiac disease151 (46)326Intubation and mechanical ventilation74 (22)338Age group (y)13-1723 (29)8018-2421 (16)13025-5023 (20)115≥517 (54)13Past cardiac disease**Heart failure, heart attack, or other heart conditions.5 (31)16No past cardiac disease70 (21)326Corticosteroids252 (88)287Improved after corticosteroids114 (82)140Duration of hospitalization (days)Mean (median)RangeAge group (y)13-176.9 (6)0-2318-246.2 (5)0-3825-506.6 (6)0-40≥5114.8 (12)3-31Past cardiac disease8.9 (4)3-31No past cardiac disease6.6 (5)0-40Average hospital stay6.7 (5)0-40Abbreviation: E-cigarette = electronic cigarette.* For cases that had full medical chart abstraction data available.† Surveillance data through October 3, 2019, from the following 29 U.S 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.§ Patients with missing data were excluded from denominators for selected characteristics.¶ Self-reported fever, chills, and unexpected weight loss.** Heart failure, heart attack, or other heart conditions. Open table in a new tab Abbreviation: E-cigarette = electronic cigarette. 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 (eg, 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.c 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. 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 1), 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 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.d 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/mm3 and 93% had an ESR > 30mm/hr; 50% of patients had elevated liver transaminases (aspartate aminotransferase or alanine aminotransferase > 35 U/L).3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar 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.1Schier JG Meiman JG Layden J et al.CDC 2019 Lung Injury Response GroupSevere pulmonary disease associated with electronic-cigarette-product use—interim guidance.MMWR Morb Mortal Wkly Rep. 2019; 68: 787-790Crossref PubMed Scopus (77) Google Scholar,7Henry TS Kanne JP Kligerman SJ Imaging of vaping-associated lung disease.N Engl J Med. 2019; 381: 1486-1487Crossref PubMed Scopus (131) Google Scholar 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.3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar 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 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 (eg, 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 1); 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. 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.BOX 2Management of patients with suspected e-cigarette, or vaping, product use associated lung injury (EVALI)Admission criteria and outpatient management•Strongly consider admitting patients with potential lung injury, especially if respiratory distress present, have comorbidities that compromise pulmonary reserve, or decreased (<95%) O2 saturation (consider modifying factors such as altitude to guide interpretation).•Outpatient management for patients with suspected lung injury who have less severe injury might be considered on a case-by-case basis.Medical treatment•Consider initiation of corticosteroids.•Early initiation of antimicrobial coverage for community-acquired pneumonia should be strongly considered in accordance with established guidelines.*•Consider influenza antivirals in accordance with established guidelines.†Patients not admitted to hospital•Recommend follow-up within 24-48 hours to assess and manage possible worsening lung injury.•Outpatients should have normal oxygen saturation, reliable access to care and social support systems, and be instructed to promptly seek medical care if respiratory symptoms worsen.•Consider empiric use of antimicrobials and antivirals.Post-hospital discharge follow-up•Schedule follow-up visit no later than 1-2 weeks after discharge that includes pulse-oximetry testing.•Consider additional follow-up testing including spirometry and diffusion capacity testing, and consider repeat chest radiograph in 1-2 months.•Consider endocrinology consultation for patients treated with high-dose corticosteroids.Cessation services and preventive care•Strongly advise patients to discontinue use of e-cigarette, or vaping, products.•Provide education and cessation assistance for patients to aid nicotine addiction and treatment or referral for patients with marijuana-use-disorder.§•Emphasize importance of routine influenza vaccination.¶•Consider pneumococcal vaccine.***https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST#readcube-epdf; https://academic.oup.com/cid/article/53/7/e25/424286/.† https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm; https://www.idsociety.org/practice-guideline/influenza/.§ Substance Abuse and Mental Health Services Administrations treatment locator (https://www.samhsa.gov/find-treatment) to find treatment in your area or call 1-800-662-HELP (4357).¶ https://www.cdc.gov/flu/prevent/vaccinations.htm.** https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm?s_cid. •Strongly consider admitting patients with potential lung injury, especially if respiratory distress present, have comorbidities that compromise pulmonary reserve, or decreased (<95%) O2 saturation (consider modifying factors such as altitude to guide interpretation).•Outpatient management for patients with suspected lung injury who have less severe injury might be considered on a case-by-case basis. •Consider initiation of corticosteroids.•Early initiation of antimicrobial coverage for community-acquired pneumonia should be strongly considered in accordance with established guidelines.*•Consider influenza antivirals in accordance with established guidelines.† •Recommend follow-up within 24-48 hours to assess and manage possible worsening lung injury.•Outpatients should have normal oxygen saturation, reliable access to care and social support systems, and be instructed to promptly seek medical care if respiratory symptoms worsen.•Consider empiric use of antimicrobials and antivirals. •Schedule follow-up visit no later than 1-2 weeks after discharge that includes pulse-oximetry testing.•Consider additional follow-up testing including spirometry and diffusion capacity testing, and consider repeat chest radiograph in 1-2 months.•Consider endocrinology consultation for patients treated with high-dose corticosteroids. •Strongly advise patients to discontinue use of e-cigarette, or vaping, products.•Provide education and cessation assistance for patients to aid nicotine addiction and treatment or referral for patients with marijuana-use-disorder.§•Emphasize importance of routine influenza vaccination.¶•Consider pneumococcal vaccine.** *https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST#readcube-epdf; https://academic.oup.com/cid/article/53/7/e25/424286/. † https://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm; https://www.idsociety.org/practice-guideline/influenza/. § Substance Abuse and Mental Health Services Administrations treatment locator (https://www.samhsa.gov/find-treatment) to find treatment in your area or call 1-800-662-HELP (4357). ¶ https://www.cdc.gov/flu/prevent/vaccinations.htm. ** https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm?s_cid. 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.3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar Health care providers should instruct all patients to seek medical care promptly if respiratory symptoms worsen. Corticosteroids might be helpful in treating this injury. Several case reports describe improvement with corticosteroids, likely because of a blunting of the inflammatory response.3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491072&dopt=AbstractGoogle Scholar, 4Davidson K Brancato A Heetderks P et al.Outbreak of electronic-cigarette–associated acute lipoid pneumonia—North Carolina, July–August 2019.MMWR Morb Mortal Wkly Rep. 2019; 68: 784-786Crossref PubMed Scopus (81) Google Scholar, 5Maddock SD Cirulis MM Callahan SJ et al.Pulmonary lipid-laden macrophages and vaping.N Engl J Med. 2019; 381 (https://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=31491073&dopt=Abstract.): 1488-1489Crossref PubMed Scopus (141) Google Scholar 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".3Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. 2019. https://www.ncbi.nlm.nih.go
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