Vaping-Associated Lung Injury: Updated Interim Guidance for Healthcare Providers

Posted October 17, 2019. Past health advisories and alerts are archived for historical purposes and are not maintained or updated.

Over 1,299 reports (as of October 8) of lung injury cases associated with the use of vaping (or e-cigarette) products have been reported from 49 states, the District of Columbia, and one U.S. territory. Twenty-six deaths have been confirmed. Roughly 80% of patients are under 35 years old.

All cases reported vaping prior to illness but to date we have not identified a product, device, or additive common to all cases.  Investigations into the specifics of products, devices, and additives is ongoing. Most patients report a history of vaping THC-containing products. The latest national and state findings suggest products containing THC, particularly those obtained off the street or from other informal sources are linked to most of the cases and play a major role in the outbreak. However, exclusive use of nicotine containing products has been reported by some cases and therefore the possibility that nicotine-containing products play a role in this outbreak cannot be excluded.

Locally, seven cases have been confirmed in Washington, two of which were reported in Spokane. Effective October 10, the Washington State Board of Health unanimously approved a 120-day emergency ban on the sale of flavored vape products. Additionally, during the last legislative session, the state Legislature passed a law raising the age to purchase tobacco and vaping products to 21. The new law will go into effect January 1, 2020.

Healthcare providers are now required to report possible cases of vaping/e-cigarette-associated lung injury for further investigation. If vaping/e-cigarette product use is suspected as a possible cause for a patient’s acute lung illness, a detailed history of the substances used, the sources, and the devices used should be obtained, and efforts should be made to determine if any remaining product, devices, and liquids are available for testing.

Actions Requested:

  • Be aware of reports of vaping-associated lung injury from multiple U.S. states. Seven cases have been reported from Washington State and two in Spokane County.
  • Ask all patients with severe acute lung illness whether they have used any vaping/e-cigarette or have “dabbed” in the last 90 days. This is for both nicotine and THC-containing products.
  • Report hospitalized patients with suspected vaping-associated lung injury to Spokane Regional Health District at 509-324-1442. Healthcare providers and healthcare facilities are required to report vaping-associated lung injury per an emergency rule passed by the State Board of Health on October 9th and, as a rare disease of public health significance, per WAC 246-101-101 and WAC 246-101-301.
  • If vaping/e-cigarette product use is suspected as a possible etiology of a patient’s severe acute lung illness, obtain detailed history regarding substance(s) used, substance source(s), device(s) used, product modifications by the user, where the product(s) were purchased, method of substance use,  and other potential cases.
  • Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the local or state health departments
  • Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and vaping/e-cigarette product use. Evaluate and treat for other possible causes of illness (e.g., infectious, rheumatologic, neoplastic) as clinically indicated. Consider consultation with specialists (pulmonary, infectious disease, critical care, medical toxicology) as appropriate.
  • Remind patients that their healthiest option is to stop vaping and stop using tobacco products.
  • CDC will be hosting a webinar for healthcare providers on Thursday, October 17 11 am to 12 pm Pacific time. Update: Interim Guidance for Healthcare Providers Evaluation and Caring for Patients with Suspected E-Cigarette or Vaping Product Use Associated Lung Injury.
  • Be aware of updated (October 11) guidance from the CDC (MMWR: Interim Guidance for Healthcare Providers Evaluation and Caring for Patients with Suspected E-Cigarette or Vaping Product Use Associated Lung Injury.

Other clinical considerations:

  • Patients in this investigation have reported symptoms such as cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, and/or abdominal pain. Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks.
  • Clinical improvement of patients with vaping-associated lung injury has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.
  • Lipoid pneumonia associated with inhalation of lipids in aerosols generated by vaping/e-cigarette products has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.
  • Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
  • Patients who have received treatment for vaping-associated lung injury use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.

Reporting cases to public health:

Healthcare providers are required to report cases of vaping-associated lung injury within three days. Please report patients who meet the following criteria to Spokane Regional Health District Epidemiology (509-324-1442):

Any hospitalized patient who:

  • Reports vaping or dabbing in the 90 days prior to symptom onset and,
  • Has a chest X-ray with pulmonary infiltrates or a chest CT scan with ground-glass opacities and,
  • Has no pulmonary infection (i.e., negative respiratory viral panel, negative flu test, and other clinically-indicated respiratory infectious disease testing negative) or an infection has been identified, but you feel this is not the sole cause of the lung injury or complete infectious disease testing was not performed, but you feel an infection is not the sole cause of the lung injury and,
  • There is no other alternative plausible diagnosis such as a cardiac, rheumatologic or neoplastic process.

For more information, see the full CDC case definition.

Additional Updated (October 11) Resources:

Centers for Disease Control and Prevention Guidance for Healthcare Providers: Outbreak of Vaping-Associated Lung Injury

MMWR: Update: Interim Guidance for Healthcare Providers Evaluation and Caring for Patients with Suspected E-Cigarette or Vaping Product Use Associated Lung Injury

CDC educational webinar Thursday, October 17 11 am to 12 pm Pacific time. Update: Interim Guidance for Healthcare Providers Evaluation and Caring for Patients with Suspected E-Cigarette or Vaping Product Use Associated Lung Injury