Quantifying Clinical Suspicion: Identifying EVALI
How Decision Support Tools Can Help Clinicians Treat Patients With E-Cigarette Vaping-Associated Lung Injury (EVALI)
By Monique Yohanan, MD, MPH, Medical Director and Senior Director, InterQual® Content Development, Change Healthcare
In the spring of 2019, U.S. health department officials noticed a rise in unexplained lung infections in otherwise healthy individuals. Researchers collected additional data as more patients were affected, leading the Centers for Disease Control and Prevention (CDC) to identify a new pulmonary disease, electronic cigarette vaping-associated lung injury (EVALI). After cases peaked in September, the CDC declared an outbreak. By February 4 of this year, 2,758 patients had been hospitalized with EVALI, with 64 confirmed deaths.
While national epidemiologic data suggests that new EVALI hospitalizations are in decline, clinicians must remain vigilant. As the initial presentation of EVALI may be clinically indistinguishable from infectious lung disease (e.g., influenza, pneumonia), identification depends on clinical suspicion.
Clinical decision support tools, such as InterQual’s Imaging criteria and Acute Adult and Pediatric Level of Care criteria, can help physicians in both the diagnosis and treatment of EVALI. By selecting the appropriate criteria based on the patient’s presenting symptoms, clinical decision support can recommend evidence-based interventions for treatment and stabilization.
Diagnosis and Triage
Clinicians should be careful to take a thorough patient history to elicit information about e-cigarette use. Questions should include details such as duration and frequency, type (nicotine, THC, cannabis oil/dabs), delivery system (aerosol, dab, drip), source (store-bought vs. illicit/informal acquisition), and known or possible product modification. Research indicates that the use of vaping products containing diluents such as vitamin E acetate may increase risk.
Other clinical and demographic findings may be useful in triaging patients. Respiratory and GI symptoms predominate. Low oxygen levels are common for EVALI patients, but lung exams are often nonspecific. To date, most EVALI patients have been young men (median age 23).
Work-up should include tests for respiratory viruses (including influenza during flu season) and community-acquired pneumonia. Urine toxicology testing, including testing for THC, should be considered. Chest X-rays should be performed for all patients with a history of e-cigarette use and respiratory or GI symptoms. A chest CT scan should be ordered based on individual clinical circumstances.
Treatment and Recovery
Most patients with EVALI (98%) require hospital admission. For patients with milder symptoms, outpatient care for 24 to 48 hours with close follow-up attention may be considered on a case-by-case basis. Nearly half of all EVALI patients have been admitted to the ICU, and more than 20% have needed mechanical ventilation. Some patients experience complications, such as systemic inflammatory response syndrome and acute respiratory distress syndrome.
Antimicrobial/antiviral agents should be considered for all patients. While anti-infective therapy will not treat EVALI, empiric therapy may be appropriate due to the overlap in clinical presentation of EVALI and infectious lung disease. Corticosteroids may be of particular benefit to patients with severe disease, and pulmonologist consultation may be useful in guiding medical treatment, as well as possible procedures (e.g. bronchoalveolar lavage).
The long-term sequelae of EVALI is unknown. Patients should be advised on the importance of abstaining from e-cigarette/vaping device usage, and should be seen in ambulatory care one to two weeks after discharge. Follow-up examinations should include pulse oximetry and a possible repeat chest X-ray.
The one constant in medicine is change. As new diseases are identified—and diagnosis and treatment protocols evolve in their wake—physicians can rest assured that their decision support tools will be kept current. Relying on evidence-based decision support tools like InterQual can help clinicians provide appropriate, medically necessary care for all patients.
Centers for Disease Control and Prevention. February 11, 2020. “CDC, States Update Number of Hospitalized EVALI Cases and EVALI Deaths.” https://www.cdc.gov/media/releases/2020/s0211-Evali-cases-deaths.html
Evans, Mary E., Evelyn Twentyman, Eleanor S. Click, Alyson B. Goodman, David N. Weissman, Emily Kiernan, Susan Adkins Hocevar, et al. “Update: Interim Guidance for Health Care Professionals Evaluating and Caring for Patients with Suspected E-Cigarette, or Vaping, Product Use–Associated Lung Injury and for Reducing the Risk for Rehospitalization and Death Following Hospital Discharge — United States, December 2019.”
MMWR. Morbidity and Mortality Weekly Report 68, no. 5152 (March 2020): 1189–94. https://doi.org/10.15585/mmwr.mm685152e2
Layden, Jennifer E., Isaac Ghinai, Ian Pray, Anne Kimball, Mark Layer, Mark Tenforde, Livia Navon, et al. “Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin — Preliminary Report.” New England Journal of Medicine, June 2019. https://doi.org/10.1056/nejmoa1911614