What is the management approach for a patient with eVALI (e-cigarette or vaping product use-associated lung injury)?

Management of E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI)

The management of EVALI requires hospitalization for patients with respiratory distress, oxygen saturation <95% on room air, significant comorbidities, or inadequate social support, followed by comprehensive evaluation, supportive care, consideration of corticosteroids, and close follow-up within 48 hours of discharge to reduce risk of rehospitalization and death. 1, 2

Initial Assessment and Triage

• Patients should be hospitalized if they have any of the following:

  • Oxygen saturation <95% on room air 1, 2
  • Respiratory distress 1, 2
  • Comorbidities that could compromise cardiopulmonary reserve 1, 2
  • Inability to discontinue e-cigarette/vaping product use 1, 2
  • Inadequate social support or unreliable access to care 1, 2

• Patients with severe EVALI may require intensive care management, including intubation and potentially ECMO support in extreme cases 3

Clinical Evaluation

• Perform comprehensive diagnostic testing to rule out alternative diagnoses:

  • Urine toxicology and infectious disease testing (including influenza during flu season) 1
  • Chest radiograph for all patients, with CT scan consideration even if CXR is normal 1, 2
  • Detailed vaping history, including specific products used (particularly THC-containing products) 2, 4
  • Consider bronchoalveolar lavage or lung biopsy in consultation with pulmonary specialists for unclear cases 1, 5

• Consider specialist consultations:

  • Pulmonary, critical care, medical toxicology, infectious diseases consultations 1
  • Psychiatric consultation for mental health and substance use assessment 1

Inpatient Management

• Respiratory support:

  • Provide supplemental oxygen to maintain SpO2 ≥95% 2
  • For severe cases with respiratory failure, consider mechanical ventilation 3, 6

• Pharmacological management:

  • Discontinue all e-cigarette and vaping product use immediately 1, 2
  • Consider empiric antimicrobial therapy according to community-acquired pneumonia guidelines until infection is ruled out 1, 2
  • Consider systemic corticosteroids, which have shown benefit in many cases 2, 4, 7
    • High-dose steroids with tapering regimen have been effective in severe cases 6
    • Use corticosteroids with caution in outpatients due to risk of worsening respiratory infections 1, 2
  • Administer routine annual influenza vaccination if not previously received 1

Discharge Planning

• Ensure clinical stability for 24-48 hours before discharge with:

  • No clinically significant fluctuations in vital signs 1
  • Adequate oxygenation on room air 1, 2

• Medication management:

  • Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge, particularly for patients on corticosteroid taper 1
  • Evaluate patients for risk of secondary adrenal insufficiency before discharge if they received prolonged corticosteroid courses 1, 2
  • Consider corticosteroid taper and follow-up with an endocrinologist for patients who received prolonged steroid treatment 1, 2
  • Counsel patients about signs and symptoms of adrenal insufficiency (fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, postural hypotension) 1

• Ensure comprehensive follow-up planning:

  • Schedule initial outpatient follow-up appointment within 48 hours of discharge (not 2 weeks as previously recommended) 1
  • Arrange follow-up with a pulmonologist within 2-4 weeks 1
  • Screen for mental health, substance use disorders, and social care needs 1
  • Ensure access to social/mental health/substance use disorder services 1

Post-Discharge Follow-Up

• Initial outpatient follow-up (within 48 hours) should include:

  • Assessment of vital signs, physical exam, symptom resolution, and laboratory tests 1
  • Reinforcement of education about EVALI 1
  • Ensuring adherence with medication regimens, especially corticosteroid tapers 1
  • Reinforcing importance of abstinence from e-cigarette and vaping product use 1
  • Connecting patients to needed social, mental health, and substance use disorder resources 1

• Pulmonary specialist follow-up (within 2-4 weeks) should include:

  • Assessment of pulmonary function and resolution of radiographic findings 1
  • Consider follow-up testing at 1-2 months after discharge, including spirometry, diffusing capacity of the lung for carbon monoxide, and chest x-ray 1

• Additional considerations:

  • Physical therapy for patients who experienced prolonged immobilization during hospitalization 1
  • Ongoing engagement with addiction medicine and mental health services 1
  • Cessation services for all patients 1, 2

Special Considerations and Pitfalls

• Patients with cardiac disease, chronic pulmonary disease (e.g., COPD, sleep apnea), diabetes, and older age have higher risk for rehospitalization and death 1, 2

  • 70.6% of rehospitalized patients and 83.3% of patients who died had one or more chronic conditions 1
  • Median ages of patients who died, were rehospitalized, and who neither died nor were rehospitalized were 54,27, and 23 years, respectively 1

• Most rehospitalizations and deaths occur shortly after discharge:

  • Median time to readmission: 4 days (interquartile range: 2-20 days) 1
  • Median time to death: 3 days (interquartile range: 2-13 days) 1
  • At least 25% of rehospitalizations and deaths occurred within 2 days of discharge 1

• EVALI is a diagnosis of exclusion - other etiologies must be eliminated and chest imaging findings must be abnormal 4, 5

• Most patients with EVALI report using THC-containing products (92% in one cohort), making these a key focus in investigations 4, 7