CDC Recommendations for Clinicians
- Report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette or vaping product use within the past 90 days to your state or local health department.
- Ask all patients who report e-cigarette or vaping product use within the last 90 days about signs and symptoms of pulmonary illness.
- If e-cigarette or vaping product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain detailed history regarding:
- Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
- Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
- Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)
- Where the product(s) were purchased
- Method of substance use: aerosolization, dabbing, or dripping
- Other potential cases: sharing e-cigarette products (devices, liquids, refill pods, or cartridges) with others
- 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 of e-cigarette product use. Evaluate and treat for other possible causes of illness. Consider consultation with specialists (pulmonary, infectious disease, medical toxicology) as appropriate.
- Clinical improvement of patients with severe pulmonary disease associated with e-cigarette use 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 e-cigarettes 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 severe pulmonary disease related to e-cigarette or vaping product use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.
Sources: CDC website, MMWR Morb Mortal Wkly Rep. 2019;68(36):787-790.
- National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018.
- Layden J, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. Sept. 6, 2019 [epub ahead of print]
- Davidson K, Brancato A, Heetkerks P, et al. Outbreak of e-cigarette-associated acute lipoid pneumonia—North Carolina, July–August 2019. MMWR Morb Mortal Wkly Rep. 2019;68(36):784-786.
- Maddock S, Cirulis M, Callahan S, Wahlen GE. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. 2019. Sept. 6, 2019 [epub ahead of print]
- Henry TS, Kanne JP, Klingerman SJ. Imaging of vaping-associated lung disease. N Engl J Med. Sept. 6, 2019 [epub ahead of print]