Atlanta, GA—A combination of antibiotics, antivirals, or steroids should be considered to treat patients who have lung injury associated with the use of electronic cigarette or “vaping” products, according to a new report.

The CDC advised that 49 states, the District of Columbia, and one U.S. territory reported 1,299 cases of lung injury associated with the use of electronic cigarette (e-cigarette), or vaping, products as of mid-October, with 26 deaths in 21 states.

An article in the Morbidity & Mortality Weekly Report recently used the most current data to offer a framework for healthcare 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).

“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,” public health officials said.

The article advised that corticosteroids might be helpful in treating the injury, with several case reports describing improvement with corticosteroids, probably because of a blunting of the inflammatory response. Among the 140 cases reported nationally to CDC who received corticosteroids, 82% of patients improved, the authors said, cautioning, “However, the natural progression of this injury is not known, and it is possible that patients might recover without corticosteroids or by avoiding use of e-cigarette, or vaping, products. In some circumstances, it would be advisable to withhold corticosteroids while evaluating patients for infectious etiologies, such as fungal pneumonia, that might worsen with corticosteroid treatment.”

Public-health officials also urged early initiation of antimicrobial treatment for community-acquired pneumonia in accordance with established guidelines, “given the overlapping of signs and symptoms in these conditions.” The CDC also suggested that, during influenza season, healthcare providers should consider influenza in all patients with suspected EVALI and should consider administering antivirals.

At the same time, the CDC urges pharmacists and other healthcare providers evaluating patients suspected to have EVALI to ask about the use of e-cigarette, or vaping products in a “nonjudgmental and thorough manner.”

The guidance recommends a chest radiograph for patients who meet the criteria and hospital admission for those who have decreased blood oxygen saturation (<95%) on room air or who are in respiratory distress.

Public-health officials also suggest promotion of evidence-based tobacco-product cessation strategies.

To reduce the risk of recurrence, patients who have been treated for EVALI should not use e-cigarette, or vaping, products. The CDC recommends that persons should not use e-cigarette, or vaping, products that contain tetrahydrocannabinol (THC), according to the article.

In fact, the CDC recommends that people consider refraining from using e-cigarette, or vaping, products that contain nicotine.

The median age of death for patients who succumbed was 49 years, with a range of 17 to 75 years. Among 1,043 patients diagnosed with the condition with available data on age and sex, 70% were male, and the median age was 24 years (range = 13–75 years).

Most were young, however, with 80% under age 35 years and 15% under age 18 years, according to the report.

Among 573 patients who reported information on substances used in e-cigarette, or vaping, products in the 90 days preceding symptom onset, the CDC noted:
• 76% reported using THC-containing products
• 58% reported using nicotine-containing products
• 32% reported exclusive use of THC-containing products
• 13% reported exclusive use of nicotine-containing products.

“No single compound or ingredient has emerged as the cause of these injuries to date, and there might be more than one cause,” the authors write. “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.”

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