PUBLIC HEALTH
addiction medicine specialists.
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breath), gastrointestinal (e.g., abdominal pain, nausea, vomiting
and diarrhea), and constitutional symptoms (e.g., fever, chills
and weight loss) for patients who report a history of using
e-cigarette, or vaping, products. Gastrointestinal symptoms
preceded respiratory symptoms in some patients.
» »
Ask patients about recent use of e-cigarette, or vaping, products
and ask about types of substances used (e.g., THC, cannabis
[oil, dabs], nicotine, modified products or the addition of
substances not intended by the manufacturer); product source,
specific product brand and name; duration and frequency of
use, time of last use; product delivery system, and method of
use (aerosolization, dabbing, or dripping).
Physical Examination
» » Assess vital signs and oxygen saturation via pulse oximetry.
» » Pulmonary findings on auscultation have often been unre-
markable.
Laboratory Testing
» »
Initial laboratory evaluation should be guided by clinical find-
ings.
•
Consider complete blood count with differential, liver
transaminases and inflammatory markers (e.g., erythrocyte
sedimentation rate and C-reactive protein), which may be
elevated (Layden JE, 2019).
•
» »
Consider conducting urine toxicology testing, with in-
formed consent, including testing for THC.
Infectious disease evaluation to rule out other etiologies might
include
•
Respiratory viral panel including influenza testing during
flu season, Streptococcus pneumoniae, Legionella pneu-
mophila, Mycoplasma pneumoniae, endemic mycoses, and
opportunistic infections.
Imaging
» » Chest radiograph (CXR).
» » Consider chest computed tomography (CT) for evaluation of
severe or worsening disease, complications, other illnesses,
or when CXR result does not correlate with clinical findings.
» »
Radiographic findings consistent with EVALI include pulmo-
nary infiltrates on CXR and opacities on CT scan. (Henry TS,
2019; Schier JG, 2019)
Other Considerations
» »
Further evaluation of patients meeting inpatient admission
criteria might include:
•
10
Consultation with pulmonary, critical care, medical tox-
icology, infectious disease, psychology, psychiatry, and
LOUISVILLE MEDICINE
•
Additional testing with bronchoalveolar lavage (BAL) or
lung biopsy as clinically indicated, in consultation with
pulmonary specialists.
WHAT PHYSICIANS CAN DO
We need your help! Physicians can play a pivotal role in helping
to identify the specific cause of this very serious lung injury while
protecting and treating their patients.
Here is how you can help:
1. Report cases of lung injury of unclear etiology and a history of
e-cigarette or vaping product use within the past 90 days to the
Kentucky Department for Public Health using the EPID 200
form and submit via secure fax at 502-696-3803. The illness
name can be listed as “EVALI.” Please also include all patient
medical records pertaining to the lung injury. Reporting of
lung injury cases may help the CDC determine the exact cause.
2. Ask all patients who report e-cigarette, or vaping, product use
within the last 90 days about signs and symptoms of respira-
tory illness.
3. If e-cigarette, or vaping, product use is suspected as a possible
etiology of a patient’s lung injury, obtain detailed history.
4. After contacting the Kentucky Department for Public Health,
determine if any remaining product, including devices and liq-
uids, is available for testing. Please ship product samples to the
Kentucky Division of Laboratory Services, Att: Rachel Zimmer
or Leigh Ann Bates, 100 Sower Blvd., Ste 204, Frankfort, KY
40601. Product may include the e-cigarette or vaping device
(no lithium batteries), liquid, refill pods and cartridges. These
may be shipped in packaging of your choice. They do not fall
under DOT hazardous material regulation.
5. Advise adult patients who are using e-cigarettes for smoking
cessation not to return to cigarettes but to contact the Depart-
ment of Public Health and Wellness at 574-STOP (574-7867).
We offer free smoking and vaping cessation classes with FDA
approved nicotine replacement products such as patches and
gum.
This outbreak is evolving quickly and changing rapidly. Please
consult the CDC website at https://www.cdc.gov/tobacco/basic_in-
formation/e-cigarettes/severe-lung-disease.html for the most current
information. Thank you in advance for your help in bringing the
EVALI outbreak under control.
Dr. Caloia serves as Medical Director for the Louisville Department of Public Health
and Wellness.
Dr. Moyer is the Director of the Louisville Metro Department of Public Health.