December 04, 2019 04:22 pm Chris Crawford – In June, young and otherwise healthy patients began presenting to the University of Rochester Medical Center in Rochester, N.Y., with undifferentiated respiratory failure. The only commonality between them was recent use of a vaping device.
Cases accumulated in the following months and were evaluated by pulmonary, toxicology and infectious disease teams.
Collectively, these groups identified a need for an internal decision tool to assist health care professionals in diagnosis and management of what is now known as e-cigarette, or vaping, product use-associated lung injury.
The medical center's multidisciplinary team began working with the New York State Department of Health, as well as the Upstate New York Poison Center and the New York City Poison Control Center, to develop and refine the decision tool.
"The resulting algorithm functions to help providers work through a case of undifferentiated respiratory illness possibly related to vaping," said Aleksandr Kalininskiy, M.D., of the Division of Pulmonary and Critical Care Medicine at the medical center. "It includes cues for questions about vaping, common clinical signs and symptoms, suggestions for appropriate imaging studies, and laboratory investigations."
The team's work, including its algorithm tool, was highlighted in an article published online Nov. 8 in The Lancet Respiratory Medicine that Kalininskiy co-authored.
"If a case presentation is consistent with EVALI, the algorithm provides basic management guidance, including respiratory support, use of steroids and antibiotics, and suggestions for procurement and testing of vape samples," Kalininskiy told AAFP News. "Finally, it serves to remind providers to counsel their patients to stop vaping and stop smoking combustible cigarettes."
The algorithm tool, which is largely consistent with the CDC's guidance for health care professionals on EVALI, includes information about laboratory testing for inflammatory markers and possible infectious etiologies, as well as recommendations for steroid treatment, oxygen support and abstinence from further inhaled products.
"We sought to organize the information in a user-friendly way that could fit on a single page for easy reference," said Kalininskiy. "One key difference in our algorithm is the focus on recent use of e-cigarette or vaping products -- in the past 30 days rather than 90 days as proposed by the CDC."
Because of the spiking use of e-cigarettes in the United States, including more than 5 million middle/high school students reporting use in the past 30 days, Kalininskiy said the team wanted to minimize the risk of falsely attributing a current respiratory condition with remote vaping use (more than 30 days).
In the first case series published on the topic by Layden et al. in The New England Journal of Medicine,94% of patients with available data reported vaping within seven days of symptom onset, he said.
When the CDC recently updated its EVALI interim guidance for health care professionals, the agency highlighted the importance of asking patients who present with respiratory (or gastrointestinal) illness about their use of e-cigarettes, or vaping, as the 2019-2020 influenza season ramps up. In its update, the agency emphasized that EVALI is a diagnosis of exclusion because many respiratory illnesses (including influenza) can present similarly.
In tandem with that report, the CDC released a Morbidity and Mortality Weekly Report that detailed characteristics of both hospitalized and nonhospitalized patients with EVALI.
Cases managed at the University of Rochester Medical Center that were treated with corticosteroids involved patients in demonstrated respiratory failure requiring either high-flow nasal cannula or endotracheal intubation, Kalininskiy said.
"Through our recent experience and in discussion with health care professionals nationwide, corticosteroids seemed to reduce the amount of oxygen support required within 24-48 hours," he said. "Our patients were discharged on two to four weeks of oral steroids. An important focus of future research is to identify the appropriate duration of treatment with corticosteroids."
But although corticosteroids seem to improve patients with EVALI, they may worsen the clinical condition of influenza patients.
"Therefore, it's important to consider alternative diagnoses prior to starting corticosteroid therapy," Kalininskiy said. "There is some evidence to suggest that patients who vape may be more susceptible to respiratory infections than the general population. It is plausible that a patient may be suffering from influenza and EVALI at the same time."
"As health care providers, we need to advocate that everyone who is a candidate for the influenza vaccine receives the influenza vaccine," he added. "If a patient presents with suspicion of EVALI and has a positive influenza test, we recommend treatment with oseltamivir and avoidance of corticosteroids. These patients may benefit from a pulmonary consultation."
For the University of Rochester Medical Center team's research, cases were defined as patients admitted to the facility who had used e-cigarettes or another vaping device in the 30 days before presentation, and who had bilateral airspace opacification on chest imaging (CT or X-ray).
The researchers obtained case details using medical records and patient interviews from the previous three months, including symptomatology, physical exam data, imaging studies, laboratory data, vaping history and subsequent outpatient follow-up data.
There were 12 cases treated for suspected EVALI at the facility between June 6 and Sept. 15; 10 of these patients had dyspnea, fever and emesis, and nine had cough. Eleven of the 12 patients reported using e-cigarette cartridges containing tetrahydrocannabinol oil.
Although eight patients required admission to the intensive care unit for hypoxemic respiratory failure, none of them died; median hospital length-of-stay for all cases was seven days.
Half of the 12 patients treated for EVALI at the medical center completed follow-up visits; all of them had resolution of previous chest CT findings and normal spirometry.
"Though these are reassuring findings, more data is needed to draw conclusions about the long-term effects of EVALI and vaping in general," Kalininskiy said. "And though only half of our patients followed up with pulmonology after hospitalization, all patients who did had quit vaping. Based on our experience and published case series, patients who resume vaping after an EVALI risk another hospitalization from recurrent EVALI."
Follow-up also is important because there remains uncertainty about how long steroid treatment should be required, as well as the long-term consequences of EVALI in general.
"Therefore, it is important to confirm resolution of both the imaging and the clinical findings to ensure that no further intervention is required," Kalininskiy said. "The outcomes we have seen are encouraging in the short term, but more data is needed to see if there are adverse effects on pulmonary function."
Finally, follow-up visits offer another opportunity to educate patients about vaping cessation, as well as the hazards of nicotine and cannabis use.
"Many people now use e-cigarettes to quit combustible cigarette smoking, and it is important to ensure EVALI patients do not resume using tobacco or other dangerous substances," said Kalininskiy, "and behavioral treatment options for nicotine and THC use should be provided on follow-up."
Although much has now been learned about the EVALI outbreak that began sweeping across the country this year, there remain active investigations into the exact causes and long-term consequences of this condition, Kalininskiy said.
"We are still encountering new cases of EVALI every week, so we must remain vigilant and will rely on health care professionals nationwide to report cases to their respective health departments to help everyone better understand this illness," he concluded.
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