Knowledge Base Article

The first possible cases of a vaping related illness were reported to the CDC on August 1st, 2019. In response to reports of illness, the CDC, FDA, State and Local Health Departments, Clinical and Public Health Partners have been actively investigating a multi-state outbreak of lung injury associated with use of e-cigarettes, or vaping, products. The vaping related illness has been named EVALI (E-cigarette, or Vaping, Product Use-Associated Lung Injury). Information for the Public, Health Care Providers, and Health Departments is available on the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.

CDC Weekly EVALI Updates

Currently information about EVALI is being updated on this CDC webpage every Thursday. The following table recaps information made available over the last three weeks:

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• What the CDC Knows: About Patient Exposure
• All EVALI patients have reported history of using e-cigarette, or vaping, products.
• THC is present in most of the samples tested by the FDA to date, and most patients report a history of using THC-containing products.
• Findings suggest products containing THC, particularly when obtained off the street or informal sources, are linked to the most cases and play a major role in the outbreak.

• What the CDC Does Not Know:
• The FDA and CDC has not identified the cause(s) of lung injuries in these 1,479 cases. The only commonality is patient’s reporting e-cigarettes, or vaping, products.
• No one compound or ingredient has emerged as the cause of these illnesses.
• The specific chemical exposure(s) causing lung injuries associated with e-cigarette product use, or vaping, remains unknown.

• What the CDC is Recommending You Should NOT do:
• Use e-cigarette, or vaping, products containing THC.
• Buy any e-cigarette, or vaping, products off the street – particularly those containing THC
• Modify or add any substances to e-cigarettes, or vaping, products that are not intended by the manufacturer, including products purchased through retail establishments.

• What the CDC is Recommending You Should do:
• The CDC recommends considering refraining from use of all e-cigarette and vaping products. If you do not choose to refrain from use, they go on to advise careful monitoring of yourself for symptoms and to see a healthcare provider immediately if you develop the following symptoms that have been reported in this outbreak:
• Cough, shortness of breath, or chest pain,
• Nausea, vomiting, abdominal pain or diarrhea,
• Fever, chills, or weight loss.

Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected EVALI

On October 17th, a Clinician Outreach and Communication Activity (COCA) Webinar was held to discuss what the CDC has learned to date about EVALI and explain their updated interim guidance for healthcare providers. Following is a list of commonalties related to EVALI shared during the webinar:  

Common Clinical Characteristics of Patients as of October 3, 2019:

• 95% of patients initially experienced respiratory symptoms (e.g., cough, chest pain, and shortness of breath).
• 77% of patients had gastrointestinal (GI) symptoms (e.g., abdominal pain, nausea, vomiting and diarrhea). Note, GI symptoms preceded respiratory symptoms in some patients.
• 85% of patients had symptoms accompanied by constitutional symptoms (e.g., fever, chills, and weight loss).
• Vital Signs in cases of EVALI reported to the CDC included:
• 55% had tachycardia (HR>100 beats/min),
• 45% had tachypnea (respiratory rate >20 breaths/min), and
• 57% has an O2 saturation <95% at rest on room air.
• Pulmonary findings in cases of EVALI reported to the CDC were that on auscultation the exam has been unremarkable, even among patients with severe lung injury.
• Specialized Care
• 47% of patients admitted to ICU, and
• 22% required endotracheal intubation and mechanical ventilation.

EVALI Official Coding Guidelines

On October 17, 2019, the CDC released a supplement to the ICD-10-CM Official Coding Guidelines. This supplement:

• Provides guidance related to the 2019 health care encounters and deaths related to EVALI.
• Is intended to be used in conjunction with current ICD-10-CM classifications and the ICD-10-CM Official Guidelines for Coding and Reporting effective October 1, 2019.
• May not represent all possible reasons for health care encounters related to e-cigarette, or vaping, product use.

The introduction to the supplement highlights that this guidance is consistent with what is currently known about this disease and will be updated as new clinical information becomes available. Further, clinical scenarios described in the General Guidance “may not represent all possible reasons for health care encounters that  may be related to e-cigarette, or vaping, product use.”

General guidance focuses on scenarios related to the following:  

• Lung-related complications
• For patients with documented EVALI, assign the code for the specific condition. (i.e. ICD-10-CM code J680.0, (Bronchitis and pneumonitis due to chemicals, gases, fumes and vapors; includes chemical pneumonitis), and
• For patients with acute lung injury but without further documentation identifying a specific condition (pneumonitis, bronchitis), assign code: J68.9, Unspecified respiratory condition due to chemicals, gases, fumes, and vapors.
• Poisoning and toxicity,
• Substance use, abuse, and dependence, and
• Signs and Symptoms.

As mentioned previously, this guidance is consistent with current clinical knowledge. With the CDC posting weekly updates, there is a high probability there will be changes to the guidance in the future.

One way to keep up with any changes is to frequent the CDC webpage Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.  Also, for those of you reading this in Alabama, the Alabama Department of Public Health (ADPH) has a page dedicated to Vapes and E-Cigs that includes

Vape-Related Pulmonary Illnesses Alabama specific statistics.