Ask Patients with Unexplained Respiratory Illnesses about their Use of E-cigarettes and Vaping—What Questions to Ask, What to Look For

As of August 23, 2019, 22 states have reported a total of 193 potential cases of a severe lung illness. The Centers for Disease Control and states have not identified a cause, but all reported cases involve e-cigarette product use or “vaping.” Currently, there is no consistent evidence to suggest an infectious disease is causing the condition. No cases have yet been reported in Washington state.

How are patients presenting?

• In many cases, patients reported a gradual start of symptoms including breathing difficulty, shortness of breath, and/or chest pain before hospitalization. Some cases reported mild to moderate gastrointestinal illness including vomiting and diarrhea and fatigue as well.
  
  
• In many cases, patients have acknowledged recent use of tetrahydrocannabinol (THC)-containing products while speaking to healthcare personnel or in follow-up interviews by health department staff; however, no specific product has been identified in all cases, nor has any product been conclusively linked to illnesses.

The Centers for Disease Control is now advising providers to ask patients with unexpected respiratory illnesses about their use of e-cigarettes and vaping. While e-cigarettes have been on the market for a decade, their flavorings—including diacetyl, ultrafine particles, and other substances used in e-cigarette aerosols—have been linked to respiratory illnesses.

In addition to always inquiring about a patient’s potential drug (legal and illicit) use as part of a general history, what should clinicians do if a patient presents with a respiratory or pulmonary illness, especially of unclear etiology?

• Ask about the use of e-cigarette products (devices, liquids, refill pods and/or cartridges) for “vaping.”
  
  
• If possible, inquire about the types of drugs (legal or illicit) used and methods of drug use (e.g., smoking, “vaping”).
  
  
• Consider all possible causes of illness in patients presenting with these symptoms, even if they report a history of e-cigarette product use.
  
  
• Evaluate and treat for other likely causes of illness (e.g., infectious or other) as clinically indicated. Evaluation for common infectious etiologies when also suspected should be pursued and less common infections, and rheumatologic or neoplastic processes considered, as clinically indicated.
  
  
• Aggressive supportive care in these possible or suspected cases is warranted, and in severe cases, pulmonary, infectious disease and critical care specialists should be consulted.

What to do if an e-cigarette product is suspected as a possible etiology of a patient’s illness?

1. Inquire what type of product

2. Ask if the patient is:

• using commercially available devices and/or liquids (i.e. bottles, cartridges or pods)
• sharing e-cigarette products (devices, liquids, refill pods and/or cartridges) with other people
• re-using old cartridges or pods (with homemade or commercially bought products)
• heating the drug to concentrate it and then using a specific type of device to inhale the product (i.e., “dabbing”)

3. Ask patients about any retained product, including devices and liquids, in order to ascertain availability for possible testing to be coordinated by the local/state health department.

4. Report cases of significant respiratory illness of unclear etiology and a history of vaping to the appropriate state and/or local health department.

View CDC Emergency Communication Regarding Respiratory Illness and Possible Connection to e-Cigarettes/Vaping

CDC Press Release Regarding Severe Pulmonary Disease Among People Who Use E-cigarettes, Aug. 21, 2019