Updated Algorithm for Management of Patients with Suspected E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI), December 2019 - Fowchart
Updated Algorithm for Management of Patients with Suspected E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI), December 2019 - Fowchart Electronic Cigarette or Vaping--Associated Lung Injury (Evali) Electronic Cigarette or Vaping--Associated Lung Injury (Evali)
«Flowchart»

Patient with fever, cough, sore throat, shortness of breath, muscle aches, fatigue, nausea, or vomiting

Patient with fever, cough, sore throat, shortness of breath, muscle aches, fatigue, nausea, or vomiting

Patient with fever, cough, sore throat, shortness of breath, muscle aches, fatigue, nausea, or vomiting

Evaluate and manage as clinically indicated

Evaluate and manage as clinically indicated

Evaluate and manage as clinically indicated

Initial clinical assessment


Vital signs, pulse oximetry
Focused history and physical exam
Rule out other possible etiologies (e.g. Influenza, community-acquired pneumonia)

Initial clinical assessment


Vital signs, pulse oximetry
Focused history and physical exam
Rule out other possible etiologies (e.g. Influenza, community-acquired pneumonia)

Initial clinical assessment

Initial clinical assessment


Vital signs, pulse oximetry
Focused history and physical exam
Rule out other possible etiologies (e.g. Influenza, community-acquired pneumonia)


Vital signs, pulse oximetry
Focused history and physical exam
Rule out other possible etiologies (e.g. Influenza, community-acquired pneumonia)

Has patient has used e-cigarette, or vaping, products

Has patient has used e-cigarette, or vaping, products

Has patient has used e-cigarette, or vaping, products

Yes

Yes

Yes Yes

No

No

No No

End

End

End

Outpatient clinical evaluation


Consider CXR if patient has chest pain, shortness of breath, or if indicated by other clinical findings
Consider influenza testing

Management of possible EVALI


Advise discontinuation of all e-cigarette, or vaping, products
Consider corticosteroids use with caution in outpatients because of risk for worsening of respiratory infections

Management of possible EVALI with a pulmonary infection, per established guidelines


Early initiation of antivirals for possible influenza
Appropriate antibiotics for community-acquired pneumonia

Additional management


Offer cessation services to all patients; facilitate connection
Administer routine annual (inactivated or recombinant) influenza vaccination if not previously received
Ensure follow-up within 24–48 hr

Outpatient clinical evaluation


Consider CXR if patient has chest pain, shortness of breath, or if indicated by other clinical findings
Consider influenza testing

Management of possible EVALI


Advise discontinuation of all e-cigarette, or vaping, products
Consider corticosteroids use with caution in outpatients because of risk for worsening of respiratory infections

Management of possible EVALI with a pulmonary infection, per established guidelines


Early initiation of antivirals for possible influenza
Appropriate antibiotics for community-acquired pneumonia

Additional management


Offer cessation services to all patients; facilitate connection
Administer routine annual (inactivated or recombinant) influenza vaccination if not previously received
Ensure follow-up within 24–48 hr

Outpatient clinical evaluation

Outpatient clinical evaluation


Consider CXR if patient has chest pain, shortness of breath, or if indicated by other clinical findings
Consider influenza testing


Consider CXR if patient has chest pain, shortness of breath, or if indicated by other clinical findings
Consider influenza testing

Management of possible EVALI

Management of possible EVALI


Advise discontinuation of all e-cigarette, or vaping, products
Consider corticosteroids use with caution in outpatients because of risk for worsening of respiratory infections


Advise discontinuation of all e-cigarette, or vaping, products
Consider corticosteroids use with caution in outpatients because of risk for worsening of respiratory infections

Management of possible EVALI with a pulmonary infection, per established guidelines

Management of possible EVALI with a pulmonary infection, per established guidelines


Early initiation of antivirals for possible influenza
Appropriate antibiotics for community-acquired pneumonia


Early initiation of antivirals for possible influenza
Appropriate antibiotics for community-acquired pneumonia

Additional management

Additional management


Offer cessation services to all patients; facilitate connection
Administer routine annual (inactivated or recombinant) influenza vaccination if not previously received
Ensure follow-up within 24–48 hr


Offer cessation services to all patients; facilitate connection
Administer routine annual (inactivated or recombinant) influenza vaccination if not previously received
Ensure follow-up within 24–48 hr

Inpatient clinical evaluation


Urine toxicology, influenza, and other infectious disease testing as indicated by clinical findings
CXR, and consider CT scan even if CXR is normal
Consider pulmonary, critical care, medical toxicology, infectious diseases, other consultations
Consider psychiatry consultation
Bronchoalveolar lavage or lung biopsy, if clinically indicated, in consultation with pulmonary specialists

Inpatient clinical management


Discontinue e-cigarette, or vaping, products use
Offer cessation services to all patients; facilitate connection
Consider empiric antimicrobial use according to guidelines
Consider corticosteroids; use with caution
Administer routine annual (inactivated or recombinant) influenza vaccination, if not previously received

Discharge planning


Screen for mental health, substance use disorders, and social care needs before discharge
Ensure clinical stability for 24–48 hr before discharge
Ensure access to social/mental health/substance use disorder services
Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge
Ensure initial outpatient follow-up appointment, optimally within 48 hr of discharge
Follow-up with pulmonologist within 2–4 wk

Inpatient clinical evaluation


Urine toxicology, influenza, and other infectious disease testing as indicated by clinical findings
CXR, and consider CT scan even if CXR is normal
Consider pulmonary, critical care, medical toxicology, infectious diseases, other consultations
Consider psychiatry consultation
Bronchoalveolar lavage or lung biopsy, if clinically indicated, in consultation with pulmonary specialists

Inpatient clinical management


Discontinue e-cigarette, or vaping, products use
Offer cessation services to all patients; facilitate connection
Consider empiric antimicrobial use according to guidelines
Consider corticosteroids; use with caution
Administer routine annual (inactivated or recombinant) influenza vaccination, if not previously received

Discharge planning


Screen for mental health, substance use disorders, and social care needs before discharge
Ensure clinical stability for 24–48 hr before discharge
Ensure access to social/mental health/substance use disorder services
Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge
Ensure initial outpatient follow-up appointment, optimally within 48 hr of discharge
Follow-up with pulmonologist within 2–4 wk

Inpatient clinical evaluation

Inpatient clinical evaluation


Urine toxicology, influenza, and other infectious disease testing as indicated by clinical findings
CXR, and consider CT scan even if CXR is normal
Consider pulmonary, critical care, medical toxicology, infectious diseases, other consultations
Consider psychiatry consultation
Bronchoalveolar lavage or lung biopsy, if clinically indicated, in consultation with pulmonary specialists


Urine toxicology, influenza, and other infectious disease testing as indicated by clinical findings
CXR, and consider CT scan even if CXR is normal
Consider pulmonary, critical care, medical toxicology, infectious diseases, other consultations
Consider psychiatry consultation
Bronchoalveolar lavage or lung biopsy, if clinically indicated, in consultation with pulmonary specialists

Inpatient clinical management

Inpatient clinical management


Discontinue e-cigarette, or vaping, products use
Offer cessation services to all patients; facilitate connection
Consider empiric antimicrobial use according to guidelines
Consider corticosteroids; use with caution
Administer routine annual (inactivated or recombinant) influenza vaccination, if not previously received


Discontinue e-cigarette, or vaping, products use
Offer cessation services to all patients; facilitate connection
Consider empiric antimicrobial use according to guidelines
Consider corticosteroids; use with caution
Administer routine annual (inactivated or recombinant) influenza vaccination, if not previously received

Discharge planning

Discharge planning


Screen for mental health, substance use disorders, and social care needs before discharge
Ensure clinical stability for 24–48 hr before discharge
Ensure access to social/mental health/substance use disorder services
Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge
Ensure initial outpatient follow-up appointment, optimally within 48 hr of discharge
Follow-up with pulmonologist within 2–4 wk


Screen for mental health, substance use disorders, and social care needs before discharge
Ensure clinical stability for 24–48 hr before discharge
Ensure access to social/mental health/substance use disorder services
Conduct medication reconciliation and patient counseling by inpatient pharmacist before discharge
Ensure initial outpatient follow-up appointment, optimally within 48 hr of discharge
Follow-up with pulmonologist within 2–4 wk

Determine if patient is candidate for outpatient EVALI management?


O2 saturation 95% while breathing room air
No respiratory distress
No comorbidities that could 1) compromise cardiopulmonary reserve, 2) increase risk for severe disease, or 3) affect ability to discontinue e-cigarette, or vaping, product use or adhere to outpatient treatment plan
Reliable access to care/strong social support systems

Determine if patient is candidate for outpatient EVALI management?


O2 saturation 95% while breathing room air
No respiratory distress
No comorbidities that could 1) compromise cardiopulmonary reserve, 2) increase risk for severe disease, or 3) affect ability to discontinue e-cigarette, or vaping, product use or adhere to outpatient treatment plan
Reliable access to care/strong social support systems

Determine if patient is candidate for outpatient EVALI management?

Determine if patient is candidate for outpatient EVALI management?


O2 saturation 95% while breathing room air
No respiratory distress
No comorbidities that could 1) compromise cardiopulmonary reserve, 2) increase risk for severe disease, or 3) affect ability to discontinue e-cigarette, or vaping, product use or adhere to outpatient treatment plan
Reliable access to care/strong social support systems


O2 saturation 95% while breathing room air 2
No respiratory distress
No comorbidities that could 1) compromise cardiopulmonary reserve, 2) increase risk for severe disease, or 3) affect ability to discontinue e-cigarette, or vaping, product use or adhere to outpatient treatment plan
Reliable access to care/strong social support systems

Yes

Yes

Yes Yes

No

No

No No