Last summer, pediatric pulmonologists at Children's Health℠, Children’s Medical Center Dallas saw a spike in adolescent patients referred with unusual symptoms that resembled pneumonia and viral gastroenteritis. Many of these patients did not respond to antibiotics, some had extreme difficulty breathing, and some were so severely affected that they were admitted to the pediatric intensive care unit.
As Devika Rao, M.D., Pediatric Pulmonologist at Children's Health and Assistant Professor at UT Southwestern, and her colleagues worked to decipher what was causing these symptoms, a common denominator emerged: all afflicted patients had recently used vaping products. It quickly became clear that Children’s Health was on the front lines of the vaping-related illness that the Centers for Disease Control and Prevention (CDC) came to call Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI).
As the number of EVALI patients surged, Dr. Rao and her colleagues saw an important need for developing a multidisciplinary, standardized approach to care. They met this challenge by creating an innovative algorithm for diagnosing and treating EVALI, and recently published some of their insights in the journal Pediatrics.
“The EVALI outbreak instantly motivated us to optimize how we care for these patients at Children’s Health, and our approach could be informative to physicians at other centers given the possibility of more vaping-related illness in the future,” she says.
Standardizing EVALI Care
Vaping devices have been around for over 10 years and their popularity has increased dramatically in the past two years. With an array of flavors, and devices that are designed to look cool and/or be easily concealed (some e-cigarettes look like slim USB devices and even asthma inhalers), vaping is especially alluring to teenagers. Over one in four high schoolers now report using e-cigarettes.
“Vaping has increased exponentially in teenagers, and it happened so quickly that physicians weren’t necessarily screening for it or aware that it could have potentially serious consequences like EVALI,” Dr. Rao says.
As EVALI emerged, centers across the country scrambled to understand it and identify the most effective diagnostic and treatment approaches. The Centers for Disease Control and Prevention invited Dr. Rao to join a clinical working group, which provided input into clinical guidelines published in 2019. Dr. Rao and her colleagues built on this experience by developing an individualized institutional algorithm to standardize EVALI care at Children’s Health.
“Our hope is that the algorithm can guide physicians on how to approach EVALI, based on what we learned about the clinical symptoms, radiology findings and treatment response in these patients,” Dr. Rao says.
How to Diagnose EVALI
To create the algorithm, Dr. Rao assembled a multidisciplinary team that included specialists in pulmonology, pediatrics, hospital medicine, critical care and emergency medicine. The team began by investigating the clinical presentations of over 12 adolescents admitted to Children's Health with EVALI.
“Many patients presented with symptoms that were very similar to pneumonia or viral gastroenteritis, except they had extensive radiology findings that were much worse than clinicians expected. And some of these patients when on to require care in the intensive care unit,” Dr. Rao says.
The algorithm, in accordance with CDC guidelines, recommends that physicians consider EVALI as a potential diagnosis if patients have reported vaping or “dabbing” in the past 90 days and exhibit:
- Respiratory distress
- Gastrointestinal symptoms
- Radiology findings of opacities in both lungs
Recommended EVALI Treatments
When patients meet these criteria, the algorithm calls for immediate consultation with a toxicologist and pulmonologist, and for pursuing tests that include a lung function test, a CT scan, a urine drug screen and testing for infections.
“It’s very important to assess the concern for infection and to pursue treatment if the concern is substantial,” Dr. Rao says. “The decision to treat for infection can be a complex one given how EVALI presents similarly to infection.”
Many of the patients that came to Children’s Health had been treated by pediatricians in the community or in emergency departments, but had not seen their condition improve with intravenous antibiotics. Dr. Rao and her colleagues use the algorithm to guide physicians on which EVALI treatments to pursue.
If there’s a strong suspicion of infection, the algorithm recommends initial treatment with antibiotics. If a patient fails to respond to antibiotics as expected, physicians should pursue treatment with steroids. If infection suspicion and infectious workup are low, steroids should be selected as initial therapy.
“The algorithm makes specific steroid dosage recommendations depending on disease severity,” Dr. Rao says.
How to Talk to Teens About Vaping
The number of EVALI cases is declining but the threat will continue so long as vaping remains widespread.
"The products that adolescents are using can be easily adulterated with an infinite number of agents that could cause a very wide variety of clinical problems that we can't yet fathom," Dr. Rao says, "so it's crucial that we find ways to educate not just physicians, but also adolescents and their families."
She and her colleagues are developing education materials about vaping to distribute to the community. Dr. Rao says it’s especially important to teach parents to communicate with their kids about vaping and its dangers, in ways that are informative and non-judgmental.
"The EVALI outbreak caused so much suffering, and an unintended beneficial effect is that many parents and schools now want to learn more about vaping," Dr. Rao says, "We need this conversation to continue because it’s quite possible that we’ll see more vaping-related illness in the future, either as EVALI or in a different form."
Learn more about the work of the pulmonology department as they continue to solve complex cases.