Creating an Innovative Algorithm for Diagnosing and Treating EVALI (Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury)
After pediatric pulmonologists at Children’s Health saw a spike in adolescent patients referred with unusual symptoms that resembled pneumonia and viral gastroenteritis, they set out to learn why.
Featured Speaker:
Devika Rao, MD
Devika Rao, MD, helps children overcome a variety of conditions that affect breathing and the lungs. She is a Pediatric Pulmonologist at Children’s Health ℠ and an Assistant Professor of Pediatrics at UT Southwestern. She also directs the pulmonary function testing lab at UT Southwestern Medical Center. Dr. Rao received her medical degree from Baylor College of Medicine in 2006 and completed her pediatric residency at Emory University School of Medicine in 2009. She then completed her fellowship training in pediatric pulmonology at Boston Children's Hospital in 2012. Transcription:
Creating an Innovative Algorithm for Diagnosing and Treating EVALI (Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury)
Caitlin Whyte: Welcome you're listening. Do pediatric insights, advances, and innovations with children's health. I'm your host, Caitlin Whyte. Today. We are talking about creating an innovative algorithm for treating each Valley or electronic cigarette or vaping product use associated lung injury. Joining us is Dr.
Debbie corral, a pediatric pulmonologist at children's health and an assistant professor at UT Southwestern. We'll cover some of the serious injuries caused by vaping. Standardizing this Evali care and what providers can look for in adolescent patients. So I know in the summer of 2019, your clinic saw a spike in adolescent patients referred with unusual symptoms that resembled pneumonia and viral gastroenteritis.
Some of these patients were so severely affected that they were admitted to the pediatric intensive care unit. Can you share how you and your team work together to best treat these patients?
Dr. Devika Rao: One thing that we did was we worked with physicians from other disciplines in order to standardize the care of these patients.
So we worked with physicians from the emergency department, the intensive care unit and from the hospital medicine group in identifying what the common symptoms were and the best and thorough workup for these patients, as well as the best options for treatment and follow up, we created this clinical algorithm.
That was distributed to clinicians in the hospital. And I think that was really useful and standardizing the care of these patients, making sure that we're all doing the same workup, making similar decisions as much as possible. And also the algorithm I think was successful in making clinicians aware of the common symptoms that were exhibited by these patients with vaping, lung injuries.
Caitlin Whyte: So I can imagine that after providing the care that these patients needed, your next focus was to figure out what was causing these symptoms. Can you walk us through the process that you and your team went through in order to solve this medical mystery?
Dr. Devika Rao: So we were seeing these teenagers with very common symptoms.
As you had mentioned, very similar to pneumonia, coughing, shortness of breath fever. They had high levels of inflammation in their bodies. Based on some lab markers that we were following. And many of these patients also have very prominent GI symptoms like vomiting, belly pain. Some of these patients even went through.
Workup for appendicitis and they just, weren't getting better with conventional supportive care measures for patients with viral gastroenteritis. You expect some bowel rest with some IB fluids, maybe some nausea medication really helps things. And then that plus time. You tend to see these patients improve pretty quickly, especially teenagers for patients with pneumonia.
You expect them to improve with antibiotics. But what we were seeing in these teenagers with vaping, lung injuries, symptoms were persistent. They were having fever for much longer than you would anticipate with antibiotics. They would sometimes develop worsening respiratory distress, despite antibiotics for what was thought to be a pneumonia based on their x-ray or chest CT findings.
And for some of these patients, the pulmonary team was consulted and we reviewed the imaging and it just seemed very unusual. And around that time, yeah. The reports were coming out from the Midwest about adults, with vaping, lung injuries. And we started to inquire about vaping histories and these teenagers, and we found that they had a history of vaping.
And once we started treating these patients with steroids, we saw that they were getting a lot better. The other thing that we noticed was that the findings on their imaging studies were very, very significant, much more diffused, much more than perhaps what you would expect with a simple community, acquired pneumonia.
The nature of the lung injury seemed. Much more severe. Some of these patients, like you mentioned, ended up in the ICU, but with treatment with steroids, they seem to turn around really, really quickly. And really what helps us to identify these patients was asking about vaping, getting them to tell us that they had been vaping and seeing them improve with steroids rather than things like IV fluids and antibiotics.
Caitlin Whyte: After findingthis common denominator, it seems it started becoming obvious that children's health was on the front lines of the vaping related illness that the CDC calls the electronic cigarette or vaping product use associated lung injury or Evali. Can you tell us how you and your team came together to develop a multidisciplinary standardized approach to caring for these patients?
Dr. Devika Rao: Yeah. It was really a collaboration of different physicians based on our experience, the emergency room physicians. We're seeing these patients come into the ER and seeing them really, really sick. A lot of these patients. Had sought care elsewhere, like at their pediatrician or their family doctors at other urgent care facilities, some of them had had symptoms for even up to two weeks and they just were getting progressively worse.
We saw from the hospitalists. Group that these patients were on the general pediatric floor. And what should be relatively straightforward cases were relatively complex. These patients weren't getting better with standardized care for what was thought to be pneumonia or viral gastroenteritis. And what we saw from.
Patients who are admitted to the intensive care unit was that some of them were requiring ventilators to help them breathe and really quite sick. And so it was really useful to have input from all the disciplines. And of course from us in pulmonology, us being the experts in lung pathophysiology and lung function really.
Characterizing the nature of the lung injury and understanding the trajectory of the illness, right from the beginning, the emergency room all the way to when patients would sometimes get transferred to the ICU and trying to identify what treatment measures. Seem to be beneficial for these patients.
There are not large numbers of these types of patients to do like a randomized control trial. And especially in the early parts of a vaping epidemic, it's very difficult to get evidence-based guidelines on how to treat these patients. So really a collaboration of physicians and being open-minded. To be creative in the treatment options and also being very mindful that these patients need follow up after hospital discharge, I think was a really interesting aspects of managing this illness and truly a multidisciplinary collaboration amongst physicians.
Caitlin Whyte: Can you explain the innovative algorithm that you coined for diagnosing and treating each
Dr. Devika Rao: Valley? Sure. The algorithm was based not only on our clinical experience, but also based on some of the guidelines that were being put out by the CDC. The beginning part of the algorithm identified patients based on symptoms, patients who were having the respiratory symptoms and or GI symptoms, plus any radiographic or imaging findings consistent with III Valley.
At that point, the algorithm encourages clinicians to elicit a history of e-cigarette use in the 90 days prior to presentation, once those initial requirements were met, the algorithm States that a clinical suspicion for the vaping lung injury should be higher at which point a workup is recommended with various laboratory.
And at that point, a discussion should be had between physicians caring for the patient. About the necessity for steroids as a treatment for the vaping lung injury. And so at that point in the algorithm, we did recommend a discussion to make the best clinical decision on whether to treat with steroids or to treat for infection.
The algorithm does encourage the clinician. To reconsider for steroid treatment for the vaping lung injury and watching for improvement in the symptoms. Once that is done, the patient definitely needs to recover and clinicians need to arrange for proper followup.
Caitlin Whyte: So how should other healthcare providers be diagnosing Evali?
Dr. Devika Rao: That's such an interesting question at the time that we are in right now, amidst the pandemic. And it's a really important question because we've certainly seen a lot of patients who have symptoms that are very similar to the COVID-19 infection with fever and cough and breathing issues. And COVID is on a lot of people's minds.
And certainly the testing is being done for any patient that requires hospital admission. But I would encourage clinicians to also not forget about you Valley. The CDC has appeared to have stopped collecting data on case numbers of each Valley since February. But we have continued to see these cases in our hospital throughout 2020.
So I think that clinicians need to be really mindful that teenagers are still vaping during the pandemic, and that they're still getting sick with these lung injuries and that they should really. Remember to ask about vaping history e-cigarette use in their patients, inpatients who have even mild or moderate respiratory symptoms in patients who have unexplained GI symptoms like pain, nausea, vomiting, unexplained, weight loss, and all of these types of patients make sure that you get.
A vaping history from your patients, preferably privately, not in the presence of the patient's parents.
Caitlin Whyte: Now, what are some recommended treatments for each Valley?
Dr. Devika Rao: The main treatment that we have done for each Valley is. The use of steroids at varying doses, depending on the severity of the lung injury.
And this should be accompanied by supportive care. So supplemental oxygen for low oxygen levels, if needed also Ivy fluids for patients with dehydration, a lot of these patients have significant loss of appetite and vomiting, and they come in dehydrated and need IV fluids. There's often a suspicion for coinfection with, for example, a bacterial pneumonia.
And so sometimes for these patients, antibiotics are used. If there's a high suspicion for co-infection, those are really some of the main ways that we treat E Valley. So supportive care plus steroids. And the reason for steroids is because we see that there's a lot of inflammation, not only in the lungs of these patients, but even throughout other body systems.
And I think that's why these patients are having prominent GI symptoms. Is that possibly there while they're inhaling the aerosol from the e-cigarette device, that they may be ingesting some of that too, in that. Maybe leading to some inflammation of the GI tract. We've also seen some patients with some mild levels of liver inflammation.
And so the steroids seems to be really useful to reduce the levels of inflammation in the body and help patients recover quickly.
Caitlin Whyte: So wrapping up here, I mean, it's evident that vaping is dangerous. Can you share how others should approach the topic of vaping with teens?
Dr. Devika Rao: Yeah, sure. This is really important question.
And I'm so glad you asked this. I think that what all us adults need to remember is that. The rates of e-cigarette use amongst young people is extremely high. If a teenager is not currently vaping or is not using an e-cigarette device, they've definitely heard about it. And they definitely have friends or know people that use these devices.
And there's a lot of misinformation out there. We are up against very aggressive and smart marketing tactics by these e-cigarette companies. That are successful in reaching teenagers and young people, people in promoting false hoods about vaping, that vaping is safe, that vaping is a safe alternative to smoking, or that if you decide to vape just flavorings and no nicotine or no marijuana that these flavored e-cigarettes are completely harmless.
Teenagers are receiving a lot of information regarding these things that are just not true from e-cigarette companies. And they need to hear from us. That e-cigarettes are dangerous and that they're harmful and that they can even lead to nicotine addiction. In fact, we know that teenagers who vape nicotine are more than twice as likely to go on to smoke regular cigarettes.
And so my big worry and a lot of clinicians share my concern is that we're really addicting a whole new generation of young people to nicotine. And the teenage brain is more vulnerable to developing. And addiction and the type of nicotine that's used in a lot of these e-cigarettes such as Juul and puff bars.
Disposable. E-cigarettes. Is formulated specifically to be as potent as possible to deliver a strong hit to the brain. And that enables a teenager to become addicted more quickly and can be very difficult for a teenagers introduced to these e-cigarettes who maybe even wants to be able to actually quit.
And the other problem is, is that these devices are so discrete. They look like USB drives. They even make e-cigarettes that look like little lipsticks and bracelets, and you can hide them in your hoodie. You can hide them in your backpack. They're extremely discreet. And this marketing campaign by e-cigarette companies has been going on for a long time.
And I almost feel like we're only beginning to really understand. Large proportion of teenagers who are using these products and how exposed they are to e-cigarettes and how easy it is for them to get their hands on it. And so I think what teenagers need and teenagers are best at telling you this, but I think what they need is really an adult with no judgment.
And that's really hard when you're a parent. But I think if you understand, as a parent, as an educator, as a physician clinician, that. These teenagers have been the targets of these e-cigarette companies for years. It puts things into perspective that they need a knowledge mental mentor to turn, to, to express their thoughts.
And a person that they could turn to, to potentially even get help as well as being a source for truth that we have been studying the aerosol of e-cigarette devices for years now, actually these devices were introduced on the market only, just recently in 2007. I would say, at least in the past five years, the research on e-cigarettes is just exponentially increasing.
So we know more and more about these devices. We know about the toxins in the aerosol of these e-cigarette devices, like heavy metals, formaldehyde, carcinogens, benzene, all of these substances that should not be inhaled is in the aerosol of these devices. And we can educate our young people. And at least be a force of truth for these young people and possibly even be a way for them to reach out for help if they need it.
The number one reason why young people have reported using e-cigarettes is because they know a friend or family member that uses these devices. It's basically exposure and there's peer pressure. We can be role models for our young people in a nonjudgmental way. And we can start the conversation using open-ended questions.
What do you know about e-cigarettes? Have you heard that these are harmful? Have you ever tried one of these before? How do you feel about it? What are your friends saying about if we use open-ended questions and listen, then we can encourage them to talk to us about. Their exposures about their use. And at that point we can get them the help that they need so they can quit using those devices.
If that's what they're doing and make a dent in this epidemic of vaping, that's raging across our country.
Caitlin Whyte: Thank you so much today for joining us doctor and for sharing this information and as always thank you for listening to pediatric insights, you can find more on this topic at children's dot com slash discover poem.
I'm your host, Caitlin Whyte stay well.
Creating an Innovative Algorithm for Diagnosing and Treating EVALI (Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury)
Caitlin Whyte: Welcome you're listening. Do pediatric insights, advances, and innovations with children's health. I'm your host, Caitlin Whyte. Today. We are talking about creating an innovative algorithm for treating each Valley or electronic cigarette or vaping product use associated lung injury. Joining us is Dr.
Debbie corral, a pediatric pulmonologist at children's health and an assistant professor at UT Southwestern. We'll cover some of the serious injuries caused by vaping. Standardizing this Evali care and what providers can look for in adolescent patients. So I know in the summer of 2019, your clinic saw a spike in adolescent patients referred with unusual symptoms that resembled pneumonia and viral gastroenteritis.
Some of these patients were so severely affected that they were admitted to the pediatric intensive care unit. Can you share how you and your team work together to best treat these patients?
Dr. Devika Rao: One thing that we did was we worked with physicians from other disciplines in order to standardize the care of these patients.
So we worked with physicians from the emergency department, the intensive care unit and from the hospital medicine group in identifying what the common symptoms were and the best and thorough workup for these patients, as well as the best options for treatment and follow up, we created this clinical algorithm.
That was distributed to clinicians in the hospital. And I think that was really useful and standardizing the care of these patients, making sure that we're all doing the same workup, making similar decisions as much as possible. And also the algorithm I think was successful in making clinicians aware of the common symptoms that were exhibited by these patients with vaping, lung injuries.
Caitlin Whyte: So I can imagine that after providing the care that these patients needed, your next focus was to figure out what was causing these symptoms. Can you walk us through the process that you and your team went through in order to solve this medical mystery?
Dr. Devika Rao: So we were seeing these teenagers with very common symptoms.
As you had mentioned, very similar to pneumonia, coughing, shortness of breath fever. They had high levels of inflammation in their bodies. Based on some lab markers that we were following. And many of these patients also have very prominent GI symptoms like vomiting, belly pain. Some of these patients even went through.
Workup for appendicitis and they just, weren't getting better with conventional supportive care measures for patients with viral gastroenteritis. You expect some bowel rest with some IB fluids, maybe some nausea medication really helps things. And then that plus time. You tend to see these patients improve pretty quickly, especially teenagers for patients with pneumonia.
You expect them to improve with antibiotics. But what we were seeing in these teenagers with vaping, lung injuries, symptoms were persistent. They were having fever for much longer than you would anticipate with antibiotics. They would sometimes develop worsening respiratory distress, despite antibiotics for what was thought to be a pneumonia based on their x-ray or chest CT findings.
And for some of these patients, the pulmonary team was consulted and we reviewed the imaging and it just seemed very unusual. And around that time, yeah. The reports were coming out from the Midwest about adults, with vaping, lung injuries. And we started to inquire about vaping histories and these teenagers, and we found that they had a history of vaping.
And once we started treating these patients with steroids, we saw that they were getting a lot better. The other thing that we noticed was that the findings on their imaging studies were very, very significant, much more diffused, much more than perhaps what you would expect with a simple community, acquired pneumonia.
The nature of the lung injury seemed. Much more severe. Some of these patients, like you mentioned, ended up in the ICU, but with treatment with steroids, they seem to turn around really, really quickly. And really what helps us to identify these patients was asking about vaping, getting them to tell us that they had been vaping and seeing them improve with steroids rather than things like IV fluids and antibiotics.
Caitlin Whyte: After findingthis common denominator, it seems it started becoming obvious that children's health was on the front lines of the vaping related illness that the CDC calls the electronic cigarette or vaping product use associated lung injury or Evali. Can you tell us how you and your team came together to develop a multidisciplinary standardized approach to caring for these patients?
Dr. Devika Rao: Yeah. It was really a collaboration of different physicians based on our experience, the emergency room physicians. We're seeing these patients come into the ER and seeing them really, really sick. A lot of these patients. Had sought care elsewhere, like at their pediatrician or their family doctors at other urgent care facilities, some of them had had symptoms for even up to two weeks and they just were getting progressively worse.
We saw from the hospitalists. Group that these patients were on the general pediatric floor. And what should be relatively straightforward cases were relatively complex. These patients weren't getting better with standardized care for what was thought to be pneumonia or viral gastroenteritis. And what we saw from.
Patients who are admitted to the intensive care unit was that some of them were requiring ventilators to help them breathe and really quite sick. And so it was really useful to have input from all the disciplines. And of course from us in pulmonology, us being the experts in lung pathophysiology and lung function really.
Characterizing the nature of the lung injury and understanding the trajectory of the illness, right from the beginning, the emergency room all the way to when patients would sometimes get transferred to the ICU and trying to identify what treatment measures. Seem to be beneficial for these patients.
There are not large numbers of these types of patients to do like a randomized control trial. And especially in the early parts of a vaping epidemic, it's very difficult to get evidence-based guidelines on how to treat these patients. So really a collaboration of physicians and being open-minded. To be creative in the treatment options and also being very mindful that these patients need follow up after hospital discharge, I think was a really interesting aspects of managing this illness and truly a multidisciplinary collaboration amongst physicians.
Caitlin Whyte: Can you explain the innovative algorithm that you coined for diagnosing and treating each
Dr. Devika Rao: Valley? Sure. The algorithm was based not only on our clinical experience, but also based on some of the guidelines that were being put out by the CDC. The beginning part of the algorithm identified patients based on symptoms, patients who were having the respiratory symptoms and or GI symptoms, plus any radiographic or imaging findings consistent with III Valley.
At that point, the algorithm encourages clinicians to elicit a history of e-cigarette use in the 90 days prior to presentation, once those initial requirements were met, the algorithm States that a clinical suspicion for the vaping lung injury should be higher at which point a workup is recommended with various laboratory.
And at that point, a discussion should be had between physicians caring for the patient. About the necessity for steroids as a treatment for the vaping lung injury. And so at that point in the algorithm, we did recommend a discussion to make the best clinical decision on whether to treat with steroids or to treat for infection.
The algorithm does encourage the clinician. To reconsider for steroid treatment for the vaping lung injury and watching for improvement in the symptoms. Once that is done, the patient definitely needs to recover and clinicians need to arrange for proper followup.
Caitlin Whyte: So how should other healthcare providers be diagnosing Evali?
Dr. Devika Rao: That's such an interesting question at the time that we are in right now, amidst the pandemic. And it's a really important question because we've certainly seen a lot of patients who have symptoms that are very similar to the COVID-19 infection with fever and cough and breathing issues. And COVID is on a lot of people's minds.
And certainly the testing is being done for any patient that requires hospital admission. But I would encourage clinicians to also not forget about you Valley. The CDC has appeared to have stopped collecting data on case numbers of each Valley since February. But we have continued to see these cases in our hospital throughout 2020.
So I think that clinicians need to be really mindful that teenagers are still vaping during the pandemic, and that they're still getting sick with these lung injuries and that they should really. Remember to ask about vaping history e-cigarette use in their patients, inpatients who have even mild or moderate respiratory symptoms in patients who have unexplained GI symptoms like pain, nausea, vomiting, unexplained, weight loss, and all of these types of patients make sure that you get.
A vaping history from your patients, preferably privately, not in the presence of the patient's parents.
Caitlin Whyte: Now, what are some recommended treatments for each Valley?
Dr. Devika Rao: The main treatment that we have done for each Valley is. The use of steroids at varying doses, depending on the severity of the lung injury.
And this should be accompanied by supportive care. So supplemental oxygen for low oxygen levels, if needed also Ivy fluids for patients with dehydration, a lot of these patients have significant loss of appetite and vomiting, and they come in dehydrated and need IV fluids. There's often a suspicion for coinfection with, for example, a bacterial pneumonia.
And so sometimes for these patients, antibiotics are used. If there's a high suspicion for co-infection, those are really some of the main ways that we treat E Valley. So supportive care plus steroids. And the reason for steroids is because we see that there's a lot of inflammation, not only in the lungs of these patients, but even throughout other body systems.
And I think that's why these patients are having prominent GI symptoms. Is that possibly there while they're inhaling the aerosol from the e-cigarette device, that they may be ingesting some of that too, in that. Maybe leading to some inflammation of the GI tract. We've also seen some patients with some mild levels of liver inflammation.
And so the steroids seems to be really useful to reduce the levels of inflammation in the body and help patients recover quickly.
Caitlin Whyte: So wrapping up here, I mean, it's evident that vaping is dangerous. Can you share how others should approach the topic of vaping with teens?
Dr. Devika Rao: Yeah, sure. This is really important question.
And I'm so glad you asked this. I think that what all us adults need to remember is that. The rates of e-cigarette use amongst young people is extremely high. If a teenager is not currently vaping or is not using an e-cigarette device, they've definitely heard about it. And they definitely have friends or know people that use these devices.
And there's a lot of misinformation out there. We are up against very aggressive and smart marketing tactics by these e-cigarette companies. That are successful in reaching teenagers and young people, people in promoting false hoods about vaping, that vaping is safe, that vaping is a safe alternative to smoking, or that if you decide to vape just flavorings and no nicotine or no marijuana that these flavored e-cigarettes are completely harmless.
Teenagers are receiving a lot of information regarding these things that are just not true from e-cigarette companies. And they need to hear from us. That e-cigarettes are dangerous and that they're harmful and that they can even lead to nicotine addiction. In fact, we know that teenagers who vape nicotine are more than twice as likely to go on to smoke regular cigarettes.
And so my big worry and a lot of clinicians share my concern is that we're really addicting a whole new generation of young people to nicotine. And the teenage brain is more vulnerable to developing. And addiction and the type of nicotine that's used in a lot of these e-cigarettes such as Juul and puff bars.
Disposable. E-cigarettes. Is formulated specifically to be as potent as possible to deliver a strong hit to the brain. And that enables a teenager to become addicted more quickly and can be very difficult for a teenagers introduced to these e-cigarettes who maybe even wants to be able to actually quit.
And the other problem is, is that these devices are so discrete. They look like USB drives. They even make e-cigarettes that look like little lipsticks and bracelets, and you can hide them in your hoodie. You can hide them in your backpack. They're extremely discreet. And this marketing campaign by e-cigarette companies has been going on for a long time.
And I almost feel like we're only beginning to really understand. Large proportion of teenagers who are using these products and how exposed they are to e-cigarettes and how easy it is for them to get their hands on it. And so I think what teenagers need and teenagers are best at telling you this, but I think what they need is really an adult with no judgment.
And that's really hard when you're a parent. But I think if you understand, as a parent, as an educator, as a physician clinician, that. These teenagers have been the targets of these e-cigarette companies for years. It puts things into perspective that they need a knowledge mental mentor to turn, to, to express their thoughts.
And a person that they could turn to, to potentially even get help as well as being a source for truth that we have been studying the aerosol of e-cigarette devices for years now, actually these devices were introduced on the market only, just recently in 2007. I would say, at least in the past five years, the research on e-cigarettes is just exponentially increasing.
So we know more and more about these devices. We know about the toxins in the aerosol of these e-cigarette devices, like heavy metals, formaldehyde, carcinogens, benzene, all of these substances that should not be inhaled is in the aerosol of these devices. And we can educate our young people. And at least be a force of truth for these young people and possibly even be a way for them to reach out for help if they need it.
The number one reason why young people have reported using e-cigarettes is because they know a friend or family member that uses these devices. It's basically exposure and there's peer pressure. We can be role models for our young people in a nonjudgmental way. And we can start the conversation using open-ended questions.
What do you know about e-cigarettes? Have you heard that these are harmful? Have you ever tried one of these before? How do you feel about it? What are your friends saying about if we use open-ended questions and listen, then we can encourage them to talk to us about. Their exposures about their use. And at that point we can get them the help that they need so they can quit using those devices.
If that's what they're doing and make a dent in this epidemic of vaping, that's raging across our country.
Caitlin Whyte: Thank you so much today for joining us doctor and for sharing this information and as always thank you for listening to pediatric insights, you can find more on this topic at children's dot com slash discover poem.
I'm your host, Caitlin Whyte stay well.