Vaping-related cases lead to care guidelines from Intermountain

Steven Ross Johnson  December 07, 2019 01:00 AM

Hospitals across the country have been grappling with an outbreak of vaping-associated illnesses that still have no confirmed cause.

Utah is one of the states hit hardest by cases of e-cigarette- or vaping-associated lung injury, known as EVALI, with nearly all of those patients treated at the Salt Lake City-based Intermountain Healthcare system.

Having seen 105 of the state’s 112 EVALI cases as of Nov. 25, the health system developed guidelines to help clinicians more rapidly detect and treat patients.

The recommendations were published in November by Lancet.

“The power of our guidelines is not only saying this is what we did, but this is how the patients did as a result,” said study lead author Dr. Denitza Blagev, a pulmonary and critical-care physician at Intermountain. “Therefore we feel it’s safe to propose this and suggest this for others to use.”

Blagev credited the health system’s telehealth monitoring program for allowing clinicians to track, collect and share data on 60 Intermountain clinic patients with vaping-related lung illness from June 27 to Oct. 4.

The data allowed researchers to rapidly recognize the outbreak and form a task force.

By reviewing that data collected at multiple sites, the task force learned what treatments patients had received and their outcomes after discharge, providing a clearer picture of what therapies were most effective for specific patients.

Strategies

Use remote monitoring to provide real-time tracking of cases, which can lead to earlier recognition of an outbreak

Design the treatment approach based on the initial severity of the patient’s illness

Create a standardized approach to how patient data is collected

“We developed these practices first by just being really comprehensive about understanding how people were already treating these patients in the system,” Blagev said.

She said the recommendations for treating EVALI patients were broadly consistent with guidance issued by the Centers for Disease Control and Prevention in October.

Those guidelines recommend clinicians in all suspected cases perform a complete patient evaluation and consult with an intensive-care specialist to reduce the risk of respiratory complications for those who initially display mild symptoms.

But the findings also suggest clinicians may be able to take a more individualized approach based on the severity of a patient’s symptoms.

The Intermountain guidelines recommend shorter courses of moderate-dose steroids for patients with milder symptoms.

Outpatients were given oral steroids for an average of six days, while those with more moderate forms of the illness were admitted as inpatients and given steroids intravenously for an average of 10 days followed by an oral steroid regimen for seven days.

The most severe cases were treated in an ICU where they received intravenous steroids for an average of 15 days.

Nearly all patients in the study were given antibiotics.

While most patients started to improve within days, six relapsed and were readmitted.

Blagev said the lessons learned dealing with the current outbreak can help shape responses to future infectious-disease outbreaks.

“I definitely think this can serve as a model for identifying other epidemics and having a concerted system response,” she said.

The biggest challenge in developing the guidelines was that no one yet knows exactly what causes EVALI, Blagev said. CDC investigators recently identified vitamin E acetate, a chemical additive used in vaping products containing THC, as a likely cause.

Dr. Albert Rizzo, chief medical officer for the American Lung Association, said a treatment for the vaping illnesses has likely been hindered by both a lack of standardization in evaluating suspected patients and  clinicians’ failure to connect the illnesses and vaping earlier.

He said Intermountain’s guidelines give hospitals a “good start” on forming a process to collect relevant data to guide clinical decision making.

“I think this is a very good first attempt, or maybe the best attempt, at trying to get a handle on a disease that’s really not defined by a specific agent at this point and really not defined by a specific pathology,” Rizzo said.

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