CPG Management of EVALI

Kementerian Kesihatan Malaysia
Klinik Kesihatan Jaya Gading
Dr. Iskandar Firzada bin Osman

MD (USM), MMed (Family Medicine) (USM),
MAFP (Mal.), FRACGP (Australia), FAFP (Mal.),
Fellow in Adolescent Health (Melbourne),
Clinical Fellow in Adolescent Medicine (Toronto)
1
1. INTRODUCTION Kementerian Kesihatan Malaysia
• Electronic cigarette or e-cigarette (e-cig) – delivery of

nicotine or other chemicals via aerosolisation.
• Invented in 2003.
• E-cig entered Malaysian market in mid-2000s & gained
popularity in 2010s.
• NHMS 2019 – highest prevalence among aged 20 to 24.
• Tobacco & E-Cigarette Survey Among Malaysian Adolescents
(TECMA) 2016 – highest prevalence among age group 16 to
19. 2
HEALTH ISSUES Kementerian Kesihatan Malaysia
Inhalation of e-cig aerosol could potentially cause:

• adverse effects due to acute administration of nicotine, flavourants,
chemicals, other particulates.
• accidental overdose of nicotine.
• developmental effects on the brain from nicotine exposure.
• uptake of subsequent illicit drug use.
• gateway to conventional cigarettes & dual use of both types of
cigarettes.
• negative psychosocial health.
• battery explosion.
3
HEALTH ISSUES Kementerian Kesihatan Malaysia
• E-cig can induce negative cardiovascular effects through various

mechanisms e.g. oxidative stress, inflammation, DNA damage, arterial
stiffness &, altered haemodynamics & platelet activity.
• Daily e-cig use is associated with increased odds of having myocardial
infarction (OR=1.79, 95% CI 1.20 to 2.66).
• E-cig aerosol exposure is also associated with respiratory symptoms
in healthy individuals & increased symptoms of patients with asthma,
cystic fibrosis & chronic obstructive pulmonary disease (COPD/COAD).
4
EVALI Kementerian Kesihatan Malaysia
• July 2019 – large case series of pulmonary illnesses were reported in

Illinois & Wisconsin, USA.
• These were patients with history of e-cig use within 90 days of the
onset of symptoms & had pulmonary infiltrate on imaging with no
other contributable cause of the illness.
• They were termed as E-cigarette or Vaping product use-Associated
Lung Injury (EVALI).
• Till 18 February 2020 – 2,807 cases of EVALI with 68 deaths were
reported to the CDC, USA.
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6
7
International Classification of Primary Care
(ICPC) Kementerian Kesihatan Malaysia
8
International Classification of Primary Care
(ICPC) Kementerian Kesihatan Malaysia
9
** **
Treatment
10
2.1 Clinical Presentation Kementerian Kesihatan Malaysia
• History – using an e-cig in 90 days prior to symptom onset.

• Symptoms;
• respiratory symptoms • gastrointestinal symptoms
• shortness of breath • nausea
• cough • vomiting
• chest pain
• diarrhoea
• abdominal pain
• constitutional symptom
• fever
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2.1 Clinical Presentation Kementerian Kesihatan Malaysia
• History – using an e-cig in 90 days prior to symptom onset.

• Signs;
• hypoxia
• tachycardia
• tachypnoea
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** **
Treatment
13
Recommendation 2 Kementerian Kesihatan Malaysia
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2.4 Chest X-ray Kementerian Kesihatan Malaysia
• Findings include ground-glass opacities

& consolidation, usually bilateral &
almost symmetric in distribution.
• The abnormalities are lower lobe
predominant or diffuse in most cases
with sparing of the heart border & sub
pleural region (black arrows).
• Interlobular septal thickening (white
arrowhead) manifesting as Kerley B lines
can also be seen.
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16
** **
Treatment
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*Should be admitted for;

1. Thorough infectious & autoimmune workup; or
2. Patients with unfavourable condition(s)  refer
‘Yellow Box’ for referral/admission.
** **
Treatment
19
6. REFERRAL/ADMISSION Kementerian Kesihatan Malaysia
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** **
Treatment
21
22
23
Leucocytosis (TWBC)  Ref.: 4.00 – 10.00 x109/L

Neutrophil predominance  Ref.: 40.00 – 80.00%
2.000 – 7.000 x109/L
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25
Nasopharyngeal (NP) swab  PCR-based respiratory

viral panels test for influenza, respiratory syncytial
virus (RSV), adenovirus, parainfluenza virus,
coronavirus, rhinovirus, enterovirus, & human
metapneumovirus.
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27
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** **
Treatment
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4. DIFFERENTIAL DIAGNOSIS Kementerian Kesihatan Malaysia
Most common are infectious pneumonia & other inflammatory lung

diseases due to its flu-like illness:
• Infectious pneumonia; • Diffuse parenchymal lung
• bacterial diseases;
• fungal • acute hypersensitivity
• viral pneumonitis
• pneumocystis jirovecii • acute eosinophilic
pneumonia
• organising pneumonia
• cellular non-specific
interstitial pneumonia 30
Most common are infectious pneumonia & other inflammatory lung

diseases due to its flu-like illness:
• Other diffuse lung diseases;
• acute respiratory distress syndrome
• diffuse alveolar haemorrhage
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32

** **
Treatment
33
34
2.6 Case Definitions:

CDC USA
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36
37
Nasopharyngeal (NP) swab  PCR-

based respiratory viral panels test
for influenza, respiratory syncytial virus
(RSV), adenovirus, parainfluenza virus,
coronavirus, rhinovirus, enterovirus, &
human metapneumovirus.
38
39
2.6 Case Definitions:

CDC USA
40

** **
Treatment For surveillance purpose
41
42
5. TREATMENT Kementerian Kesihatan Malaysia
Symptomatic, based on presenting symptoms; respiratory,

gastrointestinal or constitutional.
• Oxygenation
• Ensure adequate oxygenation via nasal cannula, non-invasive or
invasive ventilation.
43
• Antimicrobials
• As community-acquired pneumonia (CAP) is a more common
cause for hypoxaemic respiratory failure, antibiotics are strongly
recommended with sequential de-escalation if no evidence of
pulmonary or bloodstream infection is found.
• Antibiotics coverage are recommended to be given empirically for
at least 48 hours if history is unclear, if patient is intubated or has
severe hypoxaemia despite supplemental oxygen.
44
45
• Corticosteroids
• A multicentre cross-sectional study showed a rapid improvement
within days in 95% of EVALI patients received corticosteroids
therapy.
46
• Tobacco cessation
• Smoking of tobacco and tobacco products (cigarette, electronic
cigarette/vape, shisha, pipe, cigar etc.) can lead to various
noncommunicable diseases (NCDs).
• Hence, the decision to integrate smoking treatment with NCDs is
important to reduce the prevalence of NCDs & their complications.
47
6. REFERRAL/ADMISSION Kementerian Kesihatan Malaysia
48
6. PRIMARY CARE FACILITIES Kementerian Kesihatan Malaysia
49

** **
Treatment For surveillance purpose
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6.3 Discharge from Hospital Kementerian Kesihatan Malaysia
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6.3 Discharge from Hospital Kementerian Kesihatan Malaysia
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6.3 Follow-up from Hospital Kementerian Kesihatan Malaysia
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Apply Evidence to
Practice
Spectrum of Preventive Activities in Kementerian Kesihatan Malaysia
Primary Care Medicine
Healthy Risk Factor(s) Health Issue(s) Incapacitated
Primordial Primary (1o) Secondary (2o) Tertiary (3o)

Prevention Prevention Prevention Prevention
Activities: Activities: Activities: Activities:

Health 1. Risk(s) 1. Treat for CURE 1. REHABILITATION
PROMOTION identification 2. Manage for 2. PALLIATIVE Care
2. Risk(s) CONTROL
stratification
3. Risk(s)
intervention
56
Spectrum of Preventive Activities in Kementerian Kesihatan Malaysia
Primary Care Medicine
Healthy Risk Factor(s) Health Issue(s) Incapacitated
Primordial Primary (1o) Secondary (2o) Tertiary (3o)

Prevention Prevention Prevention Prevention
Activities: Activities: Activities: Activities:

NO/STOP 1. ASK on 1. Awareness / 1. Proper follow-up;
smoking / smoking/e- suspect / vaccination.
e-cig / cig/vaping. probable / 2. QUIT program;
Vaping. 3. QUIT program; confirm. vaccination.
Vaccination. vaccination. 2. Manage. 3. PALLIATIVE Care.
3. QUIT program;
vaccination. 57
Terima Kasih
Dr. Iskandar Firzada bin Osman
+60 19 557 6334
dr_iskandar@hotmail.com
58

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Kementerian Kesihatan Malaysia

Klinik Kesihatan Jaya Gading

Dr. Iskandar Firzada bin Osman

• Electronic cigarette or e-cigarette (e-cig) – delivery of

Inhalation of e-cig aerosol could potentially cause:

• E-cig can induce negative cardiovascular effects through various

• July 2019 – large case series of pulmonary illnesses were reported in

• History – using an e-cig in 90 days prior to symptom onset.

• History – using an e-cig in 90 days prior to symptom onset.

• Findings include ground-glass opacities

*Should be admitted for;

*Should be admitted for;

Leucocytosis (TWBC)  Ref.: 4.00 – 10.00 x109/L

Nasopharyngeal (NP) swab  PCR-based respiratory

*Should be admitted for;

Most common are infectious pneumonia & other inflammatory lung

Most common are infectious pneumonia & other inflammatory lung

*Should be admitted for;

2.6 Case Definitions:

Nasopharyngeal (NP) swab  PCR-

2.6 Case Definitions:

*Should be admitted for;

Treatment For surveillance purpose

Symptomatic, based on presenting symptoms; respiratory,

*Should be admitted for;

Treatment For surveillance purpose

Primordial Primary (1o) Secondary (2o) Tertiary (3o)

Activities: Activities: Activities: Activities:

Primordial Primary (1o) Secondary (2o) Tertiary (3o)

Activities: Activities: Activities: Activities:

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