LABORATORY CLINICAL SAMPLE COLLECTION AND 

STORAGE GUIDANCE FOR E-CIGARETTE, OR VAPING, 

PRODUCT USE-ASSOCIATED LUNG INJURY (EVALI)

CDC encourages clinicians to report possible cases of e-cigarette, or vaping, product-use-associated lung 

injury (EVALI), to their local or state health department for further investigation. If use of e-cigarette, 

or vaping, products is suspected as a possible cause for a patient’s symptoms, a detailed history of the 

substances used, the devices used, and the sources of the substances and devices, should be obtained, 

as outlined in Update:Interim Guidance for Health Care Providers Evaluating and Caring for Patients with

Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. 

The below outlines general guidance regarding collection and storage of clinical samples. This may include 

retention of residual clinical samples collected for patient care, or samples collected and stored from early in 

a patient’s presentation to look for markers of exposure. 

Healthcare providers and state public health authorities should work together to make decisions about the 

collection and storage of clinical samples. Healthcare providers should initiate communication promptly with 

their local or state public health laboratory to retain samples if further analysis is anticipated.

SCOPE

The purpose of this document is to provide general 

sample collection and storage guidance for 

healthcare providers and public health laboratory 

personnel involved in the care of patients who meet 

the probable or confirmed case definitions for EVALI. 

Healthcare providers and public health laboratory 

personnel can also consider collecting and storing 

samples from patients suspected of having EVALI. 

These recommendations are not intended to direct 

laboratory guidance for patient care because these 

decisions are best made by the clinical treatment 

team. 

Empiric collection instructions are limited to 

collection and storage of blood and urine. For 

clinicians treating patients who have undergone 

bronchoalveolar lavage (BAL), instructions are 

provided for preservation of BAL fluid. This guidance 

is provided in the event that specific chemicals, 

substances, or biomarkers linked to respiratory 

disease caused by the use of e-cigarette, or vaping, 

products are identified in the future. 

Retention and storage of residual samples that were 

collected for other types of diagnostic screening and 

testing can also be considered. Healthcare providers 

should contact their hospital laboratories to identify 

and retain such samples before disposal. Healthcare 

providers should also coordinate long-term storage 

of samples with state public health authorities and 

state public health laboratories. 

NOTE: CDC recommends that healthcare providers 

consult their local or state health department for 

the department’s recommendations on collection 

and storage of clinical samples.

The decision to collect clinical samples is at the 

discretion of healthcare providers and the treatment 

team. The decision to store samples is at the 

discretion of healthcare providers and local or state 

public health authorities. 

For more information visit

https://www.cdc.gov/lunginjury

CS-316055-A
SAMPLE COLLECTION AND SHORT-TERM STORAGE – GUIDANCE FOR 

HEALTHCARE PROVIDERS AND CLINICAL LABORATORY PERSONNEL 

A. Bronchoalveolar lavage fluid (BAL fluid) 

samples 

1. Due to the invasive nature of BAL sampling, 

the decision about whether to perform BAL 

should be based on the clinical judgment of 

the treating clinicians regarding the clinical 

needs of the individual patient. 

2. Timing. BAL samples may be obtained at 

any time during the clinical course, but may 

be most informative if obtained prior to 

initiation of antimicrobial or steroid therapy. 

If antibiotics or steroids have been initiated, 

course, duration and timing relative to BAL 

should be noted. 

3. Sample collection. Collect samples in 

sterile containers. BAL fluid should undergo 

culture and routine centrifugation followed 

by cellular analyses and cytopathology, 

including lipid and other staining, as 

clinically indicated at the local institution. 

Lipoid pneumonia associated with 

inhalation of lipids in aerosols generated by 

e-cigarette, or vaping, products has been 

reported in some cases of EVALI based on the 

detection of lipid-laden alveolar macrophages 

obtained by bronchoalveolar lavage (BAL) and lipid 

staining (e.g., Oil Red O). 

Guidance for retaining residual BAL fluid 

samples after routine clinical evaluation: 

1. Remaining uncentrifuged BAL fluid and 

supernatant from centrifuged BAL fluid should 

be labeled as such and be retained. 

2. Up to 10 unstained cytology slides should be 

briefly fixed in formalin and retained for future 

evaluation. 

3. Excess cell pellet after cytopathologic 

evaluation can be divided in half, with half 

being fixed in formalin and stored at room 

temperature for further cytopathologic 

evaluation and half frozen at -20°C or lower for 

future chemical or lipid analysis. 

4. Place remaining uncentrifuged fluid and 

centrifuged supernatant from centrifuged fluid 

into sterile vials with external caps and internal 

O-ring seals. If there is no internal O-ring seal, 

then seal tightly with the available cap and secure 

with Parafilm®. Label each sample container with 

the patient’s name, ID number, the sample type, 

subsection of lung lavaged, and the date the 

sample was collected. FREEZE these samples at 

freezer temperatures of -20°C or lower. 

B. Blood samples

1. For each patient, collect up to 12 mL of blood in three (3) 4-mL PURPLE/LAVENDER-top

(K2 -EDTA) glass or plastic tubes. If only 3-mL tubes are available, four (4) 3-mL tubes may 

be collected. (Note: DO NOT use gel separators.) 

2. Mix contents of tubes by inverting them 8 –10 times. 

3. Label tubes in order of collection. Example: No. 1, No. 2, No. 3, No. 4. 

4. Place a bar-code label on each tube so that the bar-code looks like a ladder when the tube is upright. 

5. Store blood samples at 1°C to 10°C. DO NOT FREEZE. 

C. Urine samples 

1. For each patient, store 40 to 60 mL of urine in a screw-cap urine cup. 

2. Place bar-coded label on the cup when the cup is upright; the bar-code will look like a ladder. 

3. Indicate on the cup how the sample was collected if the method was other than “clean catch” 

(example: catheterization). 

4. Store urine samples in the freezer. Freezer temperatures of -20°C or lower are recommended.
LONG-TERM STORAGE – GUIDANCE FOR PUBLIC HEALTH 

LABORATORY PERSONNEL 

1. Establish communication protocols with local

hospitals and other healthcare providers 

regarding appropriate sample collection 

guidance (see sample collection above). 

2. Plan to transport collected samples on at least 

a twice-weekly basis (or more frequently 

if needed). 

3. Follow your local in-house chain of custody 

protocols (i.e., shipping manifests). 

4. Collect samples from local healthcare 

providers. 

5. Separate plasma from whole blood cells.

Centrifuge the purple/lavender top tubes 

for 15 minutes at 1000 to 1300 g-force to 

separate the plasma from whole blood cells. 

Check with the centrifuge rotor manual (or 

RCF to RPM table) for the proper RPM (e.g. 

2400 RPM) to use with your specific rotor. 

6. Aliquot plasma into cryotubes and apply 

labels. 

7. FREEZE BAL fluid, urine, and plasma samples 

at freezer temperatures of -20°C or lower. 

8. Any formalin-fixed samples (BAL pellet, 

cytology slides) should be stored at room 

temperature NOT FROZEN. 

9. Contact your state epidemiologist or outbreak

principal investigator regarding next steps. 

NOTE: Consult your local or state health department about EVALI. State health 

department officials seeking technical assistance with case reporting can contact CDC 

at EVALI@cdc.gov. State health department officials seeking technical assistance with 

laboratory testing should discuss with their state health department laboratories or 

contact CDC at EVALI@cdc.gov.

Updated: 3/16/2020