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In 2019, the United States experienced a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI). More than one-half of these patients required admission to an ICU.What are the recent literature and expert opinions which inform the diagnosis and management of patients with critical illness with EVALI?To synthesize information critical to pulmonary/critical care specialists in the care of patients with EVALI, this study examined data available from patients hospitalized with EVALI between August 2019 and January 2020; reviewed the clinical course and critical care experience with those patients admitted to the ICU; and compiled opinion of national experts.Of the 2,708 patients with confirmed or probable EVALI requiring hospitalization as of January 21, 2020, a total of 1,604 (59.2%) had data available on ICU admission; of these, 705 (44.0%) were admitted to the ICU and are included in this analysis. The majority of ICU patients required respiratory support (88.5%) and in severe cases required intubation (36.1%) or extracorporeal membrane oxygenation (6.7%). The majority (93.0%) of these ICU patients survived to discharge. Review of the clinical course and expert opinion provided insight into: imaging; considerations for bronchoscopy; medical treatment, including use of empiric antibiotics, antiviral agents, and corticosteroids; respiratory support, including considerations for intubation, positioning maneuvers, and extracorporeal membrane oxygenation; and patient outcomes.Review of the clinical course of patients with EVALI requiring ICU admission and compilation of expert opinion provided critical insight into pulmonary/critical care-specific considerations for this patient population. Because a large proportion of patients hospitalized with EVALI required ICU admission, it is important to remain prepared to care for patients with EVALI.

Rationale: Indoor particulate matter is associated with worse COPD outcomes. It remains unknown whether reductions of indoor pollutants improve respiratory morbidity. Methods: Eligible former smoke...

Rationale: Individuals with Chronic Obstructive Pulmonary Disease (COPD) have a high prevalence of depression, which is associated with increased COPD hospitalizations and readmissions. Objectives:...

Rationale: Poor indoor air quality has been associated with worse chronic obstructive pulmonary disease (COPD) morbidity. In-home portable air cleaners reduce indoor pollutants and could improve respiratory health. Factors associated with air cleaner adherence among adults with COPD remains unknown. Methods: In a 6-month trial of former smokers with COPD, participants (n=116) received active or sham portable air cleaners. Air cleaner adherence was measured by electronic monitors. Potential baseline predictors of adherence included individual factors (demographics, socioeconomic status, smoking history, psychological well-being), COPD disease severity, and housing characteristics. Time and season were also considered. Stepwise logistic regression and longitudinal fixed effect analysis were performed to assess independent predictors of adherence. Results: A total of 109 participants had an objective measure of adherence, and 76.1% used at least 1 air cleaner 80% of the time (defined a priori as adherent). Higher annual household income ≥$35,000 (odds ratio [OR]=4.4, 95% confidence interval [CI], 1.1–18.0) and use of heat pump/electricity (versus gas) for heating (OR=6.1, 95%CI, 1.7–22.4) were associated with higher odds of adherence. Further, poor quality of life (St George’s Respiratory Questionnaire, per 10-point increase) and prior year exacerbations were associated with lower odds of adherence (OR=0.65, 95%CI, 0.4–1.0) and (OR=0.26, 95%CI, 0.1–0.9), respectively. Adherence was highest during the first month and lower during winter compared to other seasons. Conclusion: These findings suggest that cold weather season, use of gas for home heating, and lower annual income negatively impact adherence. Poor quality of life and worse disease control may also decrease adherence. Addressing factors associated with air cleaner adherence should be considered when designing future environmental studies.

RATIONALE: Individuals with chronic obstructive pulmonary disease (COPD) have a high prevalence of depression, which is associated with increased COPD hospitalizations and readmissions. OBJECTIVES: Examine the impact of depressive symptoms compared with FEV(1)% on COPD morbidity. METHODS: Using longitudinal data from individuals with COPD in the Subpopulations and Intermediate Outcome Measures in COPD Study, longitudinal growth analysis was performed to assess COPD morbidity by assessing differences in baseline 6-minute walk distance and patient reported outcomes (PROs) and their rate of change over time explained by depressive symptoms or lung function, as measured by Hospital Anxiety and Depression Scale or FEV(1)% respectively. PROs consisted of in-person completion of St. George's Respiratory Questionnaire, COPD Assessment Test, Functional Assessment of Chronic Illness Therapy Fatigue, and Modified Medical Research Council Dyspnea Scale measures. RESULTS: Of the individuals analyzed (n = 1,830), 43% were female, 81% Caucasian with mean ± SD age of 65.1 ± 8.1, and 52.7 ± 27.5 pack-years smoking. Mean ± SD FEV(1)% was 60.9 ± 23.0% and 20% had clinically significant depressive symptoms. Adjusted models showed higher Hospital Anxiety and Depression Scale scores and lower FEV(1)% each were associated with worse PROs at baseline (P ⩽ 0.001). Depression accounted for more baseline variance in St. George's Respiratory Questionnaire, COPD Assessment Test, and Functional Assessment of Chronic Illness Therapy Fatigue than FEV(1)%, explaining 30–67% of heterogeneity. FEV(1)% accounted for more baseline variance in Modified Medical Research Council Dyspnea Scale and 6-minute walk distance than depression, explaining 16–32% of heterogeneity. Depressive symptoms accounted for 3–17% variance in change over time in PROs. In contrast, FEV(1)% accounted for 1–4% variance over time in PROs. CONCLUSIONS: Depression is more strongly associated with many PROs at baseline and their change over time compared with FEV(1)%. Recognizing and incorporating the impact of depressive symptoms into individualized care may improve COPD outcomes.

The adoption of prone positioning for patients with acute respiratory distress syndrome (ARDS) has historically been poor. However, in mechanically ventilated patients with COVID-19 ARDS, proning has increased. Understanding the factors influencing this change is important for further expanding and sustaining the use of prone positioning in appropriate clinical settings.To characterize factors influencing the implementation of prone positioning in mechanically ventilated patients with COVID-19 ARDS.We conducted a qualitative study using semi-structured interviews with 40 intensive care unit (ICU) team members (physicians, nurses, advanced practice providers, respiratory therapists, and physical therapists) working at two academic hospitals. We used the Consolidated Framework for Implementation Research, a widely used implementation science framework outlining important features of implementation, to structure the interview guide and thematic analysis of interviews.ICU clinicians reported that during the COVID-19 pandemic proning is viewed as standard early therapy for COVID-19 ARDS, rather than salvage therapy for refractory hypoxemia. By caring for large volumes of proned patients, clinicians gained increased comfort with proning and now view proning as a low-risk high-benefit intervention. Within ICUs, adequate numbers of trained staff, increased team agreement around proning, and the availability of specific equipment (e.g., to limit pressure-injuries), facilitated greater proning use. Hospitals level supports included proning teams, centralized educational resources specific to the management of COVID-19 (including a recommendation for prone positioning), and an electronic medical record proning order. Important implementation processes included informal dissemination of best practices through on-the-job learning and team interactions during routine bedside care.The implementation of prone positioning for COVID-19 ARDS took place in the context of evolving clinician viewpoints and ICU team cultures. Proning was facilitated by hospital support, and buy-in and leadership from bedside clinicians. The successful implementation of prone positioning during the COVID-19 pandemic may serve as a model for the implementation of other evidence-based therapies in critical care.

To determine whether school infrastructure is associated with health and academic outcomes among elementary school children with asthma.We conducted a retrospective cohort study of linked medical, academic, and facilities data from a large mid-Atlantic school district of the United States. All K-5 students with asthma who were enrolled under the state's Children's Health Insurance Program were included. We estimated associations of the infrastructure quality of the student's school, as assessed by an engineering firm in Summer 2011 and represented by the Facility Condition Index (FCI), with asthma health outcomes, absenteeism, and standardized test scores in math and reading in the two academic years thereafter.6,558 students were identified, the majority non-Hispanic Black, across 130 schools. Most schools (97/130, 75%) were in very poor or worse condition. In cluster-adjusted models accounting for demographics, grade, school-specific area deprivation, and inhaled corticosteroid use, a one standard deviation increase in FCI, corresponding to greater infrastructure deficiency, was associated with higher rates of asthma-related hospitalizations (incidence rate ratio [IRR] 1.16; 95% confidence interval [CI] 1.03, 1.32), more absenteeism (IRR 1.05; 95% CI 1.01, 1.08), and lower scores in math (mean difference [MD] -3.3; 95% CI -5.5, -1.2) and reading (MD -3.0; 95% CI -5.1, -0.9). There were no differences in rates of asthma-related emergency visits or steroid prescriptions.Children with asthma attending schools with poorer infrastructure had worse health and academic outcomes. Public policy emphasizing reinvestment in school infrastructure may be a potential means of addressing asthma disparities.

Chronic obstructive pulmonary disease (COPD) is a common, progressive lung disease that often manifests with psychiatric symptoms. Despite this, patients with COPD are not routinely screened for anxiety and depression, which substantially contribute to COPD-related morbidity.To determine the relationship among COPD symptom severity, exacerbation risk, and clinically significant anxiety and depression symptoms in ever smokers with COPD.We used baseline data from the Subpopulations and Intermediate Outcome Measures In COPD Study (SPIROMICS) cohort to examine ever smokers with COPD across Global Initiative for Obstructive Lung Disease (GOLD) disease severity groups. Multivariable logistic regression models were used to calculate odds ratios for clinically significant anxiety and depression for each GOLD group, which was compared to the control group of ever smokers without COPD. Odds ratios were adjusted for subject demographics, medical comorbidities, and substance use covariates, and comparisons were completed using 2-tailed tests.Of the 2664 subjects studied, 784 (29.4%) had clinically significant anxiety, and 497 (18.7%) had clinically significant depression. In the multivariable analysis, high pulmonary symptom groups, groups B and D, had increased adjusted odds of clinically significant anxiety (group B: adjusted odds ratios [AOR] 1.28, P = 0.03; group D: AOR 1.95, P0.0001) and depression (group B: AOR 2.09, P0.0001; group D: AOR 3.04, P0.0001). GOLD group D, the group with high pulmonary symptoms and high COPD exacerbation risk, had the greatest risk of both anxiety and depression among the GOLD groups.High COPD symptom severity, even in the absence of elevated COPD exacerbation risk, is associated with clinically significant anxiety and depression. Our separate analyses of anxiety and depression symptoms in a large, multisite, national cohort are unique within the literature and have important treatment implications for COPD patients. Our findings also highlight the utility of screening patients with high COPD symptom severity for anxiety and depression.

Individuals with Chronic Obstructive Pulmonary Disease (COPD) often develop anxiety and depression, which worsen illness management and prognosis. Physical and psychological symptoms, contextual and illness-related factors display complex reciprocal interactions, which give rise to heterogeneous presentations. Examining the patterns of association between specific physical and psychological symptoms in patients with COPD may help to focus on the precision of the patient-centred care.We used network analyses to examine the links between symptoms of COPD, depression and anxiety.Data from 1587 individuals with COPD from the COPDGene study were included. We estimated a Bayesian Gaussian Graphical Model to highlight the unique associations between symptoms of COPD (assessed with the COPD Assessment Test), depression and anxiety (assessed with the Hospital Anxiety and Depression Scale (HADS), while examining the role of sociodemographic characteristics, lung function tests, and health status.Unique Variable Analysis reduced 14 HADS items to Tension/worry (chronic anxiety), Fear/panic (acute anxiety), Restlessness, Anhedonia, Sadness and Slowing. In network analyses, chest-tightness was related to acute anxiety, while cough and weakness were connected with core depressive symptoms (sadness and lack of pleasure). Chronic anxiety was linked with acute anxiety and depressive symptoms. Findings were confirmed accounting for the role of confounders, including lung function, sex, ethnicity and lifestyle factors. A simulation based on our model yielded distinct predictions about anxiety and depression in two participants with similar COPD severity, but different symptom profiles.Network analyses highlighted specific associations between symptoms of COPD, depression and anxiety. Accounting for symptom-level interactions may help to promote personalized treatment approaches.

Physicians and nurses face high levels of burnout. The role of care teams may be protective against burnout and provide a potential target for future interventions.To explore levels of burnout among physicians and nurses and differences in burnout between physicians and nurses, to understand physician and nurse perspectives of their healthcare teams, and to explore the association of the role of care teams and burnout.A mixed methods study in two school of medicine affiliated teaching hospitals in an urban medical center in Baltimore, Maryland.Participants included 724 physicians and 971 nurses providing direct clinical care to patients.Measures included survey participant characteristics, a single-item burnout measure, and survey questions on care teams and provision of clinical care. Thematic analysis was used to analyze qualitative survey responses from physicians and nurses.Forty-three percent of physicians and nurses screened positive for burnout. Physicians reported more isolation at work than nurses (p0.001), and nurses reported their care teams worked efficiently together more than physicians did (p0.001). Team efficiency was associated with decreased likelihood of burnout (p0.01), and isolation at work was associated with increased likelihood of burnout (p0.001). Free-text responses revealed themes related to care teams, including emphasis on team functioning, team membership, and care coordination and follow-up. Respondents provided recommendations about optimizing care teams including creating consistent care teams, expanding interdisciplinary team members, and increasing clinical support staffing.More team efficiency and less isolation at work were associated with decreased likelihood of burnout. Free-text responses emphasized viewpoints on care teams, suggesting that better understanding care teams may provide insight into physician and nurse burnout.

Children spend the majority of their time indoors, and a substantial portion of this time in the school environment. Air pollution has been shown to adversely impact lung development and has effects that extend beyond respiratory health. The goal of this study was to evaluate the indoor environment in public schools in the context of an ongoing urban renovation program to investigate the impact of school building renovation and replacement on indoor air quality. Indoor air quality (CO2, PM2.5, CO, and temperature) was assessed for two weeks during fall, winter, and spring seasons in 29 urban public schools between December 2015 and March 2020. Seven schools had pre- and post-renovation data available. Linear mixed models were used to examine changes in air quality outcomes by renovation status in the seven schools with pre- and post-renovation data. Prior to renovation, indoor CO measurements were within World Health Organization (WHO) guidelines, and indoor PM2.5 measurements rarely exceeded them. Within the seven schools with pre- and post-renovation data, over 30% of indoor CO2 measurements and over 50% of indoor temperatures exceeded recommended guidelines from the American Society of Heating, Refrigerating, and Air Conditioning Engineers. Following renovation, 10% of indoor CO2 measurements and 28% of indoor temperatures fell outside of the recommended ranges. Linear mixed models showed significant improvement in CO2, indoor PM2.5, and CO following school renovation. Even among schools that generally met recommendations on key guidelines, school renovation improved the indoor air quality. Our findings suggest that school renovation may benefit communities of children, particularly those in low-income areas with aging school infrastructure, through improvements in the indoor environment.

Introduction Individuals with Sickle Cell Disease (SCD) require regular, and specialized treatment to manage their health. The COVID-19 pandemic disrupted in person medical visits for all individuals, with a rapid transition to telemedicine to provide medical care. Emerging data shows that the use of telemedicine may provide easier access to care and remove barriers to clinic attendance and improve access to appropriate medical care. Objective The purpose of this study was to use qualitative methods to understand the patients' experiences with telemedicine, identify patient preferences for type of appointment, and possible suggestions to improve telemedicine care. Methods Patients from the Johns Hopkins Sickle Cell Center for Adults who had at least one telemedicine visit were invited to participate in a semi structured interview via zoom meeting or telephone. The interview asked participants about their satisfaction with telemedicine care, barriers to telemedicine, benefits and risks of telemedicine and possible telemedicine improvements. Interviews were recorded, transcribed and coded by two independent raters using thematic analyses to understand the experiences of telemedicine during the COVID-19 pandemic. Results Overall, 30 adults with SCD who had at least one telemedicine visit were invited to participate and completed their interview (mean age 41 years ± xx, 67% female, 93% Black/African American, 3% Multi-Race, 3% Other). "...I can't ignore the convenience of not having to worry about transportation ... that there's nothing to stop me from getting there." During a SCD pain crisis it can it challenging to move and receive treatment as one participant reported "Maybe sometimes I might have pain...then moving around makes it difficult. So, getting in the car and finding somebody to drive you to a hospital or to whatever clinic would be difficult". Being able to access specialized SCD care even while in pain is important. Having the option of either having telemedicine or in person visits was important to SCD patients "I could treat my crisis here at home. I don't have to go to the emergency room for it. So, if I can see my doctor in the tele-visit appointment and it's going to be constantly every day ... And when it's getting worse, then I could go to the emergency room more if needed. If it's not needed, I don't even need to go". Another emerging theme amongst participants was despite the benefits from telemedicine, they also wanted to continue having in-person visits when they needed. SCD participants felt due to their SCD they still needed to see their doctor in person but it did not have to be for every visit "Well, I think telemedicine, for me, can be used in a setting where there's no such an emergency. Like if I'm having a routine exam, I don't mind having the telemedicine. But if ... I'm not feeling well ... I don't want to be having a telemedicine". SCD participants felt they needed a physical exam periodically. "The only thing I didn't like about it was if I'm having some discomfort or some pain... there was no way for the physician to physically examine me". Along with the lack of physical exam, there were concerns about the lack of vital signs "... the drawbacks would be the lack of the vitals being taken or there's not the personal touch and stuff". Conclusion The COVID-19 pandemic has presented many obstacles for patients to receive care. People living with SCD found telemedicine to be a positive tool to receive treatment. Patients reported the desire to continue with telemedicine even after the COVID -19 pandemic. Telemedicine allows for more accessibility for a group of individuals who already have numerous barriers to treatment. Future research can seek to identify the impact that telemedicine has on no-show rates, health care utilization, and the impact telemedicine has on patient reported quality of life. Disclosures Lanzkron: Teva: Current holder of individual stocks in a privately-held company; Shire: Research Funding; GBT: Research Funding; CSL Behring: Research Funding; Novo Nordisk: Consultancy; Bluebird Bio: Consultancy; Pfizer: Current holder of individual stocks in a privately-held company; Imara: Research Funding; Novartis: Research Funding.

Introduction: The COVID-19 pandemic presented exceptional challenges to caring for adults with sickle cell disease (SCD) and necessitated a rapid transition to telemedicine, disrupting established care systems within a population that already faces unique and challenging medical needs. Although implementation of telemedicine care assumed reliable patient access to the requisite technology, as well as adequate spaces in which to complete visits, pre-pandemic barriers to in-person visits were also considerable, and many patients lacked access to reliable transportation and childcare or could not afford to miss work to attend clinic. Given the scarcity of research on the acceptability of telemedicine care for SCD patients, the pandemic has provided a critical and necessary opportunity to study patient satisfaction when using telemedicine modalities for regular SCD care. The objective of this study was to identify which patient groups rate telemedicine high in satisfaction and usability. Methods: We surveyed 99 patients of the Sickle Cell Clinic for adults at Johns Hopkins who had any form of SCD, were age 18 or above, and participated in at least one video visit between March-July 2020. Telemedicine satisfaction was assessed by the Telemedicine Satisfaction Questionnaire (TSQ), and usability was assessed by the System Usability Scale (SUS). Patients' engagement in their healthcare was assessed by the Patient Activation Measure (PAM13). We conducted linear regression with TSQ and SUS as outcomes and participant characteristics as predictors. Results: Participant characteristics (briefly, mean age 39, 95% African American, 72% female, and 81% with education level above high school) and their association with TSQ and SUS are shown in Table 1. Mean SUS was 72/100 (SD 15), slightly above the defined average usability of 68; mean TSQ was 4.1 (SD 0.5) on a 5-point Likert scale. Participants tended to prefer video visits for their regular care (mean rating of 6.6/10, SD 2.9) but not for management of acute pain (mean rating of 4.9/10, SD 3.2). Participants who preferred video visits for regular SCD care reported higher SUS (p Conclusions: Our findings suggest that telemedicine has above-average usability and high satisfaction for SCD patients, regardless of age, sex, and income. Patients who were more engaged with their healthcare were more likely to rate telemedicine satisfaction and usability high. Because SUS was negatively associated with disability, lower education level, public insurance, and unemployment, patients within these groups may need more assistance with telemedicine. To improve usability, clinics may consider incorporating support services for patients who have difficulty using telemedicine platforms. Altogether, telemedicine demonstrates promising acceptability to SCD patients across multiple demographic groups and may serve as another method in the toolkit for increasing accessibility to high quality care for these patients. Figure 1 Figure 1. Disclosures Lanzkron: Pfizer: Current holder of individual stocks in a privately-held company; Bluebird Bio: Consultancy; Novo Nordisk: Consultancy; GBT: Research Funding; Teva: Current holder of individual stocks in a privately-held company; Shire: Research Funding; CSL Behring: Research Funding; Novartis: Research Funding; Imara: Research Funding.