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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: 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.

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.

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.

OBJECTIVE: Black children and children from low-income communities are disproportionately affected by asthma, attributed partly to pollution exposure. Air purifiers reduce indoor air pollution and improve asthma symptoms in children. In order to implement air purifier interventions, an understanding of patterns of use and potential barriers is necessary. METHODS: In a home intervention study, 127 children with asthma living in Baltimore were randomized to receive two active or two placebo air purifiers. The 16-week study period included: baseline clinic visit, home visit for air purifier installation (active or placebo) with instruction to use the high or turbo settings, and electronic adherence monitoring of air purifiers. Determinants of adherence were identified using linear regression models. RESULTS: Air purifiers were used 80% of the time, and participants demonstrated adherence to high or turbo settings for 60% of the time. In an adjusted model, season was the major determinant of air purifier adherence, with 21% lower use in the winter (p=0.025) attributed to the cold draft generated by the machine. CONCLUSION: In a clinical trial with electronic adherence monitoring, air purifier use was high and participants were adherent to use of high or turbo settings the majority of the time. Addressing practical barriers to consistent use, such as draft during the winter, in addition to financial barriers may improve air purifier adherence among children with asthma living in low-income, urban households.

Background The prevalence of burnout and depressive symptoms is high among physician trainees. Research Question What is the burden of burnout and depressive symptoms among fellows training in pulmonary and critical care medicine (PCCM) and what are associated individual fellow, program, and institutional characteristics? Study Design and Methods We conducted a cross-sectional electronic survey of fellows enrolled in pulmonary, PCCM, and critical care medicine training programs in the United States to assess burnout and depressive symptoms. Burnout symptoms were measured using the Maslach Burnout Index two-item measure. The two-item Primary Care Evaluation of Mental Disorders Procedure was used to screen for depressive symptoms. For each of the two outcomes (burnout and depressive symptoms), we constructed three multivariate logistic regression models to assess individual fellow characteristics, program structure, and institutional polices associated with either burnout or depressive symptoms. Results Five hundred two of the 976 fellows who received the survey completed it—including both outcome measures—giving a response rate of 51%. Fifty percent of fellows showed positive results for either burnout or depressive symptoms, with 41% showing positive results for depressive symptoms, 32% showing positive results for burnout, and 23% showing positive results for both. Reporting a coverage system in the case of personal illness or emergency (adjusted OR [aOR], 0.44; 95% CI, 0.26-0.73) and access to mental health services (aOR, 0.14; 95% CI, 0.04-0.47) were associated with lower odds of burnout. Financial concern was associated with higher odds of depressive symptoms (aOR, 1.13; 95% CI, 1.05-1.22). Working more than 70 hours in an average clinical week and the burdens of electronic health record (EHR) documentation were associated with a higher odds of both burnout and depressive symptoms. Interpretation Given the high prevalence of burnout and depressive symptoms among fellows training in PCCM, an urgent need exists to identify solutions that address this public health crisis. Strategies such as providing an easily accessible coverage system, access to mental health resources, reducing EHR burden, addressing work hours, and addressing financial concerns among trainees may help to reduce burnout or depressive symptoms and should be studied further by the graduate medical education community.

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.

Purpose of review The aim of this article is to describe the known health disparities that exist among patients with sarcoidosis by socioeconomic status, race, and gender, review potential contributors to health disparities in sarcoidosis, investigate the intersectionality among socioeconomic status, race, and gender in sarcoidosis, and outline a research agenda to address these disparities. Recent findings Recent studies have reported the significant financial strain a diagnosis of sarcoidosis has on individuals and the disproportionate affect the strain has on low socioeconomic status individuals, Blacks, and females. Worse dyspnea, lower health-related quality of life, and higher rates of mortality and hospitalization are more common among those who are Black, female, or of low socioeconomic status. Summary Health disparities in sarcoidosis by socioeconomic status, race, and gender have been described for decades. In this review, we describe potential contributors to health disparities including stress and propose interventions to address disparities including creating educational programs accessible for low-income patients and caregivers, targeting medication adherence and trust in physicians and the medical system, and ensuring access to high-quality care for all patients. As clinicians and researchers, we owe it to our patients to not only describe the health disparities that exist but also stimulate to achieve improvement in sarcoidosis.

A policy proposal to ban public housing smoking indoors has received support, but it is unclear how certain affected groups, specifically smokers in housing units, perceive such a policy. To review the literature on attitudes and perceptions of housing unit tenants towards an indoor smoke-free housing policy, using various databases, we searched articles for attitudes towards smoking ban enforcement in housing units. We identified fourteen articles. Non-smokers heavily favored indoor policies and current smokers heavily opposed them. Current smokers represented a substantial minority in the reviewed articles, resulting in overall outcomes of the surveys driven by non-smokers. Studies investigating attitudes about housing smoking bans largely represent the views of non-smokers and lack data about barriers and concerns of tenants who do not support a smoke-free policy. Future studies should investigate if such a discrepancy impacts the efficacy of smoke-free housing policies.

Objective Among adolescents and young adults (AYAs) with chronic illness, effective provider communication is essential for patient-centered care during a sensitive developmental period. However, communication in chronic illness care for AYAs is not well studied. Our objectives were to describe the provider communication skills in pediatric chronic kidney disease (CKD) care visits; and determine if communication skills differ by AYA characteristics. Methods We adapted a global consultation rating system for pediatric subspecialty care using audiotaped clinic encounters of 18 pediatric nephrologists with 99 AYAs (age M(SD) = 14.9(2.6)) with CKD stages 1–5 and 96 caregivers. We hypothesized that provider communication skills would differ by AYA characteristics (age, gender, and race). Results The strongest provider skills included initiating the session and developing rapport; lowest rated skills were asking patient’s perspective and checking understanding. Communication scores did not consistently differ by AYA age or race, but were rated higher with female AYAs in several domains (ps Conclusions Pediatric providers generally had adequate or good communication scores with AYAs, but improvement in certain skills, particularly with male AYAs, may further support patient-centered care. Practice implications To achieve consistent, patient-centered communication with AYAs, an observation-based global assessment may identify areas for provider improvement.

Chronic obstructive pulmonary disease (COPD) is a heterogenous condition. This study aims to quantify the heterogeneity of Health-related Quality of Life (HRQoL), and identify subgroups with the lowest HRQoL, in COPD patients in the United States (US). Methods Data from 2008-2015 Medical Expenditure Panel Survey were used to examine the heterogeneity of HRQoL between different COPD subgroups using mixed-effects modeling and G-computation. The Physical Composite Summary (PCS) and Mental Composite Summary (MCS) scores from the Short-Form-12 questionnaire were utilized. We also compared the heterogeneity of HRQoL in our COPD cohort against that in a matched non-COPD cohort. Results The final sample consisted of 1,866 (weighted = 19,952,143) COPD patients with a mean age of 63.2 years (Standard error (SE):0.38), mean MCS score of 46.84 (SE:0.35), and mean PCS score of 35.65 (SE:0.32). The adjusted MCS and PCS scores ranged from 36.19 to 53.06, and from 25.52 to 48.27, respectively, for COPD subgroups. COPD patients had statistically significantly lower MCS and PCS scores by 4.61, and 5.86 points, respectively, compared to the matched non-COPD cohort, and MCS scores showed a wider variability in the COPD cohort. Conclusion Our study quantifies substantial heterogeneity of HRQoL in COPD in the US and provides evidence for prioritizing COPD subgroups with the lowest HRQoL for targeted interventions.

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.

Objectives: Compare attended home blood pressure (BP) measurements (HBPM) with ambulatory BP monitor (ABPM) readings and examine if level of agreement between the measurement approaches differ overall and by subgroup. Methods: This was a secondary analysis of data from a 2-yr observational study of children 11-19 yrs (mean 15, SD=2.69) with chronic kidney disease. Participants had 3 standardized resting oscillometric home BPs taken by staff followed by 24-hr ABPM within 2 weeks of home BP. BP indices (measured BP/95%ile BP) were calculated for the mean triplicate attended HBPM and mean daytime ABPM readings. All paired HBPM and ABPM measurements taken during any of 5 study visits were compared using linear regression with robust standard errors. Generalized estimating equations-based logistic regression determined the sensitivity, specificity, negative, and positive predictive values with ABPM as the gold standard. Analyses were conducted for the group overall and by subgroup. Results: There were 103 participants who contributed 251 paired measurements. Indexed systolic BP did not differ between modalities (mean difference -0.002; 95% CI: -0.006, 0.003), and the difference in indexed diastolic BP was minimal (mean difference -0.033; 95% CI: -0.040, -0.025). The overall agreement between HBPM and ABPM in identifying abnormal BP was high (88.5%), and findings were consistent in each subgroup (Table). Conclusions: Attended HBPM may be a reasonable substitute for ABPM when monitoring BP. The greater accessibility and feasibility of attended HBPM has the potential to improve BP control among at-risk youth.

This study aimed to compare attended home blood pressure (BP) measurements (HBPM) with ambulatory BP monitor (ABPM) readings and examine if level of agreement between measurement modalities differs overall and by subgroup.This was a secondary analysis of data from a 2-year, multicenter observational study of children 11-19 years (mean 15, SD = 2.7) with chronic kidney disease. Participants had 3 standardized resting oscillometric home BPs taken by staff followed by 24-h ABPM within 2 weeks of home BP. BP indices (measured BP/95%ile BP) were calculated for mean triplicate attended HBPM and mean ABPM measurements. Paired HBPM and ABPM measurements taken during any of 5 study visits were compared using linear regression with robust standard errors. Generalized estimating equation-based logistic regression determined sensitivity, specificity, negative, and positive predictive values with ABPM as the gold standard. Analyses were conducted for the group overall and by subgroup.A total of 103 participants contributed 251 paired measurements. Indexed systolic BP did not differ between HBPM and daytime APBM (mean difference - 0.002; 95% CI: - 0.006, 0.003); the difference in indexed diastolic BP was minimal (mean difference - 0.033; 95% CI: - 0.040, - 0.025). Overall agreement between HBPM and 24-h ABPM in identifying abnormal BP was high (81.8%). HBPM had higher sensitivity (87.5%) than specificity (77.4%) and greater negative (89.8%) than positive (73.3%) predictive value, and findings were consistent in subgroups.Attended HBPM may be reasonable for monitoring BP when ABPM is unavailable. The greater accessibility and feasibility of attended HBPM may potentially help improve BP control among at-risk youth. A higher resolution version of the Graphical abstract is available as Supplementary information.

Urban minority preschool children are disproportionately affected by asthma with increased asthma morbidity and mortality. It is important to understand how families manage asthma in preschool children to improve asthma control.To evaluate family asthma management and asthma outcomes among a low-income urban minority population of Head Start preschool children.The family asthma management system scale (FAMSS) evaluates how families manage a child's asthma. A total of 388 caregivers completed the FAMSS at baseline. Asthma outcomes were evaluated at baseline and prospectively at 6 months, including asthma control (based on the Test for Respiratory and Asthma Control in Kids), courses of oral corticosteroids (OCSs) required, and caregiver health-related quality of life (Pediatric Asthma Caregiver's Quality of Life Questionnaire [PACQLQ]). Multiple regression models evaluated the relationship between the FAMSS total score, FAMSS subscales, and asthma outcomes.Higher FAMSS total scores were associated with fewer courses of OCSs required (b = -0.23, P.01) and higher PACQLQ scores (b = 0.07, P.05). At baseline, higher integration subscale scores (b = -0.19, P.05) were associated with fewer courses of OCSs required, and higher family response scores were associates with higher PACQLQ scores (b = 0.06, P.05). Nevertheless, higher collaboration scores were associated with lower PACQLQ at baseline (b = -0.06, P.05) and 6 months (b = -0.07, P.05).Among this population of low-income minority preschool children, understanding how a family manages their child's asthma may help identify gaps for education to possibly improve caregiver asthma-related quality of life and reduce courses of OCSs.ClinicalTrials.gov Identifier: NCT01519453 (https://clinicaltrials.gov/ct2/show/NCT01519453); protocol available from meakin1@jhmi.edu.

OBJECTIVE: This qualitative study analyzed the perspective of patients living with sickle cell disease (SCD) on their process of deciding whether to take hydroxyurea (HU), and the role of physician communication in patients’ decision-making process. METHODS: From October 2015- July 2016, we conducted semi-structured interviews among patients with SCD (N=20) that were audio-recorded and transcribed. Participants were ≥ 18 years old, a patient of an urban adult sickle cell center, able to provide informed consent, and English-speaking. We iteratively developed codes and used thematic analysis to organize the key themes. RESULTS: Most participants were female (65%), middle aged (M=44, SD=12.2), and 55% were prescribed HU for an average of 10.4 (SD=4.7) years. Participants described 3 key factors that influenced their decision regarding HU treatment: 1) Lifestyle, 2) Health status, and 3) HU characteristics. Four themes emerged about provider communication and HU treatment decisions: 1) Provider’s advisement, 2) Shared-decision making, 3) “Wrestled,” and 4) Not feeling heard. CONCLUSION: Providers who engaged in shared-decision making empowered participants to decide whether to start HU treatment. Participants who felt their providers were not listening to their concerns expressed disengaging from HU treatment. During discussions about HU with patients living with SCD, providers must understand the multi-faceted aspects that impact patients’ decision and empower patients to engage in such discussions. Further research is needed to understand the role of shared-decision making among patients with SCD to improve management of SCD.

Rationale: Increasingly, patients are surviving acute respiratory failure (ARF), prompting the need to better understand standardized outcome measures commonly used during ARF follow-up studies. Objectives: Investigate standardized outcome measures (patient-reported physical and mental health measures, and cognitive testing) compared with findings from semistructured, qualitative interviews. Methods: As part of two ARF multicenter follow-up studies, standardized outcome measures were obtained, followed by qualitative evaluation via an in-depth, semistructured interview conducted and coded by two independent researchers. Qualitative interviews revealed the following post-ARF survivorship themes: physical impairment; anxiety, depression, and post-traumatic stress disorder symptoms; and cognitive impairment. Scores from standardized measures related to these themes were compared for ARF survivors reporting versus not reporting these themes in their qualitative interviews. Results: Of 59 invited ARF survivors, 48 (81%) completed both standardized outcome measures and qualitative interviews. Participants’ median (interquartile range) age was 53 (43–64) years; 54% were female, and 88% were living independently before hospitalization. The two independent reviewers classifying the presence or absence of themes from the qualitative interviews had excellent agreement (κ = 0.80). There were significantly worse scores on standardized outcome measures for survivors reporting (vs. not reporting) physical and mental health impairments in their qualitative interviews. However, standardized cognitive test scores did not differ between patients reporting versus not reporting cognitive impairments in their qualitative interviews. Conclusions: These findings support the use of recommended, commonly used standardized outcome measures for physical and mental health impairments in ARF survivorship research. However, caution is needed in interpreting self-reported cognitive function compared with standardized cognitive testing.

CONTEXT Secondhand smoke exposure (SHSe) affects up to half of all children in the United States. Many studies have identified factors associated with in-home SHSe, but few have contrasted these factors between households with and without residential smokers. In the latter case, exposure occurs from only external sources that enter the home, such as visitors or environmental incursion. OBJECTIVE Among children with SHSe at home, to examine demographic and psychosocial differences between households with and without residential smokers. DESIGN Baseline analysis of an observational cohort. SETTING Baltimore City, Maryland. PARTICIPANTS A total of 157 children with asthma, aged 5 to 12 years. MEASURES At-home airborne nicotine, caregiver-reported depression, asthma-related quality of life, functional social support, and demographics. Univariable comparisons were performed between SHS-exposed households with and without residential smokers. Multivariable logistic regression models were fit to examine associations between measured factors and absence of residential smokers. RESULTS Children (78.3%) had at-home SHSe. Of these, 40.7% lived in households without residential smokers. Compared with households with residential smokers, these caregivers endorsed stronger beliefs in SHS harms and also worse functional social support and asthma-related stress, despite no differences in asthma morbidity. In adjusted models, SHS-exposed children with caregivers in the lowest tertile of functional social support (adjusted odds ratio, 3.50; 95% confidence interval, 1.12-10.99), asthma-related quality of life (2.90; 1.06-7.95), and those living alone (5.28; 1.26-22.15) had at least twice higher odds of having exclusively external SHSe than the highest tertile (P trends < .05). CONCLUSIONS In-home SHS exposure remains alarmingly high in urban environments. However, a substantial proportion of this exposure appears to be occurring only from external sources that enter the home. Caregivers in these homes had higher desire but lower agency to avoid SHSe, driven by lack of functional support and physical isolation. Public policies targeting these factors may help remediate exposure in this especially vulnerable population.

BACKGROUND: Urban minority children are at risk for poor asthma outcomes and may not receive appropriate primary or subspecialty care. OBJECTIVE: We hypothesized that preschool children with asthma whose caregivers reported more barriers to care would be less likely to have seen their primary care provider (PCP) or an asthma subspecialist and more likely to have had a recent emergency department (ED) visit for asthma. METHODS: The Barriers to Care Questionnaire (BCQ) measures expectations, knowledge, marginalization, pragmatics, and skills. We assessed asthma control via TRACK and these outcomes: PCP visits for asthma in past six months, subspecialty care (allergist or pulmonologist) in past two years, and ED visits in past three months. RESULTS: 395 caregivers (96% African-American, 82% low-income, 96% Medicaid) completed the BCQ. Sixty percent(N=236) of children had uncontrolled asthma, 86% had seen a PCP, 23% had seen a subspecialist, and 29% had an ED visit. Barriers related to marginalization were associated with decreased likelihood of PCP (OR 0.95, p=0.014) and subspecialty visits (OR 0.92, p=0.019). Overall BCQ score was associated with decreased likelihood of subspecialty care (OR 0.98, p=0.027). Barriers related to expectations, knowledge, pragmatics, and skills were not associated with any of the care outcomes. CONCLUSIONS: Among low-income, predominantly African-American preschool children with asthma, primary and subspecialty care were less likely if caregivers reported past negative experiences with the healthcare system (marginalization). Clinicians who serve at-risk populations should be sensitive to families’ past experiences and should consider designing interventions to target the most commonly reported barriers. WHAT’S NEW: In a group of preschool-age, urban, predominantly African-American children with asthma, caregiver-reported barriers related to marginalization were associated with decreased likelihood of primary and subspecialty asthma care, indicating a potential target for future interventions to improve asthma outcomes.

Rationale: The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency. Methods: Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document’s relevance to the lay public. Results: Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction. Discussion: This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

Nonadherence to asthma medications is prevalent among adolescents and young adults (AYAs) with asthma, leading to worsened control of asthma symptoms and more frequent exacerbations. AYAs have unique developmental transitional challenges that may alter medication adherence. We aimed to use a socio-ecological framework to explore the effect of transitional challenges from adolescence to young adulthood on asthma controller medication adherence and to identify possible strategies to promote medication adherence.We conducted qualitative semi-structured interviews by phone with 7 adolescents (14 to 17 years), their respective caregivers, and 7 young adults (18 to 30 years). Participants were recruited from a respiratory clinical trial network and pulmonary clinics in 4 states at 6 different sites through convenience sampling. Interviews were audio recorded, transcribed and coded using thematic analyses.Participants identified personal challenges affecting adherence to asthma medications during the transition from adolescence to young adulthood including responsibility for asthma self-management, understanding of asthma condition and severity, embarrassment, and life demands. Health systems factors including medication cost, challenges with insurance, difficulties obtaining refills, and difficulty with access to medications at school also impacted asthma medication adherence. Participants recommended adherence strategies including improved access to inhalers, incorporating asthma medications into daily routines, and using reminders.Focusing on the transitional challenges of AYAs during the time period from adolescence to young adulthood is necessary for supporting their asthma medication adherence and creating future interventions. Socio-ecological and systems factors should also be targeted for improved asthma medication adherence.Supplemental data for this article can be accessed online at https://doi.org/10.1080/02770903.2021.1897836.

BackgroundThe purpose of this study was to explore the association between perceived social support and COPD outcomes and to determine whether the associations are mediated by depressive symptoms.MethodsSubjects with COPD who were enrolled as part of SPIROMICS were included in this analysis. Questionnaires relating to quality of life, symptom burden, and functional status were administered at annual clinic visits for over a 3 year period. In both cross-sectional and longitudinal analyses, we examined the association of social support as measured by the FACIT-F with COPD outcomes. Cross sectional analyses used multivariable linear or logistic regression, adjusting for covariates. For longitudinal analyses, generalized linear mixed models with random intercepts were used. Models were adjusted with and without depressive symptoms and mediation analyses performed.ResultsOf the 1831 subjects with COPD, 1779 completed the FACIT- F questionnaire. In adjusted cross-sectional analysis without depressive symptoms, higher perceived social support was associated with better quality of life, well-being, 6 minute walk distance, and less dyspnea. When also adjusting for depressive symptoms, all associations between social support and COPD outcomes were attenuated and no longer statistically significant. Mediation analysis suggested that depressive symptoms explained the majority (> = 85%) of the association between social support and measured COPD outcomes. Results of the longitudinal analysis were consistent with the cross-sectional analyses. There was no association between social support and odds of exacerbations.ConclusionHigher social support was associated with better COPD outcomes across several measures of morbidity including quality of life, respiratory symptoms, and functional status. In addition, these associations were largely attenuated when accounting for depressive symptoms suggesting that the beneficial association of social support with COPD outcomes may be largely mediated by the association between social support and depression.Trial registrationSPIROMICS was approved by Institutional Review Boards at each center and all participants provided written informed consent (clinicaltrials.gov:NCT01969344).

Background: Indoor particulate matter is associated with worse outcomes in adults with COPD. It remains unknown whether reductions of indoor pollutants can improve respiratory morbidity. Methods: Eligible former smokers with moderate-severe COPD received active or sham portable HEPA air cleaners and were followed for 6 months in this blinded randomized controlled trial. The primary outcome was 6-month change in Saint George’s Respiratory Questionnaire (SGRQ) . Secondary outcomes were exacerbation risk, respiratory symptoms, rescue medication use and 6MWD. Intention to treat analysis included all subjects and per protocol analysis included adherent participants (greater than 80% use of air cleaner). Findings: 116 participants were randomized of which 84.5% completed study. There was no statistically significant difference in improvement of total SGRQ, but the active filter group had greater reduction in SGRQ symptom subscale (s -7.7 [95% CI, -15.0 to -0.37]) and respiratory symptoms (BCSS, s -0.8 [95% CI, -1.5 to -0.1); and lower risk of moderate exacerbations (IRR 0.32 [95% CI, 0.12-0.91]) and rescue medication use (IRR 0.54 [95% CI, 0.33-0.86]) compared to sham group (all p

Objectives To identify staff-reported factors and perceptions that influenced implementation and sustainability of an early mobilization program (PICU Up!) in the PICU. Design A qualitative study using semistructured phone interviews to characterize interprofessional staff perspectives of the PICU Up! program. Following data saturation, thematic analysis was performed on interview transcripts. Setting Tertiary-care PICU in the Johns Hopkins Hospital, Baltimore, MD. Subjects Interprofessional PICU staff. Interventions None. Measurements and main results Fifty-two staff members involved in PICU mobilization across multiple disciplines were interviewed. Three constructs emerged that reflected the different stages of PICU Up! program execution: 1) factors influencing the implementation process, 2) staff perceptions of PICU Up!, and 3) improvements in program integration. Themes were developed within these constructs, addressing facilitators for PICU Up! implementation, cultural changes for unitwide integration, positive impressions toward early mobility, barriers to program sustainability, and refinements for more robust staff and family engagement. Conclusions Three years after implementation, PICU Up! remains well-received by staff, positively influencing role satisfaction and PICU team dynamics. Furthermore, patients and family members are perceived to be enthusiastic about mobility efforts, driving staff support. Through an ongoing focus on stakeholder buy-in, interprofessional engagement, and bundled care to promote mobility, the program has become part of the culture in the Johns Hopkins Hospital PICU. However, several barriers remain that prevent consistent execution of early mobility, including challenges with resource management, sedation decisions, and patient heterogeneity. Characterizing these staff perceptions can facilitate the development of solutions that use institutional strengths to grow and sustain PICU mobility initiatives.

Introduction: Educational campaigns have the potential to inform at risk populations about key issues relevant to lung health and to facilitate active engagement promoting healthy behaviors and risk prevention. We developed a community-based educational campaign called the Lung Health Ambassador Program (LHAP) with a goal of engaging youth and empowering them to be advocates for pulmonary health in their community. Objective: To evaluate the process outcomes and feasibility of the inaugural LHAP (2018–2019 academic year), with a specific aim to impact tobacco policy in the state of Maryland. Methods: Outcomes regarding feasibility included assessment of number of schools reached, number of students and healthcare professionals participating, and types of projects developed by participating students to impact modifiable risk factors for lung health. The courses for the LHAP were five 1 h sessions implemented at days and times identified by the community. The topics of the LHAP focused on lung anatomy, pulmonary diseases affecting school aged youth, tobacco use and prevalence, and air pollution (both indoor and outdoor). The fifth class discussed ways in which the students could impact lung health (e.g., policy and advocacy) and mitigate pulmonary disparities. Main Results: The LHAP was implemented at two elementary/middle schools, one high school, and two recreation centers within an urban metropolitan region. A total of 268 youths participated in the LHAP (age ranging from 11 to 18), whereby 72 (26.9%) were Hispanic/Latino and 110 (41.0%) were African American. Of the participating students, 240 wrote letters to local politicians to advocate for policies that would raise the legal age of acquiring tobacco products to 21. As for healthcare professionals, 18 academic faculty members participated in implementing the LHAP: 8 physicians and faculty staff and 10 nurses. Conclusions: The LHAP is a community-based program that provides education and training in advocacy with a goal of teaching about and, ultimately, reducing respiratory health disparities. The results from the first year demonstrate that the program is feasible, with success demonstrated in completing educational modules and engaging students. Next steps will include strategies to ensure sustainability and scalability to increase the reach of this program.

As evidence emerged supporting noninvasive strategies for coronavirus disease 2019 (COVID-19)–related respiratory distress, we implemented a noninvasive COVID-19 respiratory protocol (NCRP) that encouraged high-flow nasal cannula (HFNC) and self-proning across our healthcare system. To assess safety, we conducted a retrospective chart review evaluating mortality and other patient safety outcomes after implementation of the NCRP protocol (April 3, 2020, to April 15, 2020) for adult patients hospitalized with COVID-19, compared with preimplementation outcomes (March 15, 2020, to April 2, 2020). During the study, there were 469 COVID-19 admissions. Fewer patients underwent intubation after implementation (10.7% [23 of 215]), compared with before implementation (25.2% [64 of 254]) (P < .01). Overall, 26.2% of patients died (24% before implementation vs 28.8% after implementation; P = .14). In patients without a do not resuscitate/do not intubate order prior to admission, mortality was 21.8% before implementation vs 21.9% after implementation. Overall, we found no significant increase in mortality following implementation of a noninvasive respiratory protocol that decreased intubations in patients with COVID-19.