BACKGROUND:Lung protective ventilation (LPV) improves mortality in patients with ARDS and is applied widely in other patients receiving mechanical ventilation. Despite strong evidence, LPV is implemented inconsistently. RESEARCH QUESTION:Are staff-rated ICU implementation determinants associated with delivery of patient-level LPV delivery. STUDY DESIGN AND METHODS:We conducted a cross-sectional survey of ICU clinical staff (January-June 2024) and a retrospective study of patients with hypoxemic respiratory failure receiving mechanical ventilation (January 2023-December 2024). We assessed staff-rated implementation determinants using validated surveys including domains for implementation culture (eg, team cooperation), staff stress, and available resources. We assessed the association of ICU-level survey scores with patient-level LPV (defined as tidal volume [VT] ≤ 6.5 mL/kg of perdicted body weight (PBW) and plateau pressure ≤ 30 cm H2O), and, as a complementary secondary outcome, hours spent at VT > 8 mL/kg PBW on day 1 of mechanical ventilation. We used mixed-effects negative binomial models including LPV hours as the outcome, eligible time as an offset, patient and ICU covariates, and a random effect for ICU. RESULTS:Survey measures from 469 ICU staff (50% response rate) were incorporated into the cohort of 2,120 patients across 5 hospitals and 14 ICUs. Median percentage compliance with LPV on day 1 was 68% (interquartile range, 0%-100%). A 1-SD increase in ICU implementation culture score was not associated with LPV (adjusted rate ratio [aRR], 1.04 [95% CI, 0.95-1.14]; P = .37), but was associated with less time at VT > 8 mL/kg PBW (aRR, 0.48 [95% CI, 0.32-0.71]; P < .01). Increased staff stress was not associated with time at LPV (aRR, 0.98 [95% CI, 0.89-1.07]; P = .62), but was associated with more time at VT > 8 mL/kg (aRR, 1.71 [95% CI, 1.19-2.45]; P < .01). Results for ICU resources were: aRR of 1.02 (95% CI, 0.88-1.17; P = .83) for LPV and aRR of 0.36 (95% CI, 0.20-0.64; P < .01) for VT > 8 mL/kg PBW. INTERPRETATION:In this multihospital study, ICU implementation determinants were associated with receiving VT >8 mL/kg PBW, but not with a stricter LPV definition. These findings may inform development of interventions to enhance ICU implementation determinants and improve LPV delivery.

Background The American Thoracic Society recently recommended the use of race-neutral rather than race-specific equations for spirometry interpretation. The uptake of and clinicians’ opinions about these practices remain unclear. Research Question What are clinicians’ current practices and opinions around race-specific vs race-neutral reference equations? Study Design and Methods We conducted a national survey of pulmonologists identified through the American Lung Association and Pulmonary Fibrosis Foundation. Participants completed an electronic survey about their opinions and practices related to race in spirometry reference equations. Descriptive and thematic analyses were conducted. Results We received and analyzed 66 responses (29% response rate). Respondents had a median age of 48 years (interquartile range, 41-55), and 63 (95%) worked in an academic setting. A total of 34 respondents (54%) reported that their pulmonary function testing laboratory is already using a race-neutral equation. Most (n = 42, 64%) recommended that race-neutral equations should be used for spirometry interpretation, and 6 (9%) recommended race-specific equations alone should be used. When considering alternatives to race-specific equations, the use of Global Lung Function Initiative (GLI)-Global or GLI-Other as a single race-neutral equation was the most preferred alternative (n = 47, 71%). The most cited advantages of race-neutral equations were (1) improving equity, fairness, and bias (48%); and (2) improving accuracy and classification of disease (40%). The most cited disadvantages were (1) misclassification of respiratory disease (25%) and (2) loss of precision of lung function estimates (13%). Interpretation Our results show that most academic pulmonologists would prefer to use a race-neutral rather than race-specific equation for spirometry interpretation. Although most have already transitioned to a race-neutral approach, significant gaps in implementing GLI-Global remain and indicate needs for ongoing research and education.

Home oxygen therapy is a well-accepted treatment for advanced respiratory disease; however, there are substantial evidence gaps and implementation challenges. The patient experience varies widely; oxygen therapy devices are often poorly matched to patient needs; and adherence is suboptimal. Recent clinical trials have failed to demonstrate positive outcomes of home oxygen therapy across a range of indications and patient groups, raising new questions regarding which patients will benefit. We convened a home oxygen therapy summit, bringing together experts in the fields of hypoxia biology, biomarkers, home oxygen therapy, behavioural science, and clinical trials, to identify the critical steps necessary to advance the science and practice of home oxygen therapy. Prescription of oxygen therapy depends on identification of hypoxaemia, with or without evidence of end-organ dysfunction. However, this does not acknowledge that hypoxaemia does not always yield hypoxia, and ignores adaptation to hypoxia. There is a pressing need for a hypoxia biomarker that is sensitive and specific, reflects the mechanisms of adaptation and maladaptation to chronic hypoxia, and is responsive to change with supplemental oxygen. Advances in research and clinical care will require more “usable” devices that meet the needs of patients and provide value for payers. Optimising oxygen devices will require new technologies with greater portability and greater capacity for oxygen delivery. Registry-based clinical trials may allow measurement of long-term outcomes and identification of patients most likely to benefit from oxygen therapy. Collaborations between patients, clinicians, researchers, payers and industry will be critical to drive this field forward.

RATIONALE:Indoor particulate matter (PM) is linked to worse respiratory outcomes in adults with chronic obstructive -pulmonary disease (COPD). It is unclear if reducing indoor pollutants can improve respiratory health among current smokers. OBJECTIVE:This study aimed to assess whether a multicomponent environmental intervention to improve home air quality (PM and secondhand smoke [SHS] exposure) improves respiratory morbidity among current smokers with COPD. METHODS:Current smokers with moderate-to-severe COPD were randomized to receive active portable high-efficiency -particulate air cleaners and motivational interviewing (MI) for PM and SHS reduction, respectively; or sham air cleaners -without MI. The primary outcome was 6-month change in Saint George's Respiratory Questionnaire. Secondary outcomes were respiratory symptoms, exacerbation risk, and lung function. MAIN RESULTS:Among 121 randomized participants, 99 completed the study. The active intervention resulted in reduced PM levels compared to control, but no reduction in indoor SHS exposure. Those in the active arm showed a clinically and statistically significant improvement in total Saint George's Respiratory Questionnaire score compared to control (ß -4.4 [95% confidence interval, -8.2 to -0.5]; P = .025). Secondary analyses indicated significant improvement in respiratory symptoms (dyspnea and cough) and health status as measured by COPD Assessment Test and clinical COPD questionnaire among the active group (vs. control). There was no significant difference in forced expiratory volume in 1 second change, sputum symptoms, or odds of exacerbations between groups. CONCLUSIONS:This study is the first to demonstrate potential health benefits from an environmental intervention in active smokers with COPD, most likely attributable to PM reduction associated with portable high-efficiency particulate air cleaner use.

Background:Individuals with chronic obstructive pulmonary disease (COPD) often face direct and indirect medical costs from unplanned emergency department visits and hospitalizations for acute exacerbations, out-of-pocket expenses for inhaled bronchodilators, and income loss from disability. Yet financial toxicity, which describes the objective burden and subjective distress resulting from medical costs, has not been studied in COPD. Individual experiences of financial toxicity in COPD offer insight into challenges that may be unique to this population. Methods:We conducted semistructured interviews with 30 purposively sampled individuals with physician-diagnosed COPD. Transcripts were analyzed using inductive coding by 2 independent coders, and codes and were categorized through thematic analysis. Results:Thirty participants completed semistructured interviews, of whom 56% were women, 43% non-Hispanic White, and 43% non-Hispanic Black. The mean age was 69.5 years, and 24 (70%) had public health insurance only. Several themes emerged including: (1) the sources of material burden in COPD; (2) adjustments to disease management, such as medication nonadherence or foregoing treatments; (3) adjustments to financial planning, including both changes to day-to-day spending and disruptions in major financial plans; (4) emotional impact; and (5) communication with health care providers. Conclusion:Our findings are the first, to our knowledge, to describe the impact of financial toxicity in individuals with COPD. Financial toxicity in COPD is common and may adversely impact disease self-management, financial self-management, and psychological well-being. Additional research is needed to examine its impact on patient-reported outcomes and to develop interventions to reduce its burden.

Chronic obstructive pulmonary disease (COPD) is a highly prevalent and burdensome disease that develops over decades. Treatments for COPD are most commonly prescribed in later stages of the disease, leaving missed opportunities to modify the course of disease at earlier stages. This workshop was conducted to promote progress in the design and conduct of clinical trials of treatments that modify progression to COPD. The aims of the workshop were to provide an operational definition of pre-COPD and to discuss the elements and design of potential clinical trials in pre-COPD. The key focus areas of this workshop included: 1) defining a study population for pre-COPD clinical trials; 2) endpoints in pre-COPD clinical trials; and 3) design considerations for pre-COPD clinical trials.

Rationale: Medications, including inhaled bronchodilators, are essential for effective management of chronic obstructive pulmonary disease (COPD) and to improve clinical outcomes. However, medications are a major driver of out-of-pocket costs for individuals with COPD. The impact of cost of medications on clinical outcomes in COPD has not been studied. Objectives: To examine the association between difficulty affording medications and COPD morbidity, psychological well-being, and medication adherence. Methods: Individuals with a physician's diagnosis of COPD who were prescribed at least one daily maintenance medication were recruited from centers in the Mid-Atlantic area and followed for 12 months as part of the Medication Adherence Research in COPD (MARC) cohort. Patient-reported COPD outcomes, measures of psychological well-being, exacerbation data, and difficulty affording medications were assessed at 6-month intervals. Medication adherence was measured during the 12-month period using electronic monitors. The association between difficulty affording medications at baseline and outcomes at 12 months was evaluated using multivariable regression models. A fixed effects regression model was conducted to evaluate how changes in difficulty affording medications are associated with outcomes over time. Results: Of the 249 participants with completed baseline assessments, a total of 44 (18%) participants reported delaying refilling medications because of cost at baseline. Over the course of the 12-month period, 68 (27%) participants reported delaying refilling medications at any time point because of cost. After adjusting for baseline covariates, no associations between difficulty affording medications at baseline and outcomes at 12 months were observed. In the fixed effects model, changes in difficulty affording medications were associated with worse COPD health status, dyspnea, and health-related quality of life; increased symptoms of anxiety and depression; and lower objectively measured medication adherence but not occurrence of exacerbations. Conclusions: In this multicenter cohort of individuals with physician-diagnosed COPD, we found an association between changes in self-reported difficulty affording medications and increased patient-reported respiratory morbidity, increased anxiety and depression symptoms, and decreased objectively measured medication adherence over time, but no association with exacerbations. These findings suggest that cost of COPDspecific treatments is an important and potentially modifiable social determinant of health for individuals with COPD.

BACKGROUND:Eosinophilic asthma is associated with frequent exacerbations, but the relevance of peripheral eosinophil count at the time of exacerbation is unknown. OBJECTIVE:To evaluate peripheral eosinophil count during an exacerbation requiring health care utilization and its associations with exacerbation course in adults with asthma. METHODS:Adult asthma exacerbations between 2016 and 2023 which resulted in an emergency department visit or hospitalization were identified by International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes in the Johns Hopkins Asthma Precision Medicine Center of Excellence data repository. Outcomes included probability of admission, maximal level of care, length of stay, and discharge rate. We estimated associations between outcomes and eosinophil count using generalized estimating equations and generalized linear models. RESULTS:Among 11,178 asthma exacerbations, 63% had peripheral eosinophil count measured during the encounter before steroid administration, and eosinophilia (≥150 cells/µL) was present in 61% of these. Risk of admission was nonlinearly associated with eosinophil count; exacerbations with eosinophil count of 150 to 300 cells/µL at presentation were least likely to result in admission, whereas those with 30 (odds ratio: 1.39, 95% CI: 1.26-1.54, P < .001) or 1000 cells/µL (odds ratio: 1.55, 95% CI: 1.35-1.79, P < .001) had higher odds of admission. Among inpatient exacerbations (N = 3825), encounters with eosinophil count more than or equal to 300 cells/µL had shorter median length of stay (3.1 vs 2.4 days, P < .001) and higher discharge rate (hazard ratio: 1.34, 95% CI: 1.22-1.48, P < .001) than those without eosinophilia (<150 cells/µL). CONCLUSION:Peripheral eosinophil count is a biomarker for asthma exacerbation severity and duration, offering opportunities for improved assessment and management of asthma exacerbations in acute care settings.

Background: The rising popularity of electronic cigarettes (e-cigarettes), the nicotine product that is most used by adolescents since 2014, has reversed decades of progress in declining youth tobacco use. E-cigarette use in adolescents is associated with future smoking, and evidence is mounting of an increased association with nicotine dependence. Therapies used to treat nicotine dependence in adults include pharmacotherapy and behavioral interventions. Pediatric guidelines recommend routine screening for any tobacco product use beginning at age 10 years. The goal of this guideline was to develop an evidence-based clinical practice guideline for the treatment of nicotine use in adolescents. Methods: We summarized evidence addressing five PICO (patients, intervention, comparator, and outcome) questions, which were formulated by a multidisciplinary panel of experts and methodologists using the evidence-to-decision framework. The Grading of Recommendations, Assessment, Development, and Evaluation (or, GRADE) approach was used to evaluate the certainty in evidence and generate actionable recommendations, which were voted on by the panel. Results: The panel members considered the strength of the evidence as well as the potential benefits of the treatment modality from a clinical standpoint. The overall quality of the evidence was weak. Recommendations for or against the treatment modality for nicotine use were developed. Conclusions: This expert panel provides evidence-based recommendations for treating nicotine use in adolescents 10 to 18 years of age.

Rationale: Social and behavioral determinants of health such as anxiety, depression, perceived stress, and loneliness are associated with poor health outcomes, yet their trajectory following hospitalization for COPD exacerbations remain unclear. Given the medical and social challenges of this period, understanding the trajectory of these factors can inform future interventions. This study examines changes in social and behavioral determinants of health over six months post-hospitalization. Methods: We examined data from an ongoing cohort of individuals with COPD recruited during hospitalization for exacerbation, with follow up assessments 1 week and 3, 6, 9 and 12 months post discharge. Participants were current or former smokers (≥10 pack years) age ≥40 years with COPD and a primary admission diagnosis of COPD exacerbation. Participant assessments included the Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale, and UCLA Loneliness Scale administered at 1 week, 3 month, and 6 months while the Hardship Questionnaire assessed life stressors at 1 week and 6 months. Health outcomes including COPD exacerbations and rehospitalizations were assessed at the same time points, along with 9-month, and 12-months. We analyzed mean changes in social and behavioral determinants scores post-hospitalization and stratified measures based upon rehospitalization status. Unadjusted linear regression analysis was performed using interaction with re-hospitalization status to assess whether rehospitalization influenced these changes over time. Results: A total of 162 current or former smokers with COPD completed psychosocial measures from baseline to 6 months. Participants had a median age of 65.0 (IQR 13) and were 61% female, with a median smoking pack-year of 40.0 (IQR 35). Thirteen percent of participants were rehospitalized. Among all individuals, social and behavioral measures remained stable, with only hardship scores having significant change between baseline and 6 months (β -0.79, 95% CI -1.3 to -0.29). Compared to non-rehospitalized patients, those readmitted had a significant increase in anxiety scores from baseline to 6 months (β 1.88, 95% CI 0.22-3.53, p=0.042 for interaction). Those not rehospitalized experienced a decline in Hardship score (β 0.91, 95% CI -1.51 to -0.31), while loneliness, perceived stress, and depression scores remained unchanged (Table). Conclusions: Hospitalized individuals with COPD experience high levels of social and behavioral stressors which are largely unabating in the 6 months after discharge, indicating these factors are chronic rather than acute consequences of hospitalization. Increasing anxiety levels are associated with readmission, highlighting the need to address this comorbidity in strategies aimed at improving health and reducing post-hospitalization morbidity in COPD.

Introduction: Both the Global Initiative for Asthma and the National Asthma Education and Prevention Program asthma guidelines recommend the use of single maintenance and reliever therapy (MART) with an inhaled corticosteroid and rapid onset long-acting beta agonist (ICS/formoterol) inhaler for moderate to severe asthma as MART significantly reduces the risk of asthma exacerbations. Despite these guidelines, adoption and implementation of MART among patients with asthma remains low. The objective of this study was to understand patient supports needed for better adoption of MART. Methods: We conducted 27 semi-structured interviews via Zoom with patients with moderate to severe asthma who were either currently on MART or not currently on MART despite being eligible who were evaluated at the Yale Center for Asthma and Airway Disease. Patients were asked to identify challenges to transitioning to MART and resources needed to optimize the transition. Interviews were recorded, transcribed, and coded for themes. Results: Of the 27 interviewees, 21 (78%) were women with a median age of 38 years. Most interviewees identified as non-Latinx white (N=19, 70%), had completed a college degree or above (N=18, 67%), and had private insurance (N=16, 59%). Some patients expressed positive experiences using ICS/formoterol for MART and no challenges transitioning to MART. As one participant said, “I didn't find it challenging. I was willing to see if this inhaler would actually help me.” Barriers to transitioning to MART included knowledge gaps such as uncertainty regarding the appropriate frequency of MART and inability to describe a MART regimen, lack of resources including insurance coverage and appropriate dispensing of medication by pharmacies, and patient preference for alternative controllers to ICS/formoterol or for albuterol as a reliever (Table 1). Facilitators to transitioning to MART included trust in a patient's clinician, the “convenience and ease” of having only one inhaler for maintenance and relief, and patient desire to find a better asthma management regimen. Patients asked for enhanced education to help optimize the transition to MART. Conclusion: Patients endorsed a range of experiences using MART, with many patient barriers and facilitators in transitioning to MART commenting on the role of clinician communication, education, and building rapport. Better patient support and education strategies are needed to effectively transition patients to MART.

Background Individuals with sarcoidosis face many sources of illness uncertainty, including diagnostic delays, unpredictable therapeutic efficacy and toxicity, and disease-associated morbidity and mortality. Patient perspectives on illness uncertainty in sarcoidosis have not been evaluated critically and offer an opportunity for providers to contextualize and prioritize gaps in care and patient support. Research Question How do patients with sarcoidosis describe their lived experiences with the disease and challenges they face in receiving care? Study Design and Methods We conducted semistructured qualitative interviews with patients with biopsy-proven pulmonary sarcoidosis receiving treatment for the disease who were seen at a tertiary sarcoidosis center of excellence. Interviews examined patient experiences of living with sarcoidosis, including their journey with diagnosis, treatment, and monitoring of disease activity. Transcripts were coded and categorized into themes and subthemes. Saturation was defined as at least 3 interviews without new information. Results Twenty-five participants completed semistructured interviews. The median age was 60 years, with 64% of the participants being female and 68% identifying as Black. The impact of illness uncertainty was a shared component of their care journeys. Key themes that emerged were (1) the burden of limited disease awareness, (2) uncertainty about sarcoidosis management, and (3) the unpredictability of disease progression. Uncertainty emerged as a major challenge that contributed to delays in care, poor disease control, psychological distress, or a combination thereof. Interpretation Our findings are the first, to our knowledge, to highlight the impact of patient illness uncertainty on sarcoidosis disease outcomes and psychological distress. Individuals living with sarcoidosis may benefit by addressing the psychosocial impact of uncertainty. Individuals living with sarcoidosis may benefit significantly from targeted interventions to mitigate the impact of illness uncertainty.

Rationale: Financial toxicity has been associated with worse health outcomes in several chronic disease processes but has not been well studied in Chronic Obstructive Pulmonary Disease (COPD). Individuals with COPD are at high risk for financial toxicity due to unplanned ED visits and hospitalizations, income loss from disability, and high out-of-pocket costs for inhaled bronchodilators. We sought to characterize experiences of financial toxicity among individuals with COPD. Methods: We conducted semi-structured interviews with purposively sampled individuals who previously participated in a cohort study of COPD at Johns Hopkins Medicine. Transcripts were analyzed using inductive coding and were categorized through thematic analysis. Results: Ten patients were interviewed to date, of whom 60% were women, 50% non-Hispanic White, and 30% non-Hispanic Black. The mean age was 71.7 years, and 20% had a college degree or more. All participants were insured through Medicare; two participants were dually covered by Medicaid. Several emergent themes, including (1) material burden, (2) lifestyle adjustments in response to material burden, (3) financial problem-solving strategies, and (4) emotional impact, were consistent with prior research on financial toxicity that has conceptualized it in three broad domains: material conditions, psychological response, and coping behaviors (Table 1). We identified the role of healthcare providers as a novel theme impacting financial toxicity. Some individuals reported assistance from clinic staff. Many participants reported lack of conversations with their physician about the financial impact of treatment (“I may mention it to my primary. She's very nice. But she's not really interested in that kind of stuff”; “I wish they had told me about it”). Several participants who discussed medication costs with their providers reported these conversations often did not reduce their costs and, in some cases, increased them (“my medical providers are very bad at managing my prescriptions.. there have been times that I've had to go out and just pay the costs rather than wait for them to correct their errors”). Conclusions: The themes emerging from our analysis are concordant with previous research on financial toxicity. Our results also highlight the positive and negative impact that clinicians and allied healthcare professionals can have on individual experiences of financial toxicity as a novel theme. Clinicians are recommended to assess individual financial barriers. Individuals with COPD experiencing financial burden benefit from clinical programs that have dedicated allied health professionals assisting in navigating costs associated with medical care.

OBJECTIVES:To characterize the performance of an electronic health record (EHR) data-based classifier of persistent moderate-to-severe acute respiratory distress syndrome (ARDS). DESIGN:Retrospective observational study. SETTING:Six ICUs from two health systems. PATIENTS:We included adults receiving greater than or equal to 24 hours of invasive mechanical ventilation (IMV) with a Pa o2 /F io2 of less than or equal to 150 mm Hg on F io2 greater than or equal to 0.6 in the first 72 hours of IMV. We evaluated classifier performance in two temporally and geographically distinct cohorts: a development cohort including patients in one of two academic medical or three mixed community ICUs in the first 3 months of 2021 or in 2022-2023, and a validation cohort from a different academic medical ICU in 2017. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:In both cohorts, study physicians assessed patients for clinical ARDS criteria. We retrospectively applied the EHR classifier, which required a persistent Pa o2 /F io2 of less than or equal to 150 mm Hg or receipt of interventions to address severe hypoxemia (i.e., prone positioning, neuromuscular blockade, inhaled pulmonary vasodilators) in the 24 hours after initially meeting hypoxemia criteria. We also evaluated classifier definitions that used peripheral oxygen saturation (Sp o2 )/F io2 of less than or equal to 162 to indicate persistent hypoxemia. Of 924 patients in the development cohort, 504 (55%) had clinician-adjudicated ARDS. Of 90 patients in the validation cohort, 48 (53%) had clinician-adjudicated ARDS. In the development and validation cohorts, the primary EHR-based classifier identified 382 and 38 patients as having persistent moderate-to-severe ARDS, respectively (positive predictive value [PPV], 71%; 95% CI, 66-75% and PPV, 66%; 95% CI, 50-81%). When Sp o2 /F io2 was used as the second hypoxemia marker more patients were classified as ARDS in both development and validation cohorts but with lower PPVs (67% and 62%, respectively.). CONCLUSIONS:An EHR-based classifier using readily available data had acceptable performance for identifying patients with persistent moderate-severe ARDS. This open-source tool could be used for retrospective or prospective identification of this vulnerable population for research and quality improvement initiatives.

Rationale: Lung protective ventilation is among the best supported and most consequential evidence-based practices (EBP) in patients with acute respiratory failure, and yet persistent evidence-practice gaps remain. In this study, we test the hypothesis that higher staff-level ratings of ICU implementation climate, defined as shared perceptions of underlying ICU practices and organization, is associated with increased patient-level receipt of lung protective ventilation. Methods: We conducted a cross-sectional survey of ICU staff (physicians, nurses, advance practice providers and respiratory therapists) across 5 Johns Hopkins Health System hospitals (2024). Survey domains were assessed using previously validated scales measuring various aspects of implementation climate including, implementation culture, staff stress, resources, and organizational readiness for implementing change [ORIC]), and were adapted for the ICU. We then tested the association of ICU-level mean domain scores with patient-level receipt of lung protective ventilation in a retrospective cohort of patients with acute hypoxemic respiratory failure requiring mechanical ventilation in each study ICU (2022-2024). We defined lung protective ventilation as the percentage of the first 24 hours with tidal volume per kg of predicted body weight ≤ 6.5 and plateau pressure ≤ 30 cmH2O. Each survey domain score was tested separately in mixed effects models with ICU as a random effect and adjusted for pre-specified patient and ICU features. Results: The final cohort contained ICU survey scores from 469 ICU staff in 14 ICUs and 5 hospitals (50% response rate) and included n=2661 patients contributing 50,539 patient-hours of eligible mechanical ventilation. The mean percentage of the 1st24 hours in which LPV was received was 52%, with a median and interquartile range of 64% [0-100%] (Figure 1).In models adjusted for pre-specified patient and ICU-level confounders, a one standard deviation increase in ICU implementation culture score (more favorable) was associated with a 12% relative increase in lung protective ventilation receipt in the first 24 hours (rate ratio (RR)=1.12 [95% CI:1.04-1.20], p<0.01). Conversely higher ratings of ICU staff stress were associated with decreased lung protective ventilation (RR=0.92 [0.85-1.00], p=0.04). Increased ratings of ICU resources and higher scores on the ORIC survey were not associated with increased LPV (RR=1.12 [95% CI: 0.99-1.25], p=0.07 and RR=1.07 [95% CI: 0.71-1.63], p=0.75, respectively.) Conclusion: We found that ICU implementation culture and climate measures, which may be modifiable via ICU team-based interventions, are independent predictors of lung protective ventilation performance.

Background: Most studies on mental health among individuals with chronic obstructive pulmonary disease (COPD) utilize screening questionnaires, which detect psychiatric symptoms, but cannot be used to diagnose depression/anxiety disorders. We utilized the Manual of Mental Disorders, Fifth Edition diagnostic criteria and described associated disease burden in people with COPD. Methods: This is a cross-sectional, secondary analysis of a multicenter study designed to evaluate anxiety questionnaires in COPD patients. Research coordinators administered both the MINI and screening questionnaires to determine participants who met diagnostic criteria for depression/anxiety disorders and to capture symptom burden, respectively. Bivariate analyses were conducted to assess differences in COPD and patient-reported outcomes between those with and without depression/anxiety disorders. Results: Of 220 participants, 18 (8%) met the MINI criteria for depression and 17 (8%) for anxiety. Depression was associated with Assessment Test [CAT] 27 versus 17, p<0.001), worse sleep quality (Pittsburgh Sleep Quality Index 11 versus 7, p=0.001) and healthrelated quality of life (5-Level EQ-5D 0.31 versus 0.59, p<0.001). Anxiety was associated with lower CAT scores and worse healthrelated quality of life and function. Most with depression/anxiety disorders were not using antidepressants/anxiolytics, or receiving Conclusion: Depression and anxiety disorders meeting diagnostic criteria are relatively common comorbidities that substantially impair quality of life and are undertreated, highlighting a need to prioritize mental health as an integral part of comprehensive COPD care.

Objective: Caregivers of children with asthma can become overwhelmed by the burden of care provision. Guided by the socioecological framework, we examined individual and system-level factors associated with caregiver health-related quality of life (HRQoL) among preschool children (aged two to six years) enrolled in a multilevel home- and school-based asthma educational intervention in Baltimore, Maryland. Methods: The primary outcome was caregiver HRQoL measured at baseline and six months. Independent variables were baseline individual-level factors (caregiver's health literacy, self-efficacy to manage asthma, and depressive symptoms) and system-level factors (barriers to asthma care measured in five subdomains-pragmatics, health knowledge and beliefs, expectations, skills, and marginalization-and neighborhood social cohesion). Multiple regression models were used to assess the association between baseline individual and system-level factors and caregiver HRQoL at baseline and six-month follow-up adjusting for the child's asthma control, caregiver's age, household income, and study arm assignment/intervention. Results: 398 caregivers completed the baseline survey and 328 (82%) completed the six-month follow-up survey. In the adjusted multiple regression model, lower caregiver's health literacy and higher barriers to asthma care related to pragmatics were significantly associated with lower caregiver HRQoL at baseline (b = 0.38, 95% CI, 0.15-0.61, p = .002; and b = 0.01, 95% CI, 0.004-0.02, p < .001, respectively). The results were similar at the six-month follow-up. Conclusion: Caregiver health literacy and barriers to asthma care related to pragmatics and skills were found to be important determinants of asthma caregiver HRQoL. Addressing these factors may improve the quality of life among caregivers of preschool children with asthma.

Background: Individuals with chronic obstructive pulmonary disease (COPD) are disproportionately affected by social determinants of health that have been associated with worse respiratory outcomes. This study evaluates the association of perceived stress with respiratory outcomes and distinct biological mechanisms among former smokers with COPD. Methods: Participants were assessed in an observational study at baseline, 3-months, and 6-months. Questionnaires assessed perceived stress (Perceived Stress Scale, [PSS]), respiratory symptoms, and incidence of COPD exacerbations. Generalized linear mixed models evaluated the association of PSS score with COPD outcomes and biomarkers of platelet activation (urine 11-dehydro-thromboxane B2 [11dTxB2]), oxidative stress (urine thiobarbituric acid reactive substances [TBARS], 8-hydroxydeoxyguanosine, and 8-isoprostane), and inflammation. Results: Among 99 participants, the median PSS score was 13 (interquartile range 8-18) across all visits. Compared with low perceived stress (PSS 0-13), moderate (PSS 14-26) and high perceived stress (PSS 27-40) were associated with worse respiratory health status and respiratory-related quality of life, with point estimates for high perceived stress exceeding clinically important differences. Only high PSS was associated with increased moderate/severe exacerbations (odds ratio 4.15, 95% confidence interval [CI]: 1.28-13.47). Compared to low stress, high stress was associated with lower TBARS ((i=-25.5%, 95%CI:-43.8--1.2%) and higher 8-isoprostane ((i=40.1%, 95%CI: 11.5-76.0%). Among individuals with mild-moderate COPD, compared to low stress, moderate ((i=20.1%, 95%CI: 3.1-40.0%) and high ((i=52.9%, 95%CI: 22.1-91.6%) stress were associated with higher 11dTxB2. Conclusion: Among former smokers with COPD, higher perceived stress is associated with worse respiratory outcomes. Platelet activation and oxidative stress may be biological pathways through which perceived stress plays a role in COPD.

INTRODUCTION Before medically advised (BMA) discharges – alternatively known as ‘against medical advice'—are associated with poor outcomes such as increased readmission among patients with asthma. However, it is unclear what factors contribute to these worsened outcomes or what care these patients receive upon discharge. In this study, we evaluated patterns of post-discharge care (i.e. medication prescriptions, referrals, and follow-up) after hospitalizations for asthma exacerbation among patients discharging BMA versus non-BMA. METHODS We developed a cohort using electronic health record data of patients ≥ 18 years old within the Johns Hopkins Health System who had an admission for asthma exacerbation, as defined by ICD-10 codes, and were discharged to home. All admissions were classified as either a BMA or planned (i.e. non-BMA) discharge according to their discharge disposition. Demographics, clinical characteristics, and 30-day readmission were compared between BMA and non-BMA discharges using chi-square and Mann-Whitney U tests. We then evaluated the proportion of discharges in which the patient received each of the following at discharge: an oral steroid prescription, inhaled corticosteroid prescription, outpatient referral for any service, or scheduled follow-up with a primary care physician or pulmonologist within 14-days. Differences in each component of discharge care were compared using logistic regression models with clustered standard errors, adjusted for age, race, sex, length of stay, history of exacerbation, insurance, time of discharge, and medical center. RESULTS This cohort included 5,507 admissions for asthma exacerbation, of which 205 (3.7%) resulted in a BMA discharge. Compared to non-BMA discharges, those discharged BMA were younger (39 vs 48 years, p<0.001) with a higher area deprivation index (67 vs 50, p<0.001). Readmission at 30 days more commonly occurred after a BMA discharge (15 vs 10%, p=0.03). Compared to non-BMA discharges, those who discharged BMA were less likely to receive an oral steroid prescription (54% vs 76%, p<0.001 ), inhaled corticosteroid prescription (32% vs 49%, p<0.001), outpatient referral (9% vs 34%, p<0.001), or scheduled 14-day follow-up (19% vs 27%, p=0.01) (Figure 1). All results were similar in adjusted models, and patients discharging BMA were particularly less likely to receive an outpatient prescription for oral steroids (OR 0.25, 95% CI 0.18-0.35) CONCLUSIONS Compared to non-BMA discharges, patients discharged BMA following hospitalization for an asthma exacerbation were less likely to receive outpatient steroids, inhaled corticosteroids, referrals, or follow-up, and they more likely to be readmitted at 30 days. These treatment gaps present potential opportunities to improve care.