Worldwide, health-care professionals are experiencing unprecedented stress related to the coronavirus disease 2019 pandemic. Responding to a new virus for which there is no effective treatment yet and no vaccine is beyond challenging. Moral distress, which is experienced when clinicians are unable to act in the way that they believe they should, is often experienced when they are dealing with end-of-life care issues and insufficient resources. Both factors have been widespread during this pandemic, particularly when patients are dying alone and there is a lack of personal protection equipment that plagues many overburdened health-care systems. We explore here, guided by evidence, the concept and features of moral distress and individual resilience. Mitigation strategies involve individual and institutional responsibilities; the importance of solidarity, peer support, psychological first aid, and gratitude are highlighted.

Individual studies have reported widely variable rates for VTE and bleeding among hospitalized patients with coronavirus disease 2019 (COVID-19).

The clinical research we do to improve our understanding of disease and to develop new therapies has temporarily been delayed as the global health-care enterprise has focused its attention on those impacted by coronavirus disease 2019 (COVID-19). Although rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are decreasing in many areas, many locations continue to have a high prevalence of infection. Nonetheless, research must continue and institutions are considering approaches to restarting non-COVID-related clinical investigation. Those restarting respiratory research must navigate the added planning challenges that take into account outcome measures that require aerosol-generating procedures. Such procedures potentially increase risk of transmission of SARS-CoV-2 to research staff, use limited personal protective equipment, and require conduct in negative-pressure rooms. One must also be prepared to address the potential for COVID-19 resurgence. With research subject and staff safety and maintenance of clinical trial data integrity as the guiding principles, here we review key considerations and suggest a step-wise approach for resuming respiratory clinical research.

The severe acute respiratory syndrome coronavirus 2 pandemic poses extraordinary challenges. The tremendous number of coronavirus disease 2019 (COVID-19) cases in the United States has resulted in a large population of survivors with prolonged postinfection symptoms. The creation of multidisciplinary post-COVID-19 clinics to address both persistent symptoms and potential long-term complications requires an understanding of the acute disease and the emerging data regarding COVID-19 outcomes. Experience with severe acute respiratory syndrome and Middle East respiratory syndrome, post-acute respiratory distress syndrome complications, and post-intensive care syndrome also informs anticipated sequelae and clinical program design. Post-COVID-19 clinical programs should be prepared to care for individuals previously hospitalized with COVID-19 (including those who required critical care support), nonhospitalized individuals with persistent respiratory symptoms following COVID-19, and individuals with preexisting lung disease complicated by COVID-19. Effective multidisciplinary collaboration models leverage lessons learned during the early phases of the pandemic to overcome the unique logistical challenges posed by pandemic circumstances. Collaboration between physicians and researchers across disciplines will provide insight into survivorship that may shape the treatment of both acute disease and chronic complications. In this review, we discuss the aims, general principles, elements of design, and challenges of a successful multidisciplinary model to address the needs of COVID-19 survivors.

Since its appearance in late 2019, infections caused by severe acute respiratory syndrome coronavirus 2 have created unprecedented challenges for health systems worldwide. Multiple therapeutic options have been explored, including corticosteroids. Preliminary results of corticosteroids in coronavirus disease 2019 (COVID-19) are encouraging; however, the role of corticosteroids remains controversial.

Management of Mycobacterium avium complex (MAC) lung disease is complicated, frequently unsuccessful, and frustrating to patients and clinicians. The initial treatment effort may not be directed solely at MAC infection, rather it is often initiating airway clearance measures for bronchiectasis. The next important steps are deciding who to treat and when to initiate therapy. Definitive or unambiguous guidance for these decisions is often elusive. The evidence supporting the current macrolide-based regimen for treating MAC lung disease is compelling. This regimen has been recommended in consensus nontuberculous mycobacterial treatment guidelines from 1997, 2007, and 2020, although clinician compliance with these recommendations is inconsistent. Understanding the idiosyncrasies of MAC antibiotic resistance is crucial for optimal antibiotic management. As a corollary, the importance of avoiding development of macrolide resistance due to inadequate therapy cannot be overstated. An inhaled liposome amikacin preparation is now approved for treating refractory MAC lung disease and holds promise for an even broader role in MAC therapy. Surgery is also an important therapeutic adjunct for selected patients. Microbiologic recurrences due either to new infection or treatment relapse/failure are common and require the same level of rigorous assessment and clinical judgment for determining their significance as initial MAC isolates. In summary, treatment of patients with MAC lung disease is rarely straight forward and requires familiarity with multiple factors directly and indirectly related to MAC lung disease. The many nuances of MAC lung disease therapy defy simple treatment algorithms; however, with patience, attention to detail, and perseverance, the outcome for most patients is favorable.

The coronavirus disease 2019 (COVID-19) pandemic has placed unprecedented burden on the delivery of intensive care services worldwide.

The Hospital Readmissions Reduction Program (HRRP) was developed and implemented by the Centers for Medicare & Medicaid Services to curb the rate of 30-day hospital readmissions for certain common, high-impact conditions. In October 2014, COPD became a target condition for which hospitals were penalized for excess readmissions. The appropriateness, utility, and potential unintended consequences of the metric have been a topic of debate since it was first enacted. Nevertheless, there is evidence that hospital policies broadly implemented in response to the HRRP may have been responsible for reducing the rate of readmissions following COPD hospitalizations even before it was added as a target condition. Since the addition of the COPD condition to the HRRP, several predictive models have been developed to predict COPD survival and readmissions, with the intention of identifying modifiable risk factors. A number of interventions have also been studied, with mixed results. Bundled care interventions using the electronic health record and patient education interventions for inhaler education have been shown to reduce readmissions, whereas pulmonary rehabilitation, follow-up visits, and self-management programs have not been consistently shown to do the same. Through this program, COPD has become recognized as a public health priority. However, 5 years after COPD became a target condition for HRRP, there continues to be no single intervention that reliably prevents readmissions in this patient population. Further research is needed to understand the long-term effects of the policy, the role of competing risks in measuring quality, the optimal postdischarge care for patients with COPD, and the integrated use of predictive modeling and advanced technologies to prevent COPD readmissions.

Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao2:Fio2 ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.

Early IV fluid administration remains one of the modern pillars of sepsis treatment; however, questions regarding amount, type, rate, mechanism of action, and even the benefits of fluid remain unanswered. Administering the optimal fluid volume is important, because overzealous fluid resuscitation can precipitate multiorgan failure, prolong mechanical ventilation, and worsen patient outcomes. After the initial resuscitation, further fluid administration should be determined by individual patient factors and measures of fluid responsiveness. This review describes various static and dynamic measures that are used to assess fluid responsiveness and summarizes the evidence addressing these metrics. Subsequently, we outline a practical approach to the evaluation of fluid responsiveness in early septic shock and explore further areas crucial to ongoing research examining this topic.

Patients with severe coronavirus disease 2019 (COVID-19) have respiratory failure with hypoxemia and acute bilateral pulmonary infiltrates, consistent with ARDS. Respiratory failure in COVID-19 might represent a novel pathologic entity.

Guidelines are critical for facilitating cost-effective COPD care. Development and implementation in low-and middle-income countries (LMICs) is challenging. To guide future strategy, an overview of current global COPD guidelines is required.

Subsolid nodules are common on chest CT imaging and may be either benign or malignant. Their varied features and broad differential diagnoses present management challenges. Although subsolid nodules often represent lung adenocarcinomas, other possibilities are common and influence management. Practice guidelines exist for subsolid nodule management for both incidentally and screening-detected nodules, incorporating patient and nodule characteristics. This review highlights the similarities and differences among these algorithms, with the intent of providing a resource for comparison and aid in choosing management options.

Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.

Disparities in sleep health are important but underrecognized contributors to health disparities. Understanding the factors contributing to sleep heath disparities and developing effective interventions are critical to improving all aspects of heath. Sleep heath disparities are impacted by socioeconomic status, racism, discrimination, neighborhood segregation, geography, social patterns, and access to health care as well as by cultural beliefs, necessitating a cultural appropriateness component in any intervention devised for reducing sleep health disparities. Pediatric sleep disparities require innovative and urgent intervention to establish a foundation of lifelong healthy sleep. Tapping the vast potential of technology in improving sleep health access may be an underutilized tool to reduce sleep heath disparities. Identifying, implementing, replicating, and disseminating successful interventions to address sleep disparities have the potential to reduce overall disparities in health and quality of life.

Eosinophilia with pulmonary involvement is characterized by the presence of peripheral blood eosinophilia, typically ≥500 cells/mm3, by pulmonary symptoms and physical examination findings that are nonspecific, and by radiographic evidence of pulmonary disease and is further supported by histopathologic evidence of tissue eosinophilia in a lung or pleura biopsy specimen and/or increased eosinophils in BAL fluid, usually >10%. Considering that there are a variety of underlying causes of eosinophilia with pulmonary manifestations and overlapping clinical, laboratory, and radiologic features, it is essential to approach the evaluation of eosinophilia with pulmonary findings systematically. In this review, we will describe a case presentation and discuss the differential diagnosis, a directed approach to the diagnostic evaluation and supporting literature, the current treatment strategies for pulmonary eosinophilia syndromes, and the levels of evidence underlying the recommendations, where available. Overall, optimal management of eosinophilic lung disease presentations are directed at the underlying cause when identifiable, and the urgency of treatment may be guided by the presence of severe end-organ involvement or life-threatening complications. When an underlying cause is not easily attributable, management of eosinophilia with pulmonary involvement largely relies on eosinophil-directed interventions, for which biologic therapies are increasingly being used.

Change is a fact of life; the absence of change creates stagnation. This is perhaps especially true in health care, where progress in treating disease depends on innovation and progress. At the same time, change is often uncomfortable. Thus, it is helpful to model the change process to optimize the chances of successfully effecting change. Furthermore, how to lead change is a critical leadership competency. Three models for leading change are reviewed: the first-the eight stages of change-which was not designed for health care; the second called "switch"; and the third called Amicus, which was uniquely designed for health care. The models share many common features, with the explicit reminder in the third model that physicians should be involved in the change effort early. Although sparse, the evidence does suggest the applicability of these models to health care. Beyond having a roadmap for leading change, it is helpful to assess the worthiness of undertaking a change effort and of predicting the phasic response to change efforts, given that humans are often change-averse. In this regard, both the "payoff matrix" and the change curve, derived from the work of Kübler-Ross on grieving, are offered as tools. Finally, physicians' avidity for change is framed by two opposing vectors. On the one hand, physicians share in the general human aversion to change. On the other hand, physicians are data-reverent and also wish to do their best for patients, which encourages their embrace of ever-increasing evidence and change.

Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.

Early in the coronavirus disease 2019 (COVID-19) pandemic, there was serious concern that the United States would encounter a shortfall of mechanical ventilators. In response, the US government, using the Defense Production Act, ordered the development of 200,000 ventilators from 11 different manufacturers. These ventilators have different capabilities, and whether all are able to support COVID-19 patients is not evident.

Because teams can accomplish goals that individuals cannot, teams matter. Indeed, teams especially matter in settings such as health care, where favorable outcomes depend critically on the contributions of many different people with diverse skills. As important as effective teambuilding is for health care, how to build teams is often not included in medical curricula, and physicians learn to build teams through "hidden curricula." In the context that we can do better, this "How I Do It" presents an approach to building a team in a common scenario for the chest physician: picking up the inpatient Pulmonary Consult Service. The approach is informed by considering the attributes of an effective team, knowledge of common team dysfunctions, and best practices for building a team. The importance of teambuilding is underscored by substantial evidence that effective teamwork produces superior clinical outcomes.