The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Strong evidence exists for clinically relevant night-to-night variability of respiratory events in patients with suspected OSA.

Pulmonary venoocclusive disease (PVOD) is an uncommon form of pulmonary hypertension (PH) predominantly characterized by pulmonary vein and capillary involvement. An association between chemotherapy, in particular mitomycin C (MMC), and PVOD has been reported.

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.

Pulmonary exacerbations (PExs) are significant life events in people with cystic fibrosis (CF), associated with declining lung function, reduced quality of life, hospitalizations, and decreased survival. The adult CF population is increasing worldwide, with many patients surviving prolonged periods with severe multimorbid disease. In many countries, the number of adults with CF exceeds the number of children, and PExs are particularly burdensome for adults as they tend to require longer courses and more IV treatment than children. The approach to managing PExs is multifactorial and needs to evolve to reflect this changing adult population. This review discusses PEx definitions, precipitants, treatments, and the wider implications to health-care resources. It reviews current management strategies, their relevance in particular to adults with CF, and highlights some of the gaps in our knowledge. A number of studies are underway to try to answer some of the unmet needs, such as the optimal length of treatment and the use of nonantimicrobial agents alongside antibiotics. An overview of these issues is provided, concluding that with the changing landscape of adult CF care, the definitions and management of PExs may need to evolve to enable continued improvements in outcomes across the age spectrum of CF.

Invasive mechanical ventilation is often initiated in the ED, and mechanically ventilated patients may be kept in the ED for hours before ICU transfer. Although lung-protective ventilation is beneficial, particularly in ARDS, it remains uncertain how often lung-protective tidal volumes are used in the ED, and whether lung-protective ventilation in this setting impacts patient outcomes.

The prevalence of burnout and depressive symptoms is high among physician trainees.

In the context that leadership matters and that leadership competencies differ from those needed to practice medicine or conduct research, developing leadership competencies for physicians is important. Indeed, effective leadership is needed ubiquitously in health care, both at the executive level and at the bedside (eg, leading clinical teams and problem-solving on the ward). Various leadership models have been proposed, most converging on common attributes, like envisioning a new and better future state, inspiring others around this shared vision, empowering others to effect the vision, modeling the expected behaviors, and engaging others by appealing to shared values. Attention to creating an organizational culture that is informed by the seven classic virtues (trust, compassion, courage, justice, wisdom, temperance, and hope) can also unleash discretionary effort in the organization to achieve high performance. Health care-specific leadership competencies include: technical expertise, not only in one's clinical/scientific arena to garner colleagues' respect but also regarding operations; strategic thinking; finance; human resources; and information technology. Also, knowledge of the regulatory and legislative environments of health care is critical, as is being a problem-solver and lifelong learner. Perhaps most important to leadership in health care, as in all sectors, is having emotional intelligence. A spectrum of leadership styles has been described, and effective leaders are facile in deploying each style in a situationally appropriate way. Overall, leadership competencies can be developed, and leadership development programs are signature features of leading health-care organizations.

The coronavirus pandemic has disrupted clinical practice, health-care organizations, and life. In the context that "a crisis is a terrible thing to waste," as disruptive as the pandemic has been to traditional practices-both clinically and educationally-opportunities have also presented. Clinical benefits have included the propulsion of clinical innovation, including such items as the development of novel vaccines and accelerated understanding of multiplex ventilation. Approaches to educating students and other learners have also changed radically, with the suspension of live teaching in most instances and a precipitous transition to virtual instruction. This perspective considers a SWOT analysis (strengths, weaknesses, opportunities, and threats) associated with the coronavirus pandemic in health care that focuses on the implications for education. Although the obvious disadvantages (weaknesses) regard the loss of face-to-face interaction with all of its consequences (eg, isolation, risks to camaraderie, loss of hands-on training opportunities, and loss of in-person celebratory events like graduations and end-of-training celebrations), there are clearly offsetting strengths. These include growing experience with virtual teaching and virtual learning strategies, the invitation to codify best virtual teaching practices, a tightening of alignment between undergraduate and graduate medical education (eg, around virtual interview strategies), and opportunities for both self-reflection and a commitment to act virtuously. On balance, the pandemic has created the opportunity, indeed the necessity, to innovate in practice and in education, making the landscape ripe for creative practice, new mastery, and the concomitant benefits to learners and to educators.

With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support.

Emotional intelligence (EI) has become widely appreciated as an important leadership attribute, in business, education and, increasingly, in health care. Defined as "the capacity to understand your own and others' emotions and to motivate and develop yourself and others in service of improved work performance and enhanced organizational effectiveness," EI is correlated with a number of success attributes in several sectors; for example, in business, with enhanced business performance and enhanced personal career success, and in health care, with enhanced patient satisfaction, lower burnout, lower litigation risk, and enhanced leadership success. While multiple models of EI have evolved, perhaps the most popular model is framed around four general rubrics with component competencies. The general rubrics are: self-awareness, self-management, social awareness, and relationship management. EI can be measured by using available instruments, and it can be learned and taught. Indeed, teaching EI has become increasingly common in health-care organizations in service of improving health care and health-care leadership. Although more research is needed, ample evidence supports the notion that EI is a critical success element for success as a health-care leader, especially because EI competencies differ markedly from the clinical and scientific skills that are core to being a clinician and/or investigator. This review of EI presents evidence in support of the relevance of EI to health care and health-care leadership, discusses how and when EI can be developed among health-care providers, and considers remaining questions.

There is increasing interest in the effects of sleep and sleep disturbances on the brain, particularly in relation to aging and neurodegenerative processes. Parkinson disease (PD) is the second most common neurodegenerative disorder, with growing prevalence worldwide. Sleep disorders, including sleep-disordered breathing (SDB), are among the most frequent non-motor manifestations of PD. They can substantially impair quality of life and possibly affect the course of the disease. This article reviews the etiology, implications, and management of sleep disturbances in PD, such as excessive daytime sleepiness, insomnia, restless legs syndrome, rapid eye movement sleep behavior disorder, and SDB. Also briefly explored is the potential role of sleep disorders, including SDB, in the progression of neurodegeneration.

Chronic tobacco smoke exposure results in a broad range of lung pathologies including emphysema, airway disease and parenchymal fibrosis as well as a multitude of extra-pulmonary comorbidities. Prior work using CT imaging has identified several clinically relevant subgroups of smoking related lung disease, but these investigations have generally lacked organ specific molecular correlates.

Characteristics of critically ill adults with coronavirus disease 2019 (COVID-19) in an academic safety net hospital and the effect of evidence-based practices in these patients are unknown.