The flow index (FI) is a noninvasive method for monitoring inspiratory effort during pressure support ventilation (PSV). However, the impact of different sampling frequencies on FI accuracy remains unclear. This study investigates how sampling frequency affects FI measurements and its diagnostic efficacy in identifying low or high inspiratory effort. A retrospective analysis of prospectively collected data from patients with acute brain injury (ABI) and acute respiratory failure (ARF) undergoing PSV with esophageal pressure monitoring was conducted. Flow, airway pressure, and esophageal pressure data were collected at 100 (ABI) and 200 Hz (ARF), then downsampled to 100, 50, 25, and 20 Hz. FI was calculated using a Python script, and respiratory mechanics were analyzed. Bland-Altman analysis compared FI at lower frequencies to the 100 Hz reference (both ABI and ARF cohorts). Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the diagnostic accuracy of FI in identifying low or high inspiratory effort across sampling frequencies. A total of 178 records from 76 subjects were analyzed. FI values were significantly lower at 50, 25, and 20 Hz compared with 100 Hz ( < .001). Bland-Altman analysis revealed biases of -0.08 (95% CI -0.17 to 0.00), -0.20 (95% CI -0.36 to -0.04), and -0.23 (95% CI -0.39 to -0.06) for 50, 25, and 20 Hz, respectively. The corresponding limits of agreement all exceeded the predefined clinically acceptable range. Despite these differences, the diagnostic efficacy of FI in identifying low or high inspiratory effort remained consistent across all frequencies, with area under the ROC ranging from 0.84 to 0.85 and 0.85 to 0.90, respectively. Although FI demonstrated robust diagnostic performance for low or high inspiratory effort across sampling frequencies, its reduced accuracy at lower frequencies calls for cautious use and frequency-specific cutoffs for effective FI monitoring.

Patient-ventilator discordance commonly occurs in patients receiving noninvasive ventilation (NIV). Unintentional leaks contribute to trigger and cycle asynchrony. Historically, ventilators designed for NIV with an intentional leak circuit compensated for unintentional leaks better than critical care ventilators. However, many critical care ventilators now have NIV settings for leak compensation. Per bench studies and some clinical studies, NIV settings for leak compensation variably improve synchrony related to leak. Some interfaces, such as the helmet, can contribute to asynchrony. Ventilator modes such a neurally adjusted ventilatory assist might improve synchrony but might not lead to better patient outcomes. Adaptive pressure control modes have the potential to remove support with increased patient effort, resulting in work shifting from the ventilator to the patient. Moreover, these modes are complicated if the ventilator does not correctly estimate tidal volume during NIV. Adding flow to the circuit, such as adding oxygen to increase F, can also contribute to asynchrony. This article addresses issues related to discordance with NIV and strategies to improve patient-ventilator interactions during NIV.

Breathing frequency is a sensitive indicator of a neonate patient's condition and a crucial parameter in the neonatal ICU (NICU). However, conventional methods require sensors to be adhered to the newborn's sensitive skin. This study assesses a noncontact respiratory monitor, using linear frequency modulation continuous wave radar, to determine the monitor's accuracy when used in the NICU setting. An observational study was conducted on the noncontact respiration module produced by Mindray, connected to a BeneVisionN12 patient monitor. This unit collected data on breathing frequency; at the same time, the patient breathing frequency was also being measured using a CO monitor (accepted standard). Statistical analyses were performed to assess the agreement between the 2 measurements and to assess whether this noncontact monitor is sufficiently accurate for clinical use. 20 neonatal patients at 2 NICUs were enrolled in the study. The mean bias between the radar-derived and CO-derived breathing frequency was -0.29 bpm (95% CI: -0.53 to -0.04); root-mean-square error was 2.60 bpm; concordance correlation coefficient was 0.98; and Pearson correlation coefficient was 0.98. Subgroup analyses grouped by body weight show that the technology has particularly high accuracy and clinical utility for neonates with low body weight (<1.5 kg). The noncontact respiration monitoring technology and module developed by Mindray showed a high degree of agreement with the CO reference standard and met the standard of accuracy required for clinical use.

Amyotrophic lateral sclerosis (ALS) is a fatal heterogeneous neurodegenerative disease characterized by the degeneration of both upper and lower motor neurons and spinal cord. Measurement of respiratory muscle strength has been shown to be an important assessment in the decision-making process and can be assessed by maximum inspiratory (P) and expiratory pressures (P), sniff nasal inspiratory (SNIP) and expiratory (SNEP) pressures. Body position appears to have a significant effect on respiratory muscle strength. The aim of this study was to observe the difference in peak values of SNIP and SNEP of the respiratory muscles measured in 2 different positions (seated and supine with 45° elevation) in subjects with ALS and a group of matched healthy subjects. This is a case-control study of subjects with ALS and healthy subjects. Spirometry and surface electromyography (EMG) of the sternocleidomastoid, scalene, rectus abdominis, and external oblique muscles were assessed during P and P maneuvers in the seated position, and SNIP and SNEP in the seated and supine positions at 45° elevation (randomized). SNEP values in the 45° elevation were lower than in the sitting position in ALS (70.3 ± 26.7 vs 57.3 ± 22.8 cm HO, = .041). SNIP and SNEP were lower in ALS in the 45° elevation compared with healthy subjects (69.1 ± 27.2 vs 95.5 ± 23.5 cm HO; 57.3 ± 22.5 vs 92.7 ± 26.4 cm HO, = .041). In subjects with ALS, baseline electromyographic activity of the sternocleidomastoid muscle at rest was higher than in healthy subjects in both positions ( = .041). No significant differences in electrical activity were found for other variables and measurements. In ALS, nasal pressure may be affected by reduced diaphragm and abdominal muscle effectiveness in the supine position. The sternocleidomastoid muscle showed increased electrical activity in the supine position with 45° elevation compared with controls, which may indicate muscle weakness.

Limited data exist regarding both the absolute values and the percentage of predicted values of impulse oscillometry (IOS) when measured using different devices. We aimed to compare IOS values and their percentages of predicted values obtained from the MasterScreen-IOS and the MostGraph-02 in individuals with chronic respiratory diseases. A retrospective analysis was conducted in subjects with COPD and asthma. IOS measurements were obtained from the same individuals using both the MasterScreen-IOS and the MostGraph-02. Thai reference values, previously derived from MasterScreen-IOS, were used to calculate percent predicted IOS parameters. Paired sample test was used to compare IOS values derived from the two devices. Correlations between IOS values obtained from the two devices were analyzed using Pearson's correlation and Bland-Altman analysis was employed to determine the limits of agreement between the IOS values derived from these devices. A total of 54 subjects (36 with asthma and 18 with COPD) with a mean age of 65.7 ± 10.8 years, of whom 33 (61.1%) were male, were included. The reactance values, including the absolute values and percent predicted values for resonant frequency (Fres) and the area under the reactance curve between 5 Hz and the resonant frequency (AX), were significantly higher with the MasterScreen-IOS compared with the MostGraph-02. Discrepancies in IOS measurements, particularly in percent predicted values for heterogeneity of resistance between R5 and R20 (R5-R20), Fres, and AX, were observed when comparing the two devices. Significant differences in IOS reactance values were found between the MasterScreen-IOS and MostGraph-02. Device-specific reference equations may contribute to differences in percent predicted values. Therefore, IOS measurements from these devices should be interpreted cautiously and not considered interchangeable for longitudinal assessments.

High-flow nasal cannula (HFNC) therapy was originally considered only for its targeted O delivery but has been shown to also assist in the removal of end-expiratory CO. Variables that influence the capability of this modality to reduce end-expiratory CO are being proposed and investigated. Two types of HFNC therapy were precisely modeled at numerous mouth openings to investigate the effect that mouth open percent (MOP) had on airway CO reduction (flush) and upper airway pressure generation for each therapy. Computational fluid dynamics models were run at MOPs of 0%, 2%, 5%, 10%, 20%, 30%, 40%, and 100%, and each was administered therapy via a large-bore cannula, small-bore cannula, or no therapy. All models were initially run with less accurate, but cheaper, modeling parameters to establish the range of MOPs to be tested with higher-accuracy modeling parameters. Higher-accuracy models were run for MOPs of 5%, 10%, 20%, 30%, and 100%. CO and pressure in the upper airway were analyzed to provide information on the effect of MOP, therapy type, and therapy flow. The distinction between cannulas peaked at an MOP of 20%, with large-bore having ∼3.5 mg more CO entrained at end-exhale than small-bore. Increasing MOP and increasing therapy flow each decreased CO retention in the airway. Therapy with a large-bore cannula resulted in less CO flush than with a small-bore cannula, if all other factors were identical. Decreasing MOP and increasing therapy flow each increased distending pressure generation, while small-bore generated higher pressures than large-bore when all other factors were the same. The results collected using the lower-cost models highlighted the necessity of high-accuracy modeling methodology. The CO and pressure results from the higher-accuracy models can inform clinicians as to the benefits of certain HFNC modalities at intermediate mouth openings (pursed-lip breathing).

Respiratory therapy (RT) departments need to deliver care efficiently. There are limited data describing staffing models used by RT departments and how daily assignments are determined. We aimed to describe RT department staffing models. We targeted an electronic survey to directors, managers, and supervisors of RT departments via social media, professional networks, and a manager work group. We asked questions about hospital demographics, staffing models, daily assignments, full-time equivalent (FTE) calculations, and attitudes about staffing. Data analysis was descriptive and we compared those with high versus low vacancy rates. We received 116 responses; 86% were managers or directors. The number of RT FTEs was reported as below what they need for 67% of respondents, 38% believed hospital leadership agreed the number of RT FTEs was below what they need, 63% reported the number of FTEs was determined above the RT director level, and 41% of RT departments owned the reports used to determine the number of FTEs. The AARC Safe and Effective Staffing Guide was used by 19% of respondents, 20% used only billable activities, and 24% used relative value units. For assignments and daily work load, 68% of respondents accounted for unplanned activities, 39% used a point system for daily assignments, 14% used an objective system to determine daily assignments, and 55% stated the charge or lead RT determined daily assignments. Forty percent of respondents reported no maximum for number of ventilators per RT and 81% reported RTs staffed in the ICU also have assignments outside the ICU. In a small sample of RT leaders, there was limited consensus on how daily assignments, FTE calculations, and target work load were determined among respondents. Most reported RTs having assignments outside the ICU and 40% did not have a maximum number of ventilated patients per RT.

Neurally Adjusted Ventilatory Assist (NAVA) is a ventilator mode providing improved patient-ventilator synchrony compared to flow- or pressure-triggered modes. We examined the effect of various NAVA, pressure support (PSV), and PEEP combinations in infants with acute viral bronchiolitis. This was a mechanistic study, nested within a randomized controlled feasibility trial. A set of 16 ventilatory combinations (each of 10-15 min), including PEEP of 1, 5, and 10 cm HO; PSV of 20 cm HO; and NAVA support ranging from 0.5 to 2.0 cm HO/μV, were administered on each of 2 consecutive days to 13 invasively ventilated infants: mean (range) age 4 months (0.1-10.0). Outcome measures were grouped according to respiratory drive, respiratory efficiency, expiratory air flow limitation, gas exchange, and tolerability. Higher PEEP levels were associated with better respiratory drive ( < .001 for electrical activity of the diaphragm and P), respiratory efficiency (higher tidal volumes and lower breathing frequency, both < .001) and improved oxygenation ( = .02). Minute ventilation remained constant ( = .67), as did transcutaneous CO ( = .60). Expiratory air flow limitation was minimal overall; however, it was reduced on NAVA compared with PSV ( < .001 for β angle). A NAVA support of 0.5 cm HO/μV appeared inadequate for some outcome measures; conversely, the benefit of increasing support beyond 1.0 was modest, and not always apparent across all outcome measures. Altering PEEP did not produce clinically adverse effects on hemodynamics or patient tolerability (COMFORT-B score). Higher PEEP values of up to 10 cm HO may improve respiratory mechanics in acute viral bronchiolitis, without adversely impacting on clinical state. We could not identify an optimal level of NAVA support; however, 0.5 cm HO/μV may be inadequate.

Unplanned extubations (UE) are directly associated with morbidity, mortality, and increased health care costs amongst critically-ill children. Multi-center implementation of the Solutions for Patient Safety Network prevention bundle has been successful, but UE rates remain a common cause of preventable health care harm. This was a longitudinal (2020-2025), multi-intervention quality improvement (QI) project in a single quaternary care pediatric intensive care unit (PICU) driven largely by a new QI respiratory therapist. Interventions built upon the initial implementation of the UE prevention bundle. The smart aim of this project was to sustainably decrease UE/100 invasive ventilation days in the PICU at Children's of Alabama by 50% through multiple Plan-Study-Do-Act (PDSA) cycles. The baseline event rate was 0.58 UE/100 invasive ventilation days. Criteria for a center line shift to 0.16 UE/100 invasive mechanical ventilation days (72.5% decrease) were met in the first quarter of 2023 following four PDSA cycles and sustained through the end of the project. There was no change in invasive ventilation days/patient/quarter, but the percentage of PICU patients exposed to invasive ventilation by quarter starting dropped from 42% to 33% beginning in the first quarter of 2021. There were no center line shifts in post-UE outcomes over the project period including re-intubation within 1 h, re-intubation with cardiopulmonary resuscitation, or no re-intubation. Through multiple interventions, UE/100 invasive ventilation days decreased by 72.5% and has been sustained from the first quarter of 2023 through the second quarter of 2025 without impacting balancing measures such as invasive ventilation duration. These results support the importance of building upon the Solutions for Patient Safety Network UE prevention bundle and having a dedicated champion to drive improvement and sustainability.

Mechanical ventilation management remains one of the most complex and critical interventions in intensive care medicine. As ventilation strategies continue to evolve from gas exchange optimization to comprehensive lung and diaphragm protection, the cognitive burden on clinicians has increased substantially. Decision assist systems represent a promising technological advancement that can help bridge the gap between evidence-based protocols and individualized patient care. Unlike fully automated closed-loop systems, decision assist tools maintain clinician oversight while providing real-time, data-driven recommendations to optimize ventilator management. This narrative review examines the current landscape of decision assist systems in mechanical ventilation, exploring their potential benefits in improving health equity, reducing practice variation, and enhancing adherence to protective ventilation strategies. We discuss the technical challenges, implementation barriers, and future directions for these systems, with particular emphasis on balancing the competing priorities of lung protection and diaphragm preservation. We illustrate these principles using examples from the development and implementation of a decision assist system called REDvent (real-time effort driven ventilator management) which was recently tested in a phase 2 clinical trial. While fully automated ventilation remains challenging due to the complexity of clinical decision-making and the need for contextual judgment, decision assist systems offer a pragmatic approach to improving ventilator management in the contemporary intensive care unit.

Community-based pulmonary rehabilitation (PR) programs preserve essential PR elements such as exercise, disease education, and social support while addressing barriers to cost and transportation by offering low equipment options and flexible location delivery. We evaluated the feasibility of a 10-week community-based PR program, COPD Wellness, with and without Health Advocates (HA), who assist with unmet social needs in patients with COPD receiving care within a safety-net health care setting. In this single-center feasibility study (September 2017 to January 2020), participants with moderate-to-severe COPD were randomized to COPD Wellness alone or with HA support. The program included 10 weekly supervised 90-min sessions. Feasibility outcomes included recruitment rates, attendance, and adherence (≥6 sessions). Clinical outcomes included COPD Assessment Test (CAT) scores, 6-min walk distance (6MWD), depressive symptoms (PHQ-8), and exacerbation, analyzed using paired -tests for within-group comparisons and independent -tests for exploratory between-group analyses. In total, 39 participants were enrolled (61% acceptance rate), with 19 randomized to COPD Wellness alone and 20 to COPD Wellness with HA. Median session attendance was higher in the HA group (6 vs 4 sessions), with greater adherence (53% vs 37%). CAT scores improved significantly overall (mean improvement 3.2, = .01), with greater improvements among participants in the HA group (5.6-point reduction, = .01). No significant changes were observed in the 6MWD, D-12 score, PH-8, or exacerbation rates. No adverse events were reported. The COPD Wellness program demonstrated feasibility, safety, and acceptability within a safety-net health care setting. The integration of HA addressed key social barriers, improving adherence and leading to greater improvements in COPD symptom burden compared with the COPD Wellness program alone. Future studies should explore scaling this model and assessing its long-term benefits in resource-limited environments.

The role of noninvasive ventilation (NIV) and heated humidified high-flow nasal cannula (HFNC) in children with high risk for extubation failure is not established. The objective of our study was to compare the re-intubation rate within 48 h of extubation in high-risk children while receiving HFNC or NIV. This open-label, parallel, noninferiority randomized trial was conducted on high-risk cases in a 12-bed quaternary-level pediatric ICU. All patients aged 1 month to 18 years receiving invasive mechanical ventilation through an endotracheal tube for >48 h were screened for eligibility. Criteria for high-risk patients for extubation, spontaneous breathing trial, extubation readiness, and re-intubation were defined a priori. Subjects were randomized immediately prior to extubation to receive NIV or HFNC. F, NIV settings, and flow setting for HFNC were selected according to a predefined algorithm. All subjects were monitored for hemodynamic instability and increased work of breathing, and the target S was 92%. Intention-to-treat analysis was done with 142 subjects in each group. At baseline, both groups were comparable for severity of disease and organ dysfunction. Re-intubation was required in 15 (10.5%) cases in the NIV and 17 (11.9%) of the HFNC group, with no absolute difference ( = .74). The dosage of dexmedetomidine was significantly lower in the HFNC as compared with the NIV group [(0.85 ± 0.22 versus 1.02 ± 0.13 µg/kg/h; 95% CI 0.12-0.21, < .001)]. Median (interquartile range) postextubation PICU stay was significantly shorter in HFNC subjects [3 (2-4.75) vs 4 (3-5)] days ( = .02). HFNC was noninferior to NIV as respiratory support in high-risk children after extubation.