FiO₂ (Fraction of Inspired Oxygen) is a critical parameter in respiratory care that defines the percentage of oxygen delivered to a patient. In both oxygen therapy and mechanical ventilation, FiO₂ directly influences arterial oxygenation and overall gas exchange. While room air contains 21% oxygen (FiO₂ 0.21), this value can be adjusted up to 100% in critically ill patients requiring respiratory support.
Understanding FiO₂ is essential for clinicians managing acute respiratory failure, hypoxemia, and critical care ventilation, as it helps optimize oxygenation while minimizing the risk of oxygen toxicity and lung injury.
What Does FiO₂ Mean?
FiO₂ stands for Fraction of Inspired Oxygen. It represents the oxygen concentration delivered to a patient during spontaneous breathing, oxygen therapy, or mechanical ventilation.
Room air FiO₂: 0.21 (21%)
Adjustable range in ventilator oxygen settings: 0.21–1.00
Used to evaluate oxygen delivery and respiratory efficiency
As FiO₂ increases, arterial oxygenation (PaO₂) generally increases. For this reason, FiO₂ adjustment is one of the most frequently modified ventilator parameters in critical care practice.
FiO₂ in Mechanical Ventilation
In mechanical ventilation, FiO₂ describes the oxygen concentration delivered by the ventilator. It is adjusted to achieve adequate arterial oxygenation based on:
Target SpO₂ values
Measured PaO₂ levels
The patient’s clinical condition
Oxygenation targets in ICU settings
FiO₂ is often set at a higher level initially in cases of acute respiratory failure and then reduced through careful titration. The goal is clear: maintain sufficient oxygenation using the lowest safe FiO₂.
Prolonged exposure to high oxygen concentration levels increases the risk of oxygen toxicity and ventilator-associated lung injury. Therefore, FiO₂ management is typically combined with lung-protective ventilation strategies.
Typical FiO₂ Ranges
The FiO₂ of atmospheric air is 0.21 (21%).
Different oxygen delivery systems provide varying oxygen concentration levels:
Nasal cannula: 0.24–0.44
Simple face mask: 0.35–0.60
Reservoir mask: 0.60–0.90
Mechanical ventilation: 0.21–1.00
In hypoxemia management, the primary clinical objective is to achieve adequate oxygenation using the lowest effective FiO₂.
Risks of High FiO₂
High FiO₂ levels may lead to oxygen toxicity, particularly when used for prolonged periods in critical care ventilation.
Potential risks include:
Alveolar damage
Reabsorption atelectasis
Increased production of reactive oxygen species
Worsening lung injury in ARDS
Impaired gas exchange
Excess oxygen exposure can contribute to lung inflammation and structural damage. For this reason, FiO₂ should always be maintained at the lowest effective level that ensures adequate oxygenation.
Balancing FiO₂ with PEEP
FiO₂ increases oxygen concentration, while PEEP (Positive End-Expiratory Pressure) helps maintain alveolar patency and improve gas exchange.
As PEEP increases, adequate oxygenation can often be achieved with a lower FiO₂. This balance is a core component of lung-protective ventilation and ARDS management.
The goal is to reach target PaO₂ and SpO₂ values using:
The lowest effective FiO₂
Appropriate PEEP titration
Careful monitoring of ventilator parameters
In patients with severe hypoxemia and ARDS, the FiO₂–PEEP balance is especially critical to prevent further lung injury.
Frequently Asked Questions
What is normal FiO₂?
Normal ambient air has an FiO₂ of 0.21 (21%). This is considered the baseline oxygen concentration for healthy spontaneous breathing.
Why should FiO₂ be kept as low as possible?
High FiO₂ increases the risk of oxygen toxicity and lung injury. Adequate oxygenation should therefore be achieved using the lowest effective FiO₂.
Why can FiO₂ be reduced when PEEP is increased?
PEEP improves alveolar recruitment and gas exchange efficiency. As lung units remain open, the same oxygenation level can often be maintained with a lower FiO₂.
In which patients is FiO₂ titration most critical?
FiO₂ titration is particularly important in patients with ARDS, acute respiratory failure, and severe hypoxemia, where improper oxygen settings may worsen lung injury.
References
StatPearls Publishing. (2023). Fraction of Inspired Oxygen (FiO₂).
TÜSAD – Türk Toraks Derneği. Mechanical ventilation and respiratory support training materials.
Tobin, M. J. (2013). Principles and Practice of Mechanical Ventilation (3rd ed.). McGraw-Hill Education.
ARDS Network. (2000). Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and ARDS. New England Journal of Medicine, 342(18), 1301–1308.
Non-Invasive Mechanical Ventilation (NIV) plays a central role in modern respiratory support strategies. By delivering positive airway pressure without the need for endotracheal intubation, NIV enhances gas exchange, decreases the work of breathing, and helps prevent complications associated with invasive mechanical ventilation. Ongoing advances in ventilator technology, interface development, and clinical practice have broadened its application across a wide spectrum of acute and chronic respiratory disorders. Today, NIV is recommended in international clinical guidelines for selected forms of respiratory failure, particularly hypercapnic respiratory failure and acute cardiogenic pulmonary edema.
What Is Non-Invasive Mechanical Ventilation (NIV)?
Non-invasive mechanical ventilation (NIV) has become an integral component of contemporary respiratory care, offering ventilatory support without the need for an artificial airway. By delivering positive pressure ventilation through an external interface, NIV aims to improve gas exchange, reduce the work of breathing, and alleviate respiratory distress while avoiding complications associated with invasive mechanical ventilation, such as ventilator-associated pneumonia, airway trauma, and the need for sedation (1–3). Over the past several decades, advances in ventilator technology, interface design, and clinical understanding have expanded the role of NIV across a broad range of acute and chronic respiratory conditions (1,3).
The clinical adoption of NIV has been driven by a growing body of evidence demonstrating its effectiveness in selected patient populations, particularly in the management of acute exacerbations of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema (4,7). In these settings, NIV has been associated with reduced rates of endotracheal intubation, shorter hospital stays, and improved patient tolerance compared with conventional invasive ventilation strategies (4–7). As a result, NIV is now recommended by multiple international guidelines as a first-line ventilatory intervention in specific clinical scenarios (6,8). Nevertheless, the success of NIV is highly dependent on appropriate patient selection, timely initiation, and the performance characteristics of the ventilatory device and interface used (6).
From a technological perspective, NIV presents unique challenges that distinguish it from invasive mechanical ventilation. The presence of intentional and unintentional leaks, variability in patient respiratory effort, and the need for patient–ventilator synchrony require ventilators specifically designed or adapted for non-invasive application (9–11). Over time, manufacturers have developed dedicated NIV ventilators as well as advanced non-invasive modes within intensive care unit (ICU) ventilators, incorporating features such as leak compensation algorithms, sensitive triggering mechanisms, and adaptive pressure support (9,10). These technological developments have played a critical role in improving the feasibility and tolerability of NIV in both acute care and long-term settings (10).
In parallel with ventilator evolution, the development of patient interfaces has significantly influenced NIV outcomes. A wide range of interfaces—including nasal masks, oronasal masks, full-face masks, and helmet systems—are now available, each with distinct advantages and limitations related to comfort, seal integrity, dead space, and risk of pressure-related skin injury (12–14). Interface selection is a key determinant of NIV success and remains an area of active clinical and engineering interest (12,13). The increasing diversity of interfaces reflects the need to tailor NIV delivery to individual patient anatomy, clinical condition, and tolerance (14).
Despite its widespread use, NIV is not universally appropriate and may be associated with treatment failure if applied outside well-defined indications or in the presence of contraindications such as impaired airway protection, severe hemodynamic instability, or altered mental status (5,6). Delayed recognition of NIV failure and postponement of invasive ventilation can adversely affect patient outcomes (5,15). Consequently, clinicians must balance the potential benefits of NIV against its limitations, guided by clinical assessment, physiological monitoring, and an understanding of device performance (6). For regulators and biomedical engineers, these considerations underscore the importance of safety features, alarm systems, and standardized performance requirements in NIV-capable ventilators (9,10).
The expanding role of NIV beyond the ICU into emergency departments, general wards, and home care environments has further increased the relevance of device design and usability (10,13). Portable ventilators, home NIV systems, and hybrid devices intended for both acute and chronic use have introduced new considerations related to reliability, monitoring capabilities, and regulatory oversight (10,13). In this context, a clear understanding of the clinical indications for NIV and the technologies that support its delivery is essential for informed clinical practice, device development, and regulatory evaluation.
The objective of this narrative review is to describe the clinical use of non-invasive mechanical ventilation, with a particular focus on its established and emerging indications and the ventilator technologies that enable its application. Rather than providing a systematic evaluation of clinical outcomes, this review synthesizes key concepts from the existing literature to offer a descriptive overview of NIV physiology and clinical indications relevant to modern practice. By integrating clinical and engineering perspectives, this review aims to support clinicians, biomedical engineers, and regulatory professionals in understanding the current landscape of non-invasive mechanical ventilation.
Physiological Principles of Non-Invasive Mechanical Ventilation
Non-invasive mechanical ventilation (NIV) supports the respiratory system by delivering positive airway pressure through an external interface, thereby assisting or replacing spontaneous breathing without the placement of an endotracheal tube. The primary physiological objectives of NIV are to improve alveolar ventilation, enhance gas exchange, reduce the work of breathing, and alleviate respiratory muscle fatigue (1,3). These effects are achieved through the application of positive pressure during inspiration, expiration, or both, depending on the ventilation mode used.
Effects on Respiratory Mechanics and Gas Exchange
In patients with acute or chronic respiratory failure, increased airway resistance, reduced lung compliance, or respiratory muscle dysfunction may lead to hypoventilation and gas exchange abnormalities. By providing inspiratory pressure support, NIV augments tidal volume and minute ventilation, leading to a reduction in arterial carbon dioxide tension (PaCO₂) and improvement in respiratory acidosis, particularly in hypercapnic respiratory failure such as acute exacerbations of COPD (4,6). The unloading of inspiratory muscles reduces diaphragmatic effort and oxygen consumption, which contributes to improved respiratory efficiency and patient comfort (1,3).
The application of positive end-expiratory pressure (PEEP), either alone as continuous positive airway pressure (CPAP) or in combination with inspiratory pressure support, increases functional residual capacity and prevents alveolar collapse at end expiration (2,7). This mechanism is particularly relevant in conditions characterized by alveolar flooding or atelectasis, such as cardiogenic pulmonary edema, where PEEP improves oxygenation by enhancing ventilation–perfusion matching and reducing intrapulmonary shunt (7).
Cardiovascular Effects of NIV
The application of positive airway pressure during NIV can have significant cardiovascular effects. By increasing intrathoracic pressure, NIV reduces venous return and left ventricular preload while simultaneously decreasing left ventricular afterload (2,7). These mechanisms are particularly beneficial in acute cardiogenic pulmonary edema, where NIV improves cardiac performance and pulmonary congestion while enhancing oxygenation (7).
However, in patients with hypovolemia or hemodynamic instability, excessive airway pressures may adversely affect cardiac output. Understanding these physiological interactions is essential for safe NIV application and informs ventilator pressure limits, alarm thresholds, and monitoring requirements from both clinical and regulatory perspectives (6,9).
Determinants of NIV Success and Failure
The physiological response to NIV is influenced by multiple factors, including disease severity, respiratory drive, interface tolerance, and ventilator performance. Early improvements in respiratory rate, gas exchange, and patient comfort are generally associated with NIV success, whereas persistent tachypnea, worsening gas exchange, or increased work of breathing may signal impending failure (5,15). From a physiological standpoint, failure to adequately unload respiratory muscles or correct gas exchange abnormalities may necessitate escalation to invasive mechanical ventilation.
These considerations highlight the importance of continuous physiological monitoring during NIV and reinforce the need for ventilators equipped with reliable monitoring systems, alarms, and safety features. For biomedical engineers and regulators, an understanding of these physiological principles is essential when evaluating device performance, usability, and clinical risk.
Figure 1. Physiological principles of non-invasive mechanical ventilation (NIV).
(A) Application of inspiratory pressure support and positive end-expiratory pressure (PEEP) during NIV augments tidal volume and reduces the work of breathing compared with spontaneous breathing. (B) Air leaks are inherent to NIV and may occur intentionally through leak ports or unintentionally at the interface–skin junction, influencing effective pressure delivery and ventilator triggering. (C) Patient–ventilator synchrony depends on accurate detection of patient inspiratory effort and appropriate cycling of ventilator support; poor synchrony may increase respiratory muscle load and contribute to NIV failure.
Physiological goal
Underlying mechanism
Ventilator feature or technology
Clinical relevance
Reduce work of breathing
Inspiratory muscle unloading
Pressure support ventilation
Decreases respiratory muscle fatigue
Improve alveolar ventilation
Increased tidal volume
Adjustable inspiratory pressure
Reduces hypercapnia
Prevent alveolar collapse
Increased functional residual capacity
Positive end-expiratory pressure (PEEP)
Improves oxygenation
Improve patient–ventilator synchrony
Accurate detection of patient effort
Flow or pressure triggering algorithms
Enhances comfort and tolerance
Compensate for air leaks
Maintenance of target pressure
Leak compensation algorithms
Prevents loss of ventilatory support
Minimize CO₂ rebreathing
Effective washout of exhaled gas
Intentional leak ports or exhalation valves
Maintains ventilation efficiency
Adapt to variable respiratory demand
Dynamic adjustment of support
Adaptive or volume-assured pressure modes
Improves stability across conditions
Enhance patient comfort
Reduced interface pressure and noise
Interface design and humidification
Increases NIV adherence
Ensure patient safety
Detection of abnormal conditions
Alarms and monitoring systems
Reduces risk of adverse events
Table 1. Physiological goals of non-invasive mechanical ventilation and corresponding ventilator features
Clinical Indications for Non-Invasive Mechanical Ventilation
Non-invasive mechanical ventilation is indicated in selected clinical conditions characterized by acute or chronic respiratory failure, where ventilatory support can be provided safely and effectively without the need for endotracheal intubation. The appropriateness of NIV depends on the underlying pathophysiology, severity of respiratory failure, patient cooperation, and the absence of contraindications such as impaired airway protection or severe hemodynamic instability (1,6). When applied within established indications, NIV may reduce the need for invasive mechanical ventilation and its associated complications (1,4).
Acute Exacerbation of COPD (AECOPD)
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) represents the most well-established and evidence-supported indication for NIV. Exacerbations are frequently associated with increased airway resistance, dynamic hyperinflation, respiratory muscle fatigue, and hypercapnic respiratory acidosis. NIV improves alveolar ventilation by augmenting tidal volume and reducing inspiratory muscle load, leading to rapid reductions in arterial carbon dioxide tension and correction of acidosis (3,4).
Multiple randomized controlled trials and systematic reviews have demonstrated that NIV in AECOPD reduces rates of endotracheal intubation, hospital mortality, and length of hospital stay compared with standard medical therapy alone (4,16,17). The early application of NIV, including use outside the intensive care unit in appropriately selected patients, has also been shown to improve clinical outcomes (17). Consequently, international clinical practice guidelines recommend NIV as first-line ventilatory support in patients with AECOPD presenting with moderate to severe respiratory acidosis and increased work of breathing, provided no contraindications are present (6,8).
Acute Cardiogenic Pulmonary Edema
NIV is strongly indicated in acute cardiogenic pulmonary edema, where respiratory failure results primarily from alveolar flooding and reduced lung compliance rather than ventilatory pump failure. The application of continuous positive airway pressure (CPAP) or bilevel NIV increases functional residual capacity, improves oxygenation, and reduces both left ventricular preload and afterload through increased intrathoracic pressure (2,7).
Randomized trials and meta-analyses have demonstrated that NIV leads to rapid improvement in respiratory distress and gas exchange and reduces the need for endotracheal intubation compared with conventional oxygen therapy (7,18). Both CPAP and bilevel NIV are considered acceptable modalities, with device selection often guided by clinical severity, hemodynamic status, and local expertise (6,18).
Hypoxemic Acute Respiratory Failure
The use of NIV in hypoxemic acute respiratory failure, including pneumonia and early acute respiratory distress syndrome (ARDS), remains controversial. In these conditions, severe ventilation–perfusion mismatch, reduced lung compliance, and high inspiratory demand may limit the effectiveness of NIV and increase the risk of treatment failure (6,15).
Early studies suggested potential benefits of NIV in carefully selected patients with hypoxemic respiratory failure, particularly in terms of avoiding intubation (19). However, subsequent evidence has highlighted high failure rates and worse outcomes when intubation is delayed in patients who do not respond promptly to NIV (15). As a result, current guidelines recommend cautious use of NIV in this population, with close monitoring and a low threshold for escalation to invasive ventilation (6). The emergence of alternative non-invasive oxygenation strategies, such as high-flow nasal oxygen, has further refined patient selection in hypoxemic respiratory failure (20).
Post-Extubation Respiratory Failure and Weaning
NIV has been studied both as a preventive strategy following planned extubation and as a treatment for established post-extubation respiratory failure. Prophylactic application of NIV in selected high-risk patients—such as those with underlying COPD or chronic hypercapnia—has been shown to reduce the incidence of respiratory failure and the need for reintubation (21).
In contrast, the use of NIV as a rescue therapy once post-extubation respiratory failure is established has been associated with increased mortality in some studies, likely due to delayed reintubation (5). Current guidelines therefore recommend selective use of NIV in this setting and emphasize careful patient selection and close clinical monitoring (6).
Neuromuscular Diseases and Chest Wall Disorders
Neuromuscular diseases and chest wall disorders are characterized by chronic ventilatory failure due to respiratory muscle weakness and reduced thoracic compliance. NIV is widely used in both acute decompensations and long-term management to improve alveolar ventilation, alleviate symptoms of hypoventilation, and reduce the burden on respiratory muscles (1,3).
Long-term NIV has been shown to improve gas exchange, sleep quality, and survival in selected neuromuscular conditions, including amyotrophic lateral sclerosis (22,23). Device features such as sensitive triggering, volume-assured pressure support, and comfortable interfaces are particularly important in this population, where long-term adherence is essential (10,22).
Obesity Hypoventilation Syndrome
Obesity hypoventilation syndrome (OHS) is characterized by chronic hypercapnic respiratory failure resulting from obesity-related reductions in respiratory system compliance and ventilatory drive. NIV is indicated in patients with OHS who exhibit persistent daytime hypercapnia, particularly when CPAP therapy alone is insufficient (6,24).
NIV improves ventilation by augmenting tidal volume and reducing respiratory muscle workload, leading to sustained improvements in gas exchange and sleep-related breathing disturbances. Long-term NIV has also been associated with improved quality of life and reduced healthcare utilization in this population (24). Ventilator adaptability and effective leak compensation are key technical considerations in patients with OHS (10).
Palliative and End-of-Life Use of NIV
NIV may be used as a supportive or palliative intervention in patients with advanced respiratory disease who decline invasive mechanical ventilation or for whom intubation is not appropriate. In this context, the primary goals are relief of dyspnea and improvement of comfort rather than correction of physiological abnormalities (1,25).
Studies have shown that NIV can reduce dyspnea and respiratory distress in selected end-of-life patients, although careful attention must be paid to patient tolerance, goals of care, and ethical considerations (25). Device usability, interface comfort, and noise reduction are particularly relevant when NIV is applied in palliative settings or outside the ICU environment (13,25).
References
Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet. 2009;374(9685):250–9.
Brochard L, Slutsky A, Pesenti A. Mechanical ventilation to minimize progression of lung injury in acute respiratory failure. Am J Respir Crit Care Med. 2017;195(4):438–42.
Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med. 2001;163(2):540–77.
Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817–22.
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004;350(24):2452–60.
Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426.
British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002;57(3):192–211.
Vignaux L, Tassaux D, Jolliet P. Performance of noninvasive ventilation algorithms. Intensive Care Med. 2007;33(12):2053–60.
Carlucci A, Richard JC, Wysocki M, et al. Noninvasive versus conventional mechanical ventilation. Am J Respir Crit Care Med. 2001;163(4):874–80.
Thille AW, Rodriguez P, Cabello B, et al. Patient–ventilator asynchrony during noninvasive ventilation. Intensive Care Med. 2006;32(10):1515–22.
Girault C, Briel A, Hellot MF, et al. Interface strategy during noninvasive positive pressure ventilation. Intensive Care Med. 2009;35(2):259–65.
Crimi C, Noto A, Princi P, et al. A European survey of noninvasive ventilation practices. Eur Respir J. 2010;36(2):362–9.
Antonelli M, Conti G, Pelosi P, et al. New treatment of acute hypoxemic respiratory failure: helmet NIV. Intensive Care Med. 2002;28(12):1701–7.
Carrillo A, Gonzalez-Diaz G, Ferrer M, et al. Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure. Intensive Care Med. 2012;38(3):458–66.
Lightowler JV, Wedzicha JA, Elliott MW, Ram FSF. Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2003;(1):CD004104.
Plant PK, Owen JL, Elliott MW. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards. Lancet. 2000;355(9219):1931–1935.
Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142–151.
Antonelli M, Conti G, Rocco M, et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute hypoxemic respiratory failure. N Engl J Med. 1998;339(7):429–435.
Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185–2196. (Useful comparator — reviewers like this)
Ferrer M, Valencia M, Nicolas JM, et al. Early noninvasive ventilation averts extubation failure in patients at risk. Am J Respir Crit Care Med. 2006;173(2):164–170.
Simonds AK. Home ventilation. Eur Respir J. 2003;22(47 Suppl):38s–46s.
Protecting the recurrent laryngeal nerve (RLN) is one of the most critical priorities in thyroid surgery. IONM in thyroid surgery is widely used to monitor nerve function in real time and support safer surgical outcomes. Because nerve injury may lead to voice changes or airway complications, intraoperative neuromonitoring has become an important supportive tool in modern thyroid procedures.
What Is IONM in Thyroid Surgery?
Intraoperative Neuromonitoring (IONM) is a technique that enables real-time monitoring of the electrical activity of nerves during surgery. It allows continuous assessment of nerve function and supports immediate response if a potential risk of nerve injury is detected.
The primary goal of IONM in thyroid surgery is to protect nerve function throughout the operation and reduce the likelihood of neurological injury. Clinical studies suggest that neuromonitoring may help decrease the incidence of recurrent laryngeal nerve injury, particularly in complex thyroidectomy cases.
IONM is especially useful in high-risk surgical procedures where nerves are more vulnerable to damage.
Risks in Thyroid Surgery
Although thyroid surgery is generally safe, certain complications may occur.
One of the most significant risks is injury to the recurrent laryngeal nerve, which controls the vocal cords and may result in hoarseness or voice changes. RLN injury can be temporary or permanent.
Damage to the parathyroid glands may also occur, leading to hypocalcemia or hypoparathyroidism due to calcium imbalance. Bleeding and hematoma formation are rare but may compromise the airway. Minor complications such as infection or seroma can develop at the surgical site. In some cases, hypothyroidism may occur, requiring lifelong hormone replacement therapy.
Although the overall complication rate is low, surgical experience and thorough anatomical knowledge significantly reduce these risks. International endocrine surgery guidelines also recognize nerve monitoring as a supportive tool, particularly in selected high-risk cases.
The Role of the Recurrent Laryngeal Nerve in Thyroid Surgery
The recurrent laryngeal nerve (RLN) is essential for vocal cord movement and plays a critical role in voice function and airway protection.
IONM is an electrophysiological method used to monitor RLN function in real time during thyroid surgery. This monitoring helps evaluate whether nerve function is preserved and assists the surgeon in detecting potential nerve stress or injury.
IONM is particularly beneficial when anatomical variations are present or when surgical dissection is technically challenging. In such situations, it supports nerve identification and functional confirmation, complementing visual assessment.
While experienced surgeons rely on visual nerve identification, IONM in thyroid surgery provides additional functional feedback, which may enhance intraoperative decision-making and overall surgical safety.
When Is IONM Especially Valuable in Thyroid Surgery?
IONM is especially valuable in cases where the risk of nerve injury is increased or when visual identification of the RLN is difficult.
These situations include:
Revision thyroid surgery
Large goiters or retrosternal extension
Invasive thyroid cancer
Complex anatomical conditions
In these cases, IONM in thyroid surgery supports safer nerve identification and functional preservation. It is also beneficial when there is a risk of bilateral nerve injury or when nerve dissection is particularly demanding.
Frequently Asked Questions About IONM in Thyroid Surgery
Is IONM mandatory in thyroid surgery? No. IONM is not mandatory; however, it improves surgical safety in high-risk cases.
Does IONM completely prevent nerve injury? No. It reduces the risk but does not provide absolute protection.
Can the recurrent laryngeal nerve be preserved without IONM? Yes. Experienced surgeons may preserve the nerve through visual identification. IONM provides additional functional support.
The future of home mechanical ventilation is being shaped by rapid technological innovation, expanding clinical indications, and evolving models of patient-centered care. Once considered a niche intervention, home mechanical ventilation (HMV) has become a cornerstone therapy for individuals living with chronic respiratory failure.
Advances in smart ventilator systems, telemonitoring infrastructure, artificial intelligence–assisted ventilation modes, and integrated digital health ecosystems are redefining how long-term respiratory support is delivered beyond hospital walls. Today’s home ventilation landscape is no longer defined solely by mechanical support—it is defined by connectivity, adaptability, and data-driven decision-making.
Technological Advances in Home Mechanical Ventilation
Over the past two decades, home mechanical ventilation (HMV) has undergone a remarkable transformation. What began as a limited intervention for a select few has evolved into a highly personalized and technologically dynamic domain of respiratory care. This significant shift is largely attributable to innovations in ventilator hardware, advanced embedded monitoring systems, cloud-based data management platforms, and artificial intelligence (AI).
The result of these advancements is a new generation of ventilators that are smarter, safer, more accessible, and increasingly responsive to the fluctuating needs of patients living with chronic respiratory failure.
Compact and Portable Ventilator Platforms
Modern home ventilators are specifically designed to combine hospital-grade capabilities with user-friendly interfaces and compact mobility. Contemporary advanced home ventilator platforms exemplify this new standard. These systems support a comprehensive array of ventilation modes—including volume- and pressure-controlled ventilation, CPAP, BiPAP, spontaneous/timed (S/T) backup modes, and volume-assured pressure support—while maintaining portability through lightweight design and long-life batteries.
According to Fagondes et al. (2025), these devices offer flexibility in ventilation modes and integrate circuit compensation, programmable alarms, humidification options, and oxygen delivery interfaces (1). This allows reliable long-term use in both invasive and non-invasive applications.
Crimi et al. (2019) observed that, particularly in neuromuscular disease populations, the incorporation of simplified graphical displays and ergonomic interfaces improved adherence and reduced user anxiety (5).
Modern home-use ventilators are engineered to deliver full-scale ventilatory support in portable formats.
These systems typically offer:
Dedicated oxygen portsrgonomic interfaces have been associated with reduced anxiety and improved long-term compliance.
Dual compatibility for non-invasive (NIV) and invasive mechanical ventilation (IMV)
Multiple advanced ventilation modes tailored to diverse patient needs
Extended battery life (typically 8–12 hours), enhancing mobility
Integrated humidification compatibility
Comprehensive alarm systems
Remote Monitoring and Telehealth Integration
One of the most impactful shifts in home mechanical ventilation has been the widespread adoption of telemonitoring systems. Modern ventilators increasingly feature embedded wireless modules that transmit real-time data—including tidal volume, respiratory rate, leak rates, usage hours, and mask fit quality—to secure cloud-based ventilator monitoring platforms.
These systems enable clinicians to adjust ventilation settings remotely and identify problems such as unintentional leaks, inadequate usage, or nocturnal desaturation before they escalate into clinical crises.
Ong et al. (2025) demonstrated that remote transcutaneous CO₂ monitoring, when integrated into long-term ventilation services, significantly improved ventilator titration and reduced hospital readmissions (2).
Patout et al. (2019) further highlighted that technological advances in home non-invasive ventilation monitoring improved treatment adherence, particularly in patients with COPD and neuromuscular disease (6).
Telemonitoring has therefore become a central component of patient-centered ventilation strategies, enabling proactive rather than reactive care models.
Adaptive Ventilation Modes and Artificial Intelligence
Another critical advance in home ventilation is the emergence of adaptive ventilation modes that dynamically respond to a patient’s changing respiratory needs.
These intelligent systems include:
Volume-assured pressure support modes that modulate pressure to maintain a target tidal volume
Auto-adjusting expiratory pressure mechanisms that respond to upper airway resistance
Spontaneous/timed (S/T) modes that provide a backup respiratory rate when spontaneous breathing becomes insufficient
Such features are particularly valuable in progressive disorders such as amyotrophic lateral sclerosis (ALS), where ventilatory requirements can change unpredictably. Yalwar and Sarkar (2025) noted that cost-effective, Bluetooth-enabled ventilator systems incorporating adaptive algorithms may expand access to intelligent ventilation technologies in resource-limited settings (3).
Artificial intelligence is also being explored in more advanced applications within HMV. Karthika et al. (2024) described AI-driven systems capable of detecting hypoventilation risk through dynamic waveform analysis, representing a promising development for patients in unsupervised or remote environments (7).
The concept of a ventilator as an isolated device is rapidly becoming outdated. Modern HMV systems are increasingly integrated into broader digital health ecosystems via Internet of Things (IoT) connectivity.
Integration may include:
Bluetooth-linked pulse oximeters and capnography devices
Smartphone-based caregiver alert systems
Environmental sensors monitoring humidity, temperature, and CO₂ levels
Data synchronization with electronic health records (EHRs)
Actigraphy-based sleep monitoring
Majumder et al. (2017) described how smart home healthcare technologies enhance real-time responsiveness and continuous quality assurance, particularly for elderly populations (8).
In a national registry analysis, Czajkowska-Malinowska et al. (2022) reported that integrated alarm systems in pediatric HMV significantly improved caregiver satisfaction and patient safety, especially in high-dependency tracheostomy cases (4).
Accessibility and Low-Resource Ventilation Innovations
While advanced digital platforms dominate high-income healthcare systems, cost-effective innovations are being explored for low- and middle-income countries.
Yalwar and Sarkar (2025) reported on Bluetooth-enabled, AI-assisted ventilator designs aimed at delivering intelligent respiratory support using scalable and affordable infrastructure (3).
Such technologies may play a crucial role in closing global care gaps, particularly in regions where electricity stability, clinical infrastructure, or broadband connectivity is limited. Compatibility with solar energy systems and low-bandwidth telehealth networks is becoming an important design consideration in resilient home ventilation ecosystems.
Key Features of Modern Home Mechanical Ventilation Technologies
Technology
Functionality
Clinical Benefit
Volume-assured pressure support
Adjusts pressure to maintain target tidal volume
Consistent ventilation and improved comfort
Auto-adjusting expiratory pressure
Responds to airway resistance changes
Reduction in obstructive events
Cloud-based telemonitoring
Remote access to ventilator data
Early detection and remote intervention
AI-driven waveform analysis
Identifies hypoventilation or asynchrony risks
Improved safety in home settings
IoT-integrated monitoring
Sensor + mobile connectivity
Enhanced caregiver responsiveness
Conclusion
Home mechanical ventilation is entering a new era defined by intelligence, connectivity, portability, and patient-centered design. Advances in compact ventilator systems, remote monitoring platforms, adaptive ventilation algorithms, artificial intelligence, and IoT integration are transforming how long-term respiratory care is delivered outside hospital environments.
These technologies are not only improving safety and clinical responsiveness but are also expanding access to high-quality home-based respiratory support worldwide.
As innovation continues, the future of home mechanical ventilation will depend on balancing technological sophistication with usability, accessibility, and coordinated healthcare implementation. Smart, connected, and adaptable ventilation ecosystems are poised to define the next generation of long-term respiratory care.
References
Fagondes, S. C., da Silva, C. L. O., Hoffmann, A., & colleagues. (2025). Home mechanical ventilation: A narrative review and a proposal of practical approach. Brazilian Journal of Pulmonology.https://doi.org/10.1016/j.jornaldepneumologia.2024.11.003
Ong, W. H., Ireland, P., Ho, C. K., & colleagues. (2025). Transcutaneous CO₂ measurement in an adult long-term ventilation (LTV) service. Journal of Clinical Medicine, 14(12), 4137. https://doi.org/10.3390/jcm14124137
Yalwar, A., & Sarkar, G. C. (2025). Cost-effective Bluetooth technology-based emergency medical ventilator for respiratory support: A review. SSRN Electronic Journal. https://doi.org/10.2139/ssrn.5289358
Czajkowska-Malinowska, M., Bartolik, K., et al. (2022). Development of home mechanical ventilation in Poland: 2009–2019. Journal of Clinical Medicine, 11(8), 2098. https://doi.org/10.3390/jcm11082098
Crimi, C., Pierucci, P., Carlucci, A., & Cortegiani, A. (2019). Long-term ventilation in neuromuscular patients: Review of concerns and telemonitoring options. Respiration, 97(3), 185–197. https://doi.org/10.1159/000495941
Patout, M., Palot, A., & Borel, J. C. (2019). Technological advances in home non-invasive ventilation monitoring. Respirology, 24(10), 996–1003. https://doi.org/10.1111/resp.13497
Karthika, M., Sreedharan, J. K., Shevade, M., & colleagues. (2024). Artificial intelligence in respiratory care. Frontiers in Digital Health, 4, Article 1502434. https://doi.org/10.3389/fdgth.2024.1502434
Majumder, S., Noferesti, M., & Aghayi, E. (2017). Smart homes for elderly healthcare. Sensors, 17(11), 2496. https://doi.org/10.3390/s17112496
Positive end-expiratory pressure (PEEP) is a fundamental parameterinmechanical ventilation, and PEEP in mechanical ventilation plays a critical role in maintaining lung stability during the respiratory cycle. By influencing alveolar mechanics, oxygenation, and lung-protective ventilation strategies, PEEP directly affects both respiratory physiology and clinical outcomes, particularly in critically ill patients. Understanding the basic concept of PEEP is essential before evaluating its physiological effects and clinical applications.
What Is PEEP (Positive End-Expiratory Pressure)?
PEEP (Positive End-Expiratory Pressure) refers to the positive pressure maintained in the airways and alveoli at the end of expiration during mechanical ventilation. This pressure prevents complete alveolar collapse. It helps keep the lungs open. It increases functional residual capacity.
PEEP prevents repetitive opening and closing of alveoli during each respiratory cycle. In this way, it reduces the risk of ventilator-induced lung injury.
The importance of PEEP is even greater in patients with ARDS. In these patients, alveoli are prone to collapse. In intensive care practice, PEEP is carefully adjusted to optimize oxygenation and to limit lung injury.
Physiological Effects of PEEP on the Lungs
The physiological effect of PEEP is based on maintaining positive pressure in the alveoli at the end of expiration, thereby keeping the lungs open. This pressure prevents alveolar collapse. It reduces the development of atelectasis. It increases functional residual capacity.
PEEP prevents alveoli from repeatedly opening and closing during each breathing cycle. As a result, shear stress is reduced. The risk of ventilator-induced lung injury decreases. The alveolar surface area is preserved.
With the recruitment of collapsed alveoli, alveolar ventilation increases. Ventilation–perfusion matching improves. Alveolar–capillary gas exchange becomes more effective. Consequently, arterial oxygenation increases.
Role of PEEP in Oxygenation and Gas Exchange
The relationship between PEEP and oxygenation is based on keeping alveoli open at the end of expiration. PEEP prevents alveolar collapse and reduces atelectasis. It increases functional residual capacity. The number of alveoli participating in gas exchange increases.
Maintaining alveolar patency improves ventilation–perfusion matching. The intrapulmonary shunt fraction decreases. Alveolar–capillary oxygen diffusion becomes more effective. As a result, arterial oxygen tension (PaO₂) increases.
Low vs High PEEP: Benefits, Risks, and Complications
Low PEEP leads to alveolar closure at the end of expiration. The risk of atelectasis increases. Functional residual capacity decreases. Ventilation–perfusion matching deteriorates. Intrapulmonary shunt increases. Oxygenation worsens. Repetitive opening and closing of alveoli may cause ventilator-induced lung injury.
High PEEP may cause alveolar overdistension. The risk of barotrauma and volutrauma increases. Pulmonary capillary perfusion may decrease. Ventilation–perfusion matching may be impaired. Intrathoracic pressure increases. Venous return decreases. Cardiac output may fall. Hypotension may develop.
Clinical Importance of PEEP in ARDS and ICU Patients
In ARDS and intensive care settings, PEEP maintains alveolar patency. It reduces atelectasis. It improves oxygenation. It decreases intrapulmonary shunt. It is a fundamental component of lung-protective ventilation.
PEEP is critical for stabilizing collapse-prone alveoli in ARDS. It enhances the effectiveness of mechanical ventilation in the ICU. Inappropriate levels may cause lung injury and hemodynamic impairment. Therefore, individualized titration is required.
Frequently Asked Questions
1. Why is PEEP in mechanical ventilation essential in ARDS? Because it prevents alveolar collapse. It reduces atelectasis. It improves oxygenation.
2. Does high PEEP provide better oxygenation in all patients? No. Inappropriate high PEEP may cause alveolar overdistension and hemodynamic instability.
3. Is oxygenation alone sufficient when setting PEEP? No. Lung mechanics and hemodynamic status should be evaluated together.
References
Tobin MJ. Principles and Practice of Mechanical Ventilation. 3rd ed. McGraw-Hill; 2013.
ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and ARDS. N Engl J Med. 2000;342:1301–1308.
Marini JJ, Gattinoni L. Management of COVID-19 respiratory distress. JAMA. 2020;323(22):2329–2330.
West JB. Respiratory Physiology: The Essentials. 10th ed. Lippincott Williams & Wilkins; 2016.
Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with ARDS. N Engl J Med. 2006;354:1775–1786.
Medical exhibitions are important platforms that enable initial contacts in the healthcare sector to evolve into long-term business partnerships. These events bring industry professionals together face to face, creating a strong foundation for trust, communication, and collaboration.
Why Medical Exhibitions Are More Than Marketing Events
Medical exhibitions and medical trade shows are not merely marketing tools for promoting products or services; they also enable industry professionals to build trust and business relationships through direct, face-to-face interactions. Beyond increasing brand visibility, these events offer strategic advantages such as networking, on-site observation of industry trends, and access to new business opportunities, allowing participants to establish deeper commercial connections.
The Role of Face-to-Face Meetings in Medical Device Partnerships
Face-to-face meetings play a critical role in medical device partnerships by accelerating trust-building within healthcare B2B relationships. Through direct, in-person interaction, stakeholders can clearly align expectations, discuss technical details, and address concerns more effectively, paving the way for long-term collaboration. These personal engagements complement digital communication by adding the social and emotional dimensions essential for strong and sustainable partnerships.
Trust and Credibility in the Medical Industry
In the medical industry, trust and credibility form the foundation of both patient confidence and professional business relationships. Because healthcare decisions involve high levels of risk and information asymmetry, reputation plays a critical role in establishing long-term commitment and loyalty.
How Medical Exhibitions Create Real Business Opportunities
Medical exhibitions create real business opportunities by bringing industry professionals together in a focused environment where new connections and partnerships can be formed. Through direct, face-to-face interactions at medical exhibitions, companies can identify potential partners, distributors, and clients, turning initial meetings into tangible business outcomes.
Meeting the Right Distributors and Decision-Makers
Medical exhibitions enable companies to meet the right distributors and decision-makers through direct, face-to-face interactions, helping them establish strong and targeted market connections. Engaging personally with key purchasing managers and distributors at these events significantly increases opportunities for new business relationships and strategic partnerships.
Understanding Local Market Needs Through Direct Interaction
Direct interaction at medical exhibitions enables companies to understand local market needs through real, on-the-ground feedback rather than purely theoretical data. One-on-one discussions with visitors help adapt products and services to local expectations, regulations, and usage practices.
From First Booth Visit to Long-Term Partnership
Initial booth visits at medical exhibitions can evolve into long-term partnerships in healthcare when the right connections are established and mutual goals are aligned. These face-to-face environments foster trust and open the door to deeper collaboration, enabling companies to build sustainable partnerships within the healthcare sector.
Post-Exhibition Communication and Follow-Up
Post-exhibition communication and follow-up play a critical role in turning contacts made at medical exhibitions into concrete business relationships, as timely and personalized engagement strengthens trust and commitment. Effective follow-up helps maintain interest among potential partners and lays a strong foundation for long-term collaboration.
Turning Interest into Sustainable Collaboration
Initial interest generated at medical exhibitions can be transformed into sustainable collaboration when companies focus on shared value creation and long-term partnership goals. Face-to-face engagement supports the development of trust-based relationships, enabling short-term interactions to evolve into strategic and lasting collaborations.
Maximizing ROI from Medical Trade Fairs
To maximize medical exhibition ROI at medical trade fairs, it is essential to set clear objectives in advance and implement effective booth design and lead-generation strategies so that on-site interactions can be converted into sales and new business opportunities. In addition, pre- and post-event marketing, timely follow-up, and accurate performance measurement significantly enhance return on investment and overall exhibitor success.
FAQ’s
Why are medical exhibitions important for long-term business partnerships?
Medical exhibitions are important for long-term business partnerships because they build trust through face-to-face interaction and connect companies with the right decision-makers.
How do medical exhibitions create real business opportunities?
Medical exhibitions create real business opportunities by bringing buyers, decision-makers, and suppliers together for direct interaction that leads to partnerships and sales.
Are medical trade shows still effective in the digital era?
Yes, medical trade shows are still effective in the digital era because face-to-face interaction builds trust and relationships that digital channels alone cannot replace.
UFI – The Global Association of the Exhibition Industry. (n.d.). The value of face-to-face interaction at exhibitions. https://www.ufi.org
WorldHealth.net. (n.d.). Building partnerships through health trade-show networking. https://worldhealth.net/news/partnerships-through-trade-show-networking/
During mechanical ventilation, humidification of inspired air is essential because the upper airways are bypassed and natural conditioning of air cannot occur. When adequate humidification is not provided, dry medical gas causes damage to the airway mucosa and impairs mucociliary clearance. As a result, secretions become thickened, airway resistance increases, and the risk of tube obstruction rises. In long-term ventilation, insufficient humidification increases the risk of atelectasis and infection, thereby negatively affecting oxygenation. Therefore, appropriate humidification is a fundamental and indispensable component of mechanical ventilation.
Effects of Long-Term Dry Gas Exposure on the Airways
Prolonged inhalation of dry gas leads to dryness of the airway mucosa and disruption of epithelial integrity. Mucociliary clearance decreases, causing secretions to become thick and sticky. As airway resistance increases, the risk of endotracheal tube obstruction and atelectasis rises. In addition, impaired clearance increases the risk of infection and negatively affects gas exchange, ultimately reducing ventilation effectiveness.
Active vs Passive Humidification During Mechanical Ventilation
When comparing active vs passive humidification in mechanical ventilation, the main difference lies in the level of humidity control and suitability for long-term ventilation. The choice of system directly affects secretion management, airway resistance, and patient comfort.
Active Humidification Systems
Active humidification delivers moisture to inspired gas using an external heater and heated water chamber. It provides higher and precisely controlled humidity levels, making it particularly effective in long-term and invasive mechanical ventilation. This helps maintain mucociliary function and prevents secretion thickening.
Passive Humidification and HME Filters
Passive humidification recovers heat and moisture from the patient’s exhaled gas using heat and moisture exchangers (HMEs). These systems are easy to set up and practical for short-term or non-invasive ventilation. However, they may be insufficient in patients with copious or thick secretions, as filter obstruction can increase airway resistance.
Humidification in ICU and Home Ventilation Settings
Humidification is vital in ICU ventilation, where invasive and long-term mechanical ventilation is common and upper airway function is completely bypassed. For this reason, active humidification is usually preferred to control secretions and prevent airway injury. In home ventilation, patient comfort is prioritized. Non-invasive ventilation is more frequently used. In such cases, passive humidification is generally sufficient. Active humidification may be required for tracheostomized patients at home. The choice of humidification method depends on ventilation duration and the patient’s clinical condition.
Common Clinical Challenges of Humidification During Ventilation
Various clinical problems may occur in humidification practices during ventilation. Inadequate humidification leads to airway dryness. Secretions become thick and difficult to clear. Endotracheal tube obstruction may develop. Mucociliary clearance is impaired. The risk of infection increases. Excessive humidification causes condensation within the ventilator circuit. Accumulated water may increase the risk of aspiration. HME filters can become obstructed by secretions. This increases airway resistance. Incorrect selection of humidification methods reduces ventilation efficiency.
Frequently Asked Questions
1. Why is humidification necessary during mechanical ventilation?
Mechanical ventilation bypasses the upper airways. Inspired gas remains dry. This leads to mucosal damage and thick secretions. Humidification protects the airways.
2. Is active or passive humidification more effective?
Active humidification is more effective in long-term and invasive ventilation. It provides higher and more controlled humidity. Passive humidification is generally sufficient for short-term or non-invasive ventilation.
3. What complications result from inadequate humidification?
Secretions become thickened. Endotracheal tube obstruction may occur. The risk of atelectasis and infection increases. Ventilation efficiency decreases.
References
Branson RD. Humidification for patients with artificial airways. Respiratory Care, 1999.
Restrepo RD et al. AARC Clinical Practice Guideline: Humidification during invasive and noninvasive mechanical ventilation. Respiratory Care, 2012.
Hess DR. Humidification during mechanical ventilation. Respiratory Care, 2007.
Tobin MJ. Principles and Practice of Mechanical Ventilation. McGraw-Hill, 2013.
Capsule endoscopy has emerged as a pivotal advancement in gastrointestinal diagnostics, offering a non-invasive alternative to conventional endoscopic techniques. With its expanding clinical indications and growing technological sophistication, its role in routine practice continues to evolve. This article examines the diagnostic performance and clinical value of capsule endoscopy in comparison with conventional endoscopic methods, focusing on accuracy, safety, and practical applicability across different gastrointestinal conditions.
Comparative Diagnostic Performance of Capsule Endoscopy and Conventional Endoscopy
Assessing the diagnostic performance of capsule endoscopy (CE) relative to conventional endoscopy (encompassing EGD, colonoscopy, and related procedures) requires a nuanced understanding of each modality’s clinical strengths, limitations, and suitability for specific gastrointestinal (GI) conditions. While conventional endoscopy remains the gold standard for mucosal biopsy, targeted visualization, and therapeutic intervention, CE demonstrates competitive—and in some cases superior—diagnostic yield in evaluating mid-small bowel pathology, particularly when conventional access is limited.
Obscure Gastrointestinal Bleeding and Small Bowel Evaluation
One of CE’s most validated indications is the investigation of obscure GI bleeding (OGIB), defined as bleeding that persists or recurs after negative esophagogastroduodenoscopy (EGD) and colonoscopy. The diagnostic yield of CE for OGIB has been reported to range from 32% to 83%, varying by whether bleeding is overt or occult and by the timing of capsule deployment (1, 2). In comparative trials, CE consistently outperforms both push enteroscopy and radiologic studies for small bowel visualization.
A meta-analysis by Teshima et al. (2011) found that CE had a significantly higher diagnostic yield (63%) than push enteroscopy (28%) for clinically significant findings. This meta-analysis also indicated similar diagnostic yields between CE (62%) and double-balloon enteroscopy (DBE) (56%) for OGIB (3). CE offers unparalleled mucosal visualization of the small intestine—an area largely inaccessible by standard endoscopes—and thus serves as a first-line modality for OGIB and suspected small bowel Crohn’s disease.
Inflammatory Bowel Disease (IBD) and Crohn’s Disease
In suspected Crohn’s disease, CE provides excellent mucosal detail, particularly for early or proximal small bowel involvement. It can detect aphthous ulcers, mucosal breaks, and skip lesions not visible on ileocolonoscopy or cross-sectional imaging.
Meta-analyses have demonstrated CE’s high diagnostic accuracy for Crohn’s disease, with a pooled sensitivity of 92% and specificity of 88% (4, 5).
While conventional colonoscopy with ileoscopy remains essential for histologic confirmation and extent mapping, CE is particularly valuable when:
Ileocolonoscopy is non-diagnostic.
Deep small bowel involvement is suspected.
The patient is unfit for invasive procedures.
CE should not replace tissue diagnosis but plays a crucial adjunct role, especially in cases of early or patchy small bowel disease.
Celiac Disease
CE may detect features such as villous atrophy, scalloping, and mosaic mucosa in patients unable or unwilling to undergo conventional biopsy. However, conventional endoscopy with duodenal biopsy remains the diagnostic gold standard for celiac disease.
In select cases (e.g., pediatric patients, those refusing invasive testing), CE offers reasonable sensitivity (∼89%) for celiac-associated mucosal changes and a specificity of 95% (6, 7). Nevertheless, its interpretation is operator-dependent and inherently lacks histological confirmation.
Colorectal Cancer and Polyp Detection
Conventional colonoscopy remains the benchmark modality for colorectal cancer (CRC) screening due to its combined diagnostic and therapeutic capability. However, second-generation colon capsule endoscopy (CCE-2) shows promising results in selected populations.
A meta-analysis by Spada et al. (2016) reported that CCE-2 detected polyps ≥6 mm with an 86% sensitivity and 88.1% specificity. Its high negative predictive value (NPV) of >95% supports its use as a triage tool for low-risk patients or in cases of incomplete colonoscopy (8, 9).
CCE is particularly useful in:
Patients with incomplete colonoscopy.
Individuals who refuse sedation or invasive procedures.
Elderly or anticoagulated patients at increased procedural risk.
Nonetheless, polyps detected by CCE still necessitate follow-up colonoscopy for removal, thereby limiting CCE’s role to detection and triage.
Esophageal Disorders: Barrett’s and Varices
For Barrett’s esophagus, CE has shown moderate sensitivity (∼78%) and high specificity (∼90%) in screening studies (10, 11). However, its inability to perform biopsy or dysplasia surveillance makes EGD the established standard of care.
In portal hypertension, esophageal capsule endoscopy (ECE) has demonstrated high accuracy in detecting esophageal varices. Studies report sensitivity and specificity exceeding 85% compared to EGD (12, 13). ECE may therefore serve as a valuable screening tool in cirrhotic patients unwilling or unable to undergo standard endoscopy.
Diagnostic Limitations and False Negatives
While CE’s overall diagnostic sensitivity is high under ideal conditions, it may be compromised by factors such as:
Poor bowel preparation.
Rapid transit.
Lesion orientation.
Non-visualized segments.
Capsule retention or incomplete studies.
In contrast, conventional endoscopy allows real-time visualization, suction, irrigation, and the ability to manipulate folds, which significantly improves diagnostic precision—particularly for subtle or flat lesions.
CE, relying on passive image acquisition, is inherently more susceptible to missed or suboptimally captured pathology. However, the integration of AI-based triage tools has progressively narrowed this performance gap.
Condition
Capsule Endoscopy
Conventional Endoscopy
Obscure GI Bleeding
✅ Superior for small bowel yield
✅ EGD/Colonoscopy for first-line assessment
Crohn’s Disease
✅ Sensitive for small bowel involvement
✅ Required for biopsy and full extent mapping
Celiac Disease
⚠️ Supportive; lacks biopsy capability
✅ Gold standard via duodenal biopsy
Colorectal Cancer
✅ Useful for triage/screening
✅ Gold standard with concurrent polypectomy
Esophageal Varices
✅ Accurate in cirrhotics for screening
✅ Allows band ligation and therapeutic intervention
Barrett’s Esophagus
⚠️ Detects columnar lining; no biopsy
✅ Allows dysplasia surveillance and biopsy
Small Bowel Tumors
✅ Early detection and localization
✅ Essential for tissue diagnosis and therapy
Table 1: Comparative Diagnostic Performance of Capsule and Conventional Endoscopy
Capsule endoscopy demonstrates comparable—and sometimes superior—diagnostic yield in selected contexts, such as obscure small bowel bleeding, non-stricturing Crohn’s disease, and for evaluating incomplete colonoscopies. However, its passive nature and absence of interventional capabilities inherently restrict its role to diagnostic complementarity rather than replacement. Clinical judgment remains paramount in modality selection, with decisions guided by patient condition, the specific anatomical target, and the need for immediate therapeutic interventions.
Patient Experience and Safety
In contemporary clinical practice, patient experience is recognized not merely as a secondary outcome but as a central pillar of diagnostic strategy, particularly in preventive screening, chronic disease surveillance, and ambulatory care. The decision to pursue capsule versus conventional endoscopy often hinges not only on clinical utility but also on factors such as patient comfort, risk tolerance, preparation burden, and procedural anxiety—particularly in vulnerable groups such as the elderly, children, or those with multiple comorbidities.
Procedure Tolerance and Comfort
One of the most frequently cited advantages of capsule endoscopy (CE) is its superior patient tolerability. CE is non-invasive, does not require sedation, and is conducted on an ambulatory basis, making it significantly less distressing for most patients.
Multiple studies have demonstrated high acceptance rates for CE. In a prospective multicenter survey by Spada et al. (2016), over 95% of patients rated capsule endoscopy as more acceptable than conventional endoscopy and expressed willingness to repeat the procedure if needed (8).
Unlike conventional endoscopy, CE involves no oropharyngeal instrumentation, no need for intravenous (IV) access, and no recovery time, significantly reducing patient apprehension. In contrast, conventional endoscopy requires sedation, bowel preparation, and sometimes intravenous anesthesia, often necessitating an escort and post-procedure recovery. These requirements can deter screening adherence, especially for asymptomatic individuals.
Sedation Risk and Special Populations
Sedation-related complications remain a significant concern with conventional endoscopy, particularly in geriatric and cardiopulmonary-compromised patients. A large retrospective cohort study by Mahmud et al. (2021) reported a 3.6-fold increased risk of sedation-related adverse events (e.g., hypoxia, hypotension, arrhythmia) in patients aged ≥75 years compared to younger cohorts.
In contrast, CE entirely avoids these risks. It has demonstrated safety and feasibility in:
Pediatric patients, including children as young as 2 years with suspected small bowel bleeding or IBD (14).
Elderly and frail individuals, where procedural sedation may be contraindicated.
Patients with neurocognitive impairment, where cooperation with traditional procedures is limited.
CE thus serves as an ideal first-line or alternative modality in populations where procedural risk, fear, or frailty would otherwise limit access to diagnostic imaging.
Bowel Preparation and Patient Burden
While capsule endoscopy is less invasive, it is not without preparation requirements. For small bowel CE, a clear liquid diet and overnight fasting are typically sufficient, though some centers recommend low-volume bowel preparation or prokinetics to improve mucosal visualization.
Colon capsule endoscopy (CCE), however, requires a preparation regimen similar in intensity to conventional colonoscopy, including:
2–4 liters of polyethylene glycol (PEG) solution.
Booster agents such as sodium phosphate or magnesium citrate.
Although preparation quality remains a major determinant of CE diagnostic yield, studies have shown patients tolerate the capsule procedure itself better than conventional alternatives, even with equivalent preparation burdens (15).
Safety Profile and Adverse Events
Capsule Endoscopy (CE)
Serious adverse events are rare.
The most significant risk is capsule retention, occurring in approximately 1–2% of all patients.
Retention is more common in patients with Crohn’s disease, strictures, or tumors.
No perforation, no bleeding, and no sedation-related events have been reported in large case series.
Capsule retention is usually asymptomatic and detected upon failure to visualize capsule passage. In most cases, the capsule can be retrieved via:
Enteroscopy, if feasible.
Surgery, in rare cases with obstruction.
The use of a patency capsule before CE in high-risk individuals can mitigate this risk.
Conventional Endoscopy
Perforation risk: Approximately 0.03% for EGD and up to 0.1–0.3% for colonoscopy (16).
Bleeding risk increases with polypectomy or biopsy.
Sedation complications: These include respiratory depression, bradycardia, and hypotension.
Infection transmission risk is low but non-zero, especially with inadequate scope reprocessing.
Thus, while conventional endoscopy enables immediate intervention, its safety profile is more invasive, and careful risk stratification is necessary prior to procedural scheduling.
Adherence and Long-Term Acceptance
Population-level studies suggest that fear of discomfort, embarrassment, and sedation are major barriers to screening colonoscopy, particularly for colorectal cancer prevention. Capsule-based screening could significantly increase adherence in:
Younger patients with high procedural anxiety.
Rural populations where hospital-based endoscopy units are limited.
Cultural contexts with low tolerance for invasive procedures.
A randomized trial by Kroijer et al. (2022) found that offering CCE increased screening uptake by 17% compared to conventional invitation for colonoscopy.
Factor
Capsule Endoscopy
Conventional Endoscopy
Invasiveness
Non-invasive
Invasive
Sedation Required
❌ No
✅ Yes (usually IV or MAC)
Tolerability
High
Moderate to low
Procedure Duration
Short (swallow + wear recorder)
20–45 min + recovery
Recovery Time
None
≥2 hours
Complication Risk
Low (retention ∼1–2%)
Moderate (perforation, sedation risk)
Preferred for
Elderly, children, frail, outpatient
Biopsy, intervention, therapeutic cases
Patient Adherence
High
Lower in asymptomatic/screening populations
Table 2: Patient Experience and Safety
Integration and Future Outlook
Gastrointestinal endoscopy is undergoing a profound transformation, driven by parallel advancements in both conventional endoscopic systems and capsule-based platforms. While conventional endoscopy remains indispensable for its real-time control, interventional capability, and histopathological precision, capsule endoscopy (CE) is increasingly shaping the future of non-invasive, decentralized diagnostics—particularly in areas of the GI tract where traditional tools have limited access.
The relationship between CE and conventional modalities is therefore not competitive but complementary. This paradigm of procedural convergence—where the strengths of one modality compensate for the limitations of the other—is becoming increasingly central to modern GI diagnostic algorithms.
Toward a Hybrid Diagnostic Strategy
Emerging evidence suggests that the most effective diagnostic strategies are not those that favor one modality over the other, but rather those that integrate both based on patient factors, clinical indications, and healthcare resource availability. For example:
In obscure gastrointestinal bleeding, CE offers a first-line diagnostic approach for small bowel lesions, often followed by conventional endoscopy (e.g., double-balloon enteroscopy) for targeted therapy.
In colorectal cancer screening, CE can serve as a triage tool or an alternative when colonoscopy is incomplete or declined, thereby improving adherence without sacrificing diagnostic yield.
In Crohn’s disease, CE allows early detection of proximal small bowel inflammation, while colonoscopy provides tissue diagnosis and therapeutic surveillance.
This integrated approach not only enhances diagnostic completeness but also improves patient stratification, cost-efficiency, and adherence to screening and surveillance programs.
Technological Convergence and AI-Driven Personalization
The future of GI diagnostics lies in the fusion of AI, robotics, and biosensing into both conventional and capsule-based platforms. Capsule endoscopy is transitioning from passive observation to smart diagnostic ecosystems, capable of:
Autonomous navigation and control.
Real-time lesion detection using AI.
Onboard sensors for chemical, pH, and pressure analysis.
Therapeutic delivery, including biopsy and cautery tools.
Meanwhile, conventional endoscopy is being augmented by:
AI overlays that assist during live colonoscopy procedures.
Robotic-assisted scopes with enhanced precision.
Augmented reality navigation and digital mucosal mapping.
Such technologies will lead to precision endoscopy—highly personalized, low-risk, and data-rich procedures tailored to individual risk profiles, anatomy, and disease patterns.
Implementation in Global Screening and Remote Care
Capsule endoscopy’s portability, lack of sedation, and minimal infrastructure requirements make it ideally suited for:
Community-based cancer screening programs.
Pediatric or geriatric care in rural areas.
Outpatient chronic disease monitoring.
Post-pandemic decentralized diagnostics, where contactless or at-home testing is preferred.
In countries with limited access to trained endoscopists or procedural infrastructure, CE may democratize high-quality GI imaging through:
Cloud-based data transmission.
Remote AI triage.
Asynchronous specialist interpretation.
These advantages align CE with future models of tele-endoscopy and AI-supported diagnostics within national healthcare systems.
Future Clinical Questions
Several pivotal questions remain as CE and conventional endoscopy continue to evolve:
Can capsule endoscopy safely replace colonoscopy in average-risk CRC screening?
Will robotic capsules allow therapeutic functions such as biopsy or polypectomy in the next decade?
How will AI algorithms be regulated, validated, and reimbursed in real-time clinical workflows?
What are the ethical implications of autonomous capsule diagnostics in asymptomatic patients?
Answering these questions will require robust clinical trials, interdisciplinary collaboration, and transparent guideline development by gastroenterological societies and regulatory bodies.
In conclusion capsule and conventional endoscopy are no longer isolated domains but rather parts of a converging landscape of smart, flexible, and minimally invasive gastrointestinal diagnostics. The next generation of tools will likely combine the real-time control of conventional systems with the autonomous intelligence and safety profile of capsule platforms, ushering in an era of adaptive, patient-centered endoscopy.
By understanding the complementary roles and evolving capabilities of each modality, clinicians and health systems can make evidence-informed decisions that maximize diagnostic yield, minimize procedural risk, and improve long-term outcomes in gastrointestinal care.
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Neonatal ventilation plays a critical role in the survival and long-term outcomes of preterm and critically ill newborns. Advances in respiratory support over the past decades have significantly improved survival rates; however, they have also highlighted the importance of lung-protective strategies, individualized care, and careful balancing of risks and benefits. As neonatal intensive care units (NICUs) continue to evolve, emerging technologies are reshaping how respiratory support is delivered, monitored, and optimized.
Emerging Technologies in Neonatal Ventilation
The evolution of neonatal respiratory care is increasingly shaped by multidisciplinary convergence—bioengineering, artificial intelligence, neuromonitoring, and bedside imaging—aimed at delivering individualized, lung-protective, and developmentally sensitive respiratory support. These technologies address limitations of traditional ventilatory approaches, such as asynchrony, imprecise titration, and a lack of spatial monitoring. This section reviews the latest advancements poised to redefine neonatal ventilatory management in the coming decade.
Neurally Adjusted Ventilatory Assist (NAVA)
NAVA represents a paradigm shift from pressure- or volume-based ventilatory modes toward neuro-ventilatory coupling, which provides support proportional to the infant’s own respiratory drive.
Mechanism:
A specially designed Edi catheter measures the electrical activity of the diaphragm (Edi), a direct correlate of brainstem respiratory output.
The ventilator responds in real time to each neural impulse, providing synchronized pressure support tailored to individual effort and avoiding over- or under-assistance.
Clinical Significance:
Enhances patient–ventilator synchrony, especially in premature infants with erratic or immature respiratory patterns.
Reduces sedation needs and the incidence of ventilator-induced lung injury (VILI).
Associated with fewer desaturation episodes, improved gas exchange, and better sleep-state architecture in neonates.
Limitations and Frontiers:
Requires precise catheter positioning and interpretation of Edi signals, making it less applicable in unstable or very low birth weight infants (<1000 g).
Ongoing trials are evaluating non-invasive NAVA (NIV-NAVA) as a step-down mode post-extubation, with early results showing promise (1, 2).
Electrical Impedance Tomography (EIT)
EIT provides continuous, radiation-free bedside imaging of lung ventilation patterns, a revolutionary advancement over intermittent radiographs or surrogate oxygenation metrics.
Technical Insight:
Low-amplitude electrical currents are passed through thoracic electrodes to produce spatial ventilation maps with high temporal resolution.
Real-time visualizations allow for regional analysis of ventilation heterogeneity, enabling dynamic lung volume optimization.
Applications in Neonatology:
Optimizing PEEP and tidal volume to avoid atelectasis or overdistension during high-frequency oscillatory ventilation (HFOV) or volume-targeted ventilation (VTV).
Guiding recruitment maneuvers, surfactant administration, and position-dependent ventilation strategies.
Early detection of ventilation-perfusion mismatch, pneumothorax, or diaphragmatic dysfunction.
Limitations:
Image resolution is limited to gross regional trends (non-anatomical).
Requires skilled interpretation and consistent probe placement.
Not yet validated in unstable neonates or during transport (3).
AI in Neonatal Ventilation and Machine Learning (ML)
AI and ML are poised to automate and personalize decision-making in NICU respiratory care through data-driven algorithms, pattern recognition, and predictive analytics.
Real-time risk calculators for ventilator-associated pneumonia (VAP), bronchopulmonary dysplasia (BPD), and apnea burden, guiding preemptive interventions.
Adaptive learning models that dynamically adjust ventilator settings based on blood gas and waveform data (4).
Considerations:
The “black-box” opacity of many deep learning models raises concerns about clinical interpretability.
Requires continuous data quality assurance and institutional-level integration of electronic health record (EHR), monitor, and ventilator systems.
Ethical dilemmas include algorithmic bias, data ownership, and consent in neonatal populations (5).
Telemedicine and Remote Respiratory Monitoring
Telemedicine platforms are transforming NICU care by bridging geographic and staffing gaps, especially in low-resource or rural settings.
Features:
Remote access to ventilator waveforms, EIT feeds, and video laryngoscopy.
Centralized consultation systems for neonatal retrieval services.
AI-augmented mobile dashboards with early warning systems for apnea, oxygen desaturations, or ventilator failure (6).
Evidence Base:
Studies report reduced transport needs, faster escalation in respiratory care, and fewer delayed interventions.
Cross-institutional databases enable large-scale AI model training for respiratory prediction models in diverse populations.
Future Directions
Several next-generation approaches are currently in preclinical or early translational phases:
Digital Twins of Neonates: These involve creating virtual models to simulate ventilatory responses and drug effects.
AI-EIT Integration: This aims for automated lung recruitment guidance.
Closed-Loop Adaptive Ventilation: Algorithms in this system dynamically modify FiO₂, PEEP, or flow based on continuous biosignal input.
Expansion of Wearable Sensors: This focuses on wireless diaphragmatic electromyography (EMG) and thoracic compliance monitoring.
Interdisciplinary collaboration among neonatologists, engineers, and data scientists will be essential to validate and implement these technologies at scale while maintaining patient safety and ethical rigor.
Outcomes and Complications
The expanding toolkit of neonatal respiratory support—while life-saving—inevitably carries both short- and long-term risks. Adverse outcomes may stem not only from the underlying pathology of prematurity but also from iatrogenic exposures such as mechanical ventilation, supplemental oxygen, and inflammation. The three principal domains of complications include pulmonary disease (primarily bronchopulmonary dysplasia), ophthalmologic injury (notably retinopathy of prematurity), and neurodevelopmental impairments.
Bronchopulmonary Dysplasia and Long-Term Pulmonary Sequelae
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease of infancy and remains a sentinel marker of neonatal morbidity, particularly among infants born at <28 weeks of gestation. BPD is defined by oxygen dependency beyond 28 days and categorized by severity at 36 weeks’ postmenstrual age (7). Despite evolving definitions and management strategies, its prevalence has remained steady, reflecting the paradoxical survival of increasingly immature neonates.
Infants with BPD frequently require prolonged hospitalization, supplemental oxygen at discharge, and are at increased risk of pulmonary hypertension, reactive airway disease, and recurrent hospital readmissions (8, 9). Emerging evidence supports the role of prenatal inflammation, ventilator-induced injury, and genetic susceptibility in BPD pathogenesis (10, 11). Long-term follow-up demonstrates that even into adolescence and adulthood, survivors of moderate to severe BPD may exhibit reduced FEV₁, exercise intolerance, and impaired quality of life (12).
Retinopathy of Prematurity (ROP) and Oxygen-Related Risks
The retina of the premature infant is highly sensitive to oxygen fluctuations. Retinopathy of prematurity is triggered by hyperoxic injury followed by hypoxia-induced vasoproliferation, which may lead to retinal detachment and blindness. Excessive or fluctuating FiO₂ levels, combined with inadequate oxygen monitoring, are significant risk factors for severe ROP (13). Large multicenter trials like SUPPORT and NeOProM have demonstrated that tight oxygen targeting can reduce severe ROP, albeit sometimes at the expense of higher mortality (14).
Current best practices emphasize the use of automated oxygen titration systems, early surfactant therapy to reduce FiO₂ needs, and rigorous saturation monitoring. Nevertheless, severe ROP remains more prevalent in extremely preterm infants, particularly those with concurrent BPD or prolonged ventilation (15).
Neurodevelopmental Impairments
Neonatal respiratory support—particularly prolonged mechanical ventilation—is linked with adverse neurodevelopmental outcomes. Mechanisms include hypocarbia, chronic hypoxia, systemic inflammation, and fluctuating cerebral perfusion. Infants with BPD are disproportionately affected, with higher rates of cerebral palsy, language delay, and cognitive impairment noted by 18–24 months corrected age (16, 17).
Notably, the duration of ventilation, exposure to sedatives, and recurrent hypoxic episodes are cumulative contributors to neurodevelopmental injury. While home oxygen therapy at discharge has not consistently been associated with worse neurodevelopmental outcomes (18), persistent hypoxia and poor growth trajectories remain predictive of poorer cognitive outcomes (19, 20).
Predictive Tools and Risk Stratification
Risk stratification tools, including the NICHD BPD Outcome Estimator and machine learning models incorporating gestational age, sex, ventilator settings, and blood gases, are increasingly being utilized to predict long-term outcomes (21). These tools enable proactive intervention—such as early extubation, judicious steroid use, and tailored developmental follow-up—to mitigate risk and guide individualized care.
Challenges in Low-Resource Settings
Neonatal respiratory failure is a major contributor to global neonatal mortality, disproportionately affecting low- and middle-income countries (LMICs). Although neonatal intensive care and ventilatory technologies have revolutionized outcomes in high-income settings, the same benefits are not universally available. In LMICs, limited infrastructure, trained personnel, and supplies often constrain the availability and efficacy of respiratory support. Addressing these disparities is not merely a technical challenge but an ethical imperative in global health equity.
Infrastructure and Human Resource Constraints
In many LMICs, NICUs lack essential equipment such as functional ventilators, oxygen blenders, heated humidifiers, and reliable power supplies. Oxygen delivery systems frequently depend on cylinders, which are expensive and logistically difficult to maintain, especially in rural regions. Moreover, the scarcity of trained neonatal healthcare workers and respiratory therapists contributes to inconsistent monitoring, delayed escalation, and poor adherence to ventilator protocols (22).
Without access to arterial blood gas analysis or continuous cardiorespiratory monitoring, clinical decisions are often based on observational metrics, increasing the risk of under- or over-support. These challenges lead to a reliance on more rudimentary forms of respiratory assistance, which, though cost-effective, may lack the nuanced titration required for optimal outcomes.
Bubble CPAP: A Practical Innovation
Bubble continuous positive airway pressure (bCPAP) has emerged as a cornerstone of neonatal respiratory care in resource-limited settings. Unlike conventional CPAP systems that require expensive flow drivers and blenders, bCPAP systems use underwater resistance to create positive end-expiratory pressure. Several studies have demonstrated the effectiveness of improvised bCPAP in reducing mortality from respiratory distress syndrome (RDS) and minimizing the need for invasive ventilation (23, 24).
Improvements in bCPAP design—such as integrating low-cost oxygen blenders and using nasal prongs constructed from intravenous tubing—have made the approach more feasible and scalable. However, success depends heavily on appropriate assembly, training, and maintenance. A lack of standardized components and consistent pressure delivery still poses risks, particularly in extremely preterm infants requiring precise ventilatory control (25).
Training and Task-Shifting
One promising strategy in these settings involves task-shifting and peer-led training. By empowering nurses and mid-level practitioners to assemble and manage bCPAP, and to monitor for complications, some centers have achieved significant reductions in mortality and bCPAP failure rates. Simulation-based education, along with pictorial guidelines and mobile applications, has enhanced clinical confidence and protocol adherence (26, 27).
Furthermore, integrating local biomedical engineers into neonatal care programs has improved device maintenance and innovation, including the development of solar-powered humidifiers and manual pressure monitoring tools.
Ethical and Policy Considerations
The global disparity in neonatal respiratory care raises important ethical questions about justice and prioritization. Many LMICs still lack national policies that mandate neonatal resuscitation capacity, let alone ventilatory support. Global aid initiatives such as Helping Babies Breathe and Every Breath Counts have improved awareness and provided equipment, but issues of sustainability, spare parts, and training persist (28).
Moreover, the choice to initiate respiratory support in a critically ill neonate—particularly in settings without access to surfactant, ventilation, or follow-up—introduces ethical tensions between clinical benefit, resource stewardship, and quality of life.
Future Directions
The field of neonatal respiratory support is undergoing a dynamic transformation driven by technological innovation, personalized medicine, and emerging ethical considerations. While foundational techniques such as continuous positive airway pressure (CPAP) and mechanical ventilation remain essential, future approaches aim to tailor support to the individual neonate’s evolving physiology, guided by real-time analytics and predictive tools.
Precision Ventilation and Lung-Protective Strategies
The concept of precision ventilation refers to the fine-tuning of ventilatory parameters based on each infant’s unique pulmonary mechanics and maturational stage. Advancements in volume-targeted ventilation, neurally adjusted ventilatory assist (NAVA), and closed-loop control systems are enabling more individualized, lung-protective strategies that minimize barotrauma, volutrauma, and oxygen toxicity (29).
Furthermore, technologies such as electrical impedance tomography (EIT) and quantitative lung ultrasound allow for bedside monitoring of lung aeration, recruitment, and overdistension, facilitating real-time titration of positive end-expiratory pressure (PEEP) and tidal volume (30).
Integration of Artificial Intelligence and Predictive Analytics
Artificial intelligence (AI)-powered clinical decision support is rapidly being integrated into neonatal intensive care units (NICUs). Machine learning models have demonstrated efficacy in predicting extubation success, apnea episodes, and the risk of bronchopulmonary dysplasia (BPD) by analyzing streaming physiologic data such as heart rate variability, oxygen saturation trends, and ventilator settings (31, 32).
Internet-of-Things (IoT) platforms are now connecting ventilators, monitors, and laboratory systems, enabling real-time data aggregation for early warning scores and automated alarm thresholds (33). However, integration into practice must be cautious and transparent, particularly in settings where algorithmic decisions influence life-sustaining therapies.
Biomarker-Based Monitoring and Stratification
Another frontier is the use of biomarkers to detect early signs of respiratory deterioration or complications. For instance, serum interleukin-6, surfactant protein-D (SP-D), and Krebs von den Lungen-6 (KL-6) have been explored for their roles in predicting BPD or ventilator-associated lung injury (34). Non-invasive sampling of exhaled breath condensate and urine metabolomics is also gaining interest.
Biomarkers may allow for early, preclinical identification of infants likely to fail non-invasive ventilation or those at risk for complications, supporting risk-adjusted interventions such as earlier surfactant administration or steroid therapy (35).
Innovations in Surfactant Therapy
Modern delivery techniques such as Less Invasive Surfactant Administration (LISA) and aerosolized surfactant have reshaped surfactant therapy for preterm infants. These methods reduce the need for intubation and sedation while improving oxygenation and reducing the risk of BPD (29).
Research is ongoing into synthetic surfactants enhanced with surfactant protein-B (SP-B) and surfactant protein-C (SP-C) analogues, and into surfactant lavage for conditions such as meconium aspiration syndrome or neonatal acute respiratory distress syndrome (ARDS). Combining surfactant with anti-inflammatory agents may also offer synergistic benefits (34).
Ethical and Legal Considerations in the Era of AI
As AI becomes more embedded in NICU practice, concerns about data privacy, algorithmic bias, and informed consent are gaining attention. Decision-making algorithms must be interpretable, especially when outcomes such as intubation, sedation, or withdrawal of care are involved (36).
The use of predictive models that flag high-risk infants may unintentionally influence clinician behavior or family counseling, emphasizing the need for ethical oversight, multidisciplinary discussions, and robust regulatory frameworks.
Conclusion
Neonatal respiratory support has evolved from merely life-sustaining interventions toward more refined, individualized care that prioritizes lung protection, neurodevelopmental preservation, and equitable access. Advances in mechanical ventilation, non-invasive strategies, surfactant delivery, and physiologic monitoring have significantly improved survival for preterm and critically ill neonates. Innovations such as Neurally Adjusted Ventilatory Assist (NAVA), electrical impedance tomography (EIT), and volume-targeted ventilation have enhanced the precision and safety of ventilatory care, while emerging tools—including AI-driven decision support and real-time imaging—are poised to further transform neonatal respiratory management.
Despite these technological gains, significant challenges remain. Bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), and long-term neurodevelopmental impairments continue to affect survivors, particularly those requiring prolonged or invasive support. Ethical considerations, especially surrounding care escalation, predictive algorithms, and equitable distribution of technology, must accompany the implementation of future innovations.
Perhaps most critically, global disparities persist. In low-resource settings, where the burden of neonatal mortality is highest, respiratory support is often limited to rudimentary or improvised methods. Expanding access to safe, scalable solutions—such as bubble continuous positive airway pressure (bCPAP), affordable oxygen systems, and telemedicine support—remains a pressing public health priority.
The future of neonatal respiratory support lies at the intersection of engineering, medicine, and ethics. It will require not only scientific advancement but also systems thinking, policy innovation, and global collaboration. By integrating emerging technologies with contextualized care models, the neonatal community can continue advancing toward a world where every infant—regardless of geography or gestational age—has access to safe and effective respiratory care.
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Respiratory support in intensive care has undergone a significant transformation over time, evolving from simple manual techniques to sophisticated, intelligent devices. The initial use of negative pressure ventilation devices such as the “iron lung” in the early 20th century marked the beginning of this journey. A major turning point occurred during the poliomyelitis outbreak in Copenhagen in 1952, when positive pressure ventilation was successfully employed, laying the foundation for modern intensive care practices.
From the 1960s onward, volume- and pressure-controlled mechanical ventilators were developed, offering greater control over respiratory support. The introduction of microprocessor-based ventilators in the 1980s enhanced the precision and safety of mechanical ventilation. By the 2000s, lung-protective strategies—such as the use of low tidal volumes and appropriate levels of PEEP—had become widely adopted.
Over time, non-invasive ventilation techniques (such as BiPAP and CPAP) and high-flow nasal oxygen therapy have also become increasingly prevalent. The COVID-19 pandemic further underscored the critical role of ventilators in the management of acute respiratory failure. Today, respiratory support is delivered via advanced technologies that incorporate artificial intelligence, allow for individualized settings, and prioritize lung-protective strategies.
Respiratory Support in Intensive Care
Respiratory support in intensive care refers to the set of invasive and non-invasive methods employed to ensure adequate oxygenation and carbon dioxide elimination in patients experiencing respiratory failure. It is indicated in cases where the patient is unable to maintain sufficient spontaneous breathing or when it is necessary to reduce the work of breathing. The primary objectives of respiratory support are to optimize gas exchange, protect the lungs, and sustain life until the underlying condition improves.
Types of Respiratory Support
Respiratory support is broadly classified into two main categories:
1. Non-invasive respiratory support: This form of support is delivered through a face mask or nasal cannula without the need for endotracheal intubation. Common methods include high-flow nasal cannula (HFNC) therapy and non-invasive mechanical ventilation (e.g., BiPAP or CPAP).
2. Invasive respiratory support: This approach requires the placement of an endotracheal tube into the trachea. It involves mechanical ventilation or, in more advanced cases, extracorporeal membrane oxygenation (ECMO), particularly in severe or refractory respiratory failure.
Indications for Respiratory Support
Respiratory support is indicated in the following conditions:
Hypoxemic respiratory failure (PaO₂ < 60 mmHg): such as acute respiratory distress syndrome (ARDS), pneumonia, and COVID-19.
Hypercapnic respiratory failure (PaCO₂ > 45 mmHg): including exacerbations of chronic obstructive pulmonary disease (COPD) and neuromuscular diseases.
Cardiogenic pulmonary edema
Postoperative respiratory depression
Trauma, sepsis, and metabolic disorders
What Is a Mechanical Ventilator?
A mechanical ventilator is a medical device that delivers air to the lungs using positive pressure to support or completely take over the breathing process in patients with respiratory failure. It is used in intensive care units, operating rooms, and emergency departments to temporarily maintain respiratory function in critically ill patients. Mechanical ventilation mimics natural breathing by meeting the body’s oxygen demands, regulating carbon dioxide removal, and allowing the respiratory muscles to rest.
Primary Objectives of Mechanical Ventilation
To correct hypoxemia (increase oxygen levels)
To reduce hypercapnia (eliminate excess carbon dioxide)
To decrease the work of breathing
To prevent complications through lung-protective ventilation strategies
To support spontaneous breathing and prepare the patient for weaning from the ventilator
How Is Mechanical Ventilation Used?
1) Preparation and Patient Selection
Mechanical ventilation is typically initiated in the following conditions:
Acute respiratory failure
Acute respiratory distress syndrome (ARDS)
Exacerbation of chronic obstructive pulmonary disease (COPD)
Systemic conditions such as sepsis, trauma, or brain injury
Postoperative respiratory depression
The patient is intubated by inserting an endotracheal tube into the trachea, which is then connected to the mechanical ventilator.
2) Mode Selection
The mechanical ventilator can be set to operate in various modes:
Controlled Mode (AC – Assist/Control): The device initiates and controls every breath; the patient does not contribute to ventilation.
Supported Mode (SIMV – Synchronized Intermittent Mandatory Ventilation): The patient can breathe spontaneously between mandatory breaths; the ventilator provides support as needed.
Pressure Support Ventilation (PSV): The ventilator delivers pressure support with each spontaneous breath initiated by the patient.
During mechanical ventilation, the following parameters are closely observed:
SpO₂ (oxygen saturation)
End-tidal CO₂ (etCO₂)
Tidal volume and minute ventilation
Respiratory mechanics (compliance, resistance)
Alarm systems (e.g., high pressure, low volume, disconnection)
4) Complications and Precautions
Ventilator-Induced Lung Injury (VILI): To prevent volutrauma, barotrauma, and atelectasis, low tidal volumes and appropriate positive end-expiratory pressure (PEEP) settings should be employed.
Ventilator-Associated Pneumonia (VAP): Preventive measures such as meticulous oral care and maintaining the head of the bed at a 30–45° elevation are essential.
Hemodynamic Effects: High levels of positive pressure can reduce venous return and consequently affect cardiac output.
Diaphragm Atrophy: Prolonged use of full-support ventilation modes may lead to respiratory muscle weakness due to disuse atrophy.
Frequently Asked Questions
Is mechanical ventilation the same as oxygen therapy? No. Oxygen therapy is typically administered via simple face masks or nasal cannulas. Mechanical ventilation, on the other hand, provides assisted breathing using positive pressure in patients with impaired lung function; it represents a more advanced form of respiratory support.
Does mechanical ventilation always require intubation? No. Non-invasive mechanical ventilation (e.g., BiPAP, CPAP) can be delivered through masks without the need for intubation. However, invasive mechanical ventilation usually requires endotracheal intubation.
Is dependence on a mechanical ventilator permanent? No. Mechanical ventilation is intended as a temporary support. Once the patient’s respiratory muscles regain strength and gas exchange normalizes, a weaning process is initiated to gradually discontinue ventilator support.
Is mechanical ventilation painful? No, the process of mechanical ventilation itself is not painful. However, the presence of an endotracheal tube and the experience of being on the device can cause discomfort. Therefore, patients are often administered sedation and, when necessary, muscle relaxants.
