Course Articles

Editor’s note: This text-based course is an edited transcript of the webinar, Supporting Neurodiverse Staff, Colleagues and Patients, presented by Gabrielle Davis, MPH, MA, RRT, RRT-ACCS, RRT-NPS, TTS, LPC, NCC, FAARC. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

• Recognize and support neurodivergent patients, while gaining a deeper understanding of neurodiversity and its implications in healthcare
• Identify and apply strategies to dismantle barriers that limit equitable access to care for neurodivergent individuals
• Discuss the skills to implement affirming and inclusive care practices, ensuring that neurodivergent patients receive respectful and equitable respiratory care

Why This Topic? Why Now?

I chose to present this topic for several reasons. About a year ago, I attended a national conference where an educator—a college professor—asked the presenter a question that has stayed with me ever since. While I do not recall the specific topic the presenter was discussing, the professor’s question stood out: “What do we do with students who have IEPs? Should they not be discouraged from working in healthcare? Should they even be allowed to care for patients?”

Hearing those words deeply angered me. The question implied that individuals with Individualized Education Programs (IEPs) or other accommodations were inherently unfit to pursue careers in healthcare. Unfortunately, it was the final question of the session, and although I raised my hand to respond, there was no time for me to speak. That moment stayed with me, fueling my decision to address this topic—not just out of frustration but because it is an issue that demands attention.

I am someone who has ADHD, a condition I was diagnosed with later in life. Despite the challenges it presents, I have been able to achieve incredible things in my career and personal life. The idea that someone’s need for accommodations or support automatically disqualifies them from providing exceptional patient care is unfair and untrue. It perpetuates harmful stereotypes and undermines the potential of countless capable individuals.

It is essential to challenge these misconceptions and remind others that success in healthcare—or any field—is not defined by the absence of challenges. People with IEPs, ADHD, mental health conditions, or other needs for assistance prove every day that they are not only capable but can thrive in their chosen professions. By acknowledging this, we create a more inclusive and supportive environment for everyone.

Community-Powered Presentation

This presentation is community-powered, meaning it was shaped by input from individuals with lived experience related to this topic. While literature and evidence-based research are invaluable, they often exclude the voices of people from minoritized groups—particularly those with certain conditions—due to longstanding mistrust, including medical mistrust. By incorporating insights from the community, this presentation highlights perspectives that might otherwise be overlooked.

One key idea to consider as we explore this topic is that diagnosis itself is a privilege—one that not everyone has access to. For example, I am 42 years old and was only diagnosed with ADHD in 2017. My diagnosis came not through seeking medical help but because a teacher in my mental health therapy program pulled me aside and raised the possibility. Despite having access to insurance and other resources throughout my life, no one had ever brought it up before. It took someone paying close attention to connect the dots.

When I received my diagnosis, everything about my past suddenly made sense—the difficulties I had focusing on one thing, my need for extra time to complete tasks, and my tendency to juggle multiple things at once. ADHD manifests in diverse ways, and having a diagnosis provides clarity. However, not everyone is fortunate enough to have the opportunity to gain that clarity, which underscores why diagnosis is a privilege.

Another critical point is that language and science are constantly evolving. It is essential to stay informed about how terms and concepts shift over time. For instance, ongoing discussions in the neurodiversity community address the distinction between “neurodivergent” and “neurodiversity.” Some individuals do not wish to be labeled “neurodivergent,” even if science might categorize them differently. In these cases, it is vital to honor the language someone uses to describe themselves. It is not our role to correct or challenge how a person chooses to identify.

Lastly, this presentation is an educational offering, not a formal training. I use the term “educational offering” intentionally, as training often implies completion or mastery. In past presentations, I have had participants ask, “When do I get my certificate?” CEUs are valuable—clearly, or I would not be here—but it is important to understand that this is not the final destination. Instead, consider this one step on a much longer educational journey.

Let’s Talk Terms!

Let’s begin by defining some key terms, starting with neurodiversity. I say a definition because if you search for the term online, you will find countless interpretations. The one I use most often, particularly when speaking to those new to the concept, is straightforward: neurodiversity refers to the natural diversity of human brains. It emphasizes that every brain is unique. Notably, this definition does not mention diagnoses, which is intentional.

This distinction is important because when people hear terms like neurodiversity or neurodivergent, their understanding often defaults to ADHD or autism. While these are prominent examples, they are only part of the broader neurodivergent spectrum. The term encompasses a wide range of conditions, including dyslexia, dyspraxia, Tourette’s syndrome, and even mental health conditions such as bipolar disorder or generalized anxiety disorder. Each of these conditions can manifest differently from person to person. For instance, with ADHD, one individual might struggle with maintaining focus, while another thrives on multitasking but struggles with hyperfocus or emotional regulation.

One important concept within neurodiversity is acquired neurodiversity, which refers to changes in the brain resulting from life experiences, particularly trauma. Research indicates that approximately 70% of Americans have experienced some form of trauma, which can leave lasting effects on the brain. A commonly recognized example is post-traumatic stress disorder (PTSD), often associated with combat veterans. However, trauma affects people in many other ways and can stem from everyday experiences such as accidents, abuse, or even chronic stress.

Let me share a personal story to illustrate this. When I was 17, I had my first car, a 1988 Cougar. One day, while driving to my grandmother’s house, I stopped at an intersection to turn left. I noticed the car in front of me had children playing in the backseat—this was 1999, and seatbelt usage was not as rigorously enforced. I smiled at their antics, but then I glanced in my rearview mirror and saw a car speeding toward me. My immediate reaction was to press both feet on the brake to avoid being pushed into the car ahead. The impact spun my car into the opposite lane, but thankfully, I was not seriously hurt. However, the experience left a deep impression. For years, I avoided using my rearview mirror, angling it downward to avoid looking into it. I relied solely on my side mirrors, a habit born from that single traumatic moment.

Years later, in 2014, I was T-boned by another driver who ran a red light. Again, I was not seriously injured, but the trauma compounded my anxiety around driving. Now, whenever a car merges into the lane next to mine on the freeway, I instinctively assume it will swerve into my lane. This has led to unnecessary swerving on my part, even when no real danger exists. These experiences have made driving an activity I dread, not because of the act itself but because of how my brain now processes potential threats.

Trauma does not just affect conscious memories—it can also leave subconscious imprints. For example, I once worked with a client who had a debilitating fear of dogs. When I asked if she had ever been bitten or chased, she could not recall any such incident. However, after speaking with her family, she discovered she had been bitten on the foot at eight months old. She had no memory of the event, but her body retained the fear. This demonstrates how trauma, even when not consciously remembered, can shape our behaviors and responses.

This brings us back to the term neurodivergent. It stands in contrast to neurotypical, a word that has sparked debate. Referring to someone as neurotypical implies there’s a “normal” brain, but as we know, “normal” is a subjective and often unhelpful concept. As the saying goes, “Normal is just a setting on a washing machine.” Every brain is different, and these differences make humanity diverse and innovative.

Language within the neurodiversity movement continues to evolve. For instance, some people prefer the term neuroexpansive over neurodivergent. A group of Black disabled women coined Neuroexpansive as a response to how neurodivergent has been weaponized against marginalized populations. It rejects the framing of neurodivergence as a deficit and highlights the expansive possibilities of diverse brain function. For example, people with ADHD might hear statements like, “You cannot be trusted with this task because you are too distracted,” or “We cannot hire you because you are not reliable.” These statements perpetuate ableism, and while discrimination is illegal, it still happens.

Other terms are more playful, like neurospicy or neurosassy. I love these terms and often use them to describe myself. They provide a lighthearted way to embrace one’s neurodivergent identity while challenging the stigma around it.

As language and science continue to evolve, it is important to stay informed. If you are in a leadership position in healthcare or any field, listen to your colleagues and staff. When you encounter new terminology, take the initiative to learn about it—Google is free, after all. Proactively understanding these terms fosters inclusivity and ensures that everyone feels seen and respected.

Potential Challenges: Students/Colleagues

• Pushing to ‘work faster/harder’ constantly
• Being late and scheduling (coming to work or completing work)
• Being narrow-focused in providing/receiving instructions
• Completing modules or writing/reading in a loud space or tons of commotion
• Forced to be a trainer although they never received training in the same role
• Insisting on eye contact
• Varying ways of ‘reporting’
• Using colloquialisms or ‘common’ phrases

One of the potential challenges in working with students or colleagues is the pressure to constantly work faster or harder—especially when expectations are not clearly communicated up front. For example, outside of the mental health care space, I once worked with grocers. During a discussion on neurodiversity, one of them asked, “What do I do if someone takes four hours to complete a task that should take two hours?” Naturally, my first question was, “Why should it take two hours?” After some back and forth, the answer was, “Because it always has.”

When I pressed further, I learned that no one had ever explicitly told the person how long the task should take or offered guidance on how to complete it efficiently. Instead, they were told to “work faster.” This highlights an important point: definitions and expectations vary from person to person. My version of “fast” might not match yours, so clarity is key.

This is especially important when onboarding students or new hires. For instance, if you are a program director or manager, you need to be specific about expectations right from the start. Job descriptions, for example, often use vague terms like “morning shift” or “night shift.” For someone like me, with experience in hospitals where a morning shift typically runs from 7:00 a.m. to 7:00 p.m., I might assume that is what you mean. What if your morning shift starts at 6:00 a.m.? To avoid confusion, provide precise details—write the exact start and end times.

Another area where specificity matters is task instructions. Most workplaces have established ways of doing things, but new hires will not automatically know them. Be open to explaining processes in detail and, when appropriate, asking for feedback: “Is there another way to approach this?” or “What do you think could work better?” Encouraging input not only fosters collaboration but can also lead to improved workflows.

The environment where people work and learn also plays a significant role. For example, I spent nearly two decades working in hospitals, from 2000 to 2017. Many of the mandatory modules—on topics like sexual harassment or fire safety—had to be completed in break rooms, often with conversations and other distractions in the background. For people who struggle with focus, this can be a huge barrier. Simple accommodations, like providing noise-canceling headphones or allowing people to complete modules at home, can make a big difference. Additionally, naming the challenge upfront—acknowledging that the environment might be loud and suggesting alternative quiet spaces like a library—shows consideration and inclusivity.

Another challenge arises when individuals are promoted into newly created roles without formal training. For example, when I worked, we did not always have specialized roles like respiratory therapy leads or specialists. Often, someone was promoted into a role that did not previously exist, meaning they had to define the position and its responsibilities as they went. This can be especially challenging when they are later tasked with training someone else in a role they essentially created from scratch. Offering support, mentorship, and clear guidance can help ease this transition.

Cultural and neurodiverse factors also need to be considered. For instance, some neurodiverse individuals may find maintaining eye contact difficult or uncomfortable. Additionally, cultural norms influence the appropriateness of eye contact. In some cultures, avoiding eye contact is a sign of respect, while in others, it may be interpreted differently. Rather than assuming constant eye contact is necessary, be flexible and open to different forms of communication.

Reporting styles are another area where variation is common. In my own experience, the way I gave reports evolved. When I was new to the field, my reports were lengthy and detailed—sometimes overly so. As I gained experience, my reports became shorter and more concise while still covering the essentials. That said, even experienced colleagues might prefer a longer, more detailed approach. Accepting these variations ensures that everyone’s communication style is respected.

Finally, be mindful of using colloquialisms or common phrases. While these expressions might feel natural to you, they may not be universally understood. For instance, during a recent presentation, I learned that some of the phrases I commonly use did not make sense to others in the room. This reminds us that language can be exclusionary if we’re not careful. When in doubt, take the time to clarify your meaning or avoid overly specific idioms altogether.

By fostering clear communication, offering accommodations, and remaining open to diverse ways of thinking and working, we can create environments where everyone—regardless of their background or neurodiversity—can thrive.

Common Colloquialisms

A few years ago, I encountered a phrase I had never heard before: from soup to nuts. I was attending a webinar, and the presenter casually mentioned it in her talk. Immediately, my brain fixated on the unfamiliar phrase, and I felt compelled to figure out what it meant. I paused my attention on the presentation and opened Google to research it. As I went down the rabbit hole of definitions and origins, I realized I had missed about ten minutes of the webinar content.

Once I discovered the meaning—from soup to nuts refers to a complete process from start to finish, like a meal that begins with soup and ends with nuts for dessert—I found myself distracted by another question: Who actually eats nuts for dessert? So, I dived even deeper into irrelevant research while the webinar continued without me.

This experience highlights an important point about language and the unintended effects of using idiomatic expressions that might not be universally understood. Phrases like these can confuse listeners, pull them out of the moment, and detract from the message you are trying to convey.

Let’s look at some other examples of commonly used expressions and the potential issues they pose:

1. “Pounded into my brain” or “Don’t throw me under the bus”
   • Taken literally, these phrases sound harsh or even violent. While most people understand them metaphorically, their intensity can still be jarring, especially for individuals unfamiliar with the idiomatic usage.
2. “Let’s call a spade a spade”
   • This phrase has a troubling history rooted in racism, specifically targeting Black people. For a long time, I used this phrase without knowing its origins. It was not until someone pointed it out to me that I learned about its racist undertones. That realization led me to remove it from my vocabulary.
3. “It’s crazy in here”
   • The word crazy has been weaponized against individuals with mental health conditions, often used to dismiss or belittle their experiences. For me, removing this word from my everyday language has been one of the most challenging adjustments. It is commonly used in American English, and replacing it takes conscious effort. Over time, I have started using alternatives like wild or chaotic, but the habit did not change overnight.

These examples illustrate how language, even when used innocently, can carry unintended connotations or create confusion. For some phrases, the issue lies in their violent or extreme imagery. For others, the problem stems from their historical or cultural baggage. Still others, like crazy, perpetuate stigmas that we may not even realize we’re reinforcing.

How to Approach Language More Thoughtfully

The key is to question everything. Many of us grew up hearing and using phrases without knowing their origins or implications. Taking the time to research and reflect on the language we use can help us communicate more inclusively and respectfully. For instance:

• Be mindful of context. Consider whether the phrases you use might confuse or alienate your audience. If there’s even a small chance, opt for clearer, more direct language.
• Educate yourself. If you encounter a new or unfamiliar phrase, take a moment to look up its origins. This can be eye-opening, as I learned with call a spade a spade.
• Replace problematic terms. As I did with crazy, find alternatives that convey your intended meaning without perpetuating harm or stigma.

Adapting your language is a gradual process, but it is a worthwhile effort that promotes understanding and inclusivity. By questioning what we say and making conscious choices about the words we use, we can ensure that our communication uplifts rather than alienates us.

Considerations: Training-Employees/Students

When it comes to employees and students, one key consideration is whether the training process is standardized across the board. Most organizations have protocols, policies, or procedures in place for training—somewhere, someone has written them down. However, when it comes time to implement that training, there’s often a disconnect. Trainers typically teach in two ways: the right way, as outlined in the procedure, and their way, which reflects their personal habits or preferences. While this might seem harmless, it can create inconsistencies and confusion for trainees.

Personalizing the Training Process

It is worth asking: Can we adapt training to better suit individual learning styles? For example, on a new employee’s first day, you could ask how they best learn—whether through hands-on practice, visual aids, or written instructions. While it might not always be possible to fully accommodate their preferences, simply asking the question has value. It not only demonstrates that their needs are being considered but also allows them to mentally prepare to adapt if necessary. Furthermore, it provides insight for future training processes, helping you refine methods for the next employee.

Are Trainers Equipped to Train?

An often-overlooked aspect of the training process is whether trainers themselves have been adequately prepared. Training is more than teaching someone how to perform a task—it’s an interpersonal skill. Effective trainers know how to:

• Make others feel welcomed and included. A sense of belonging can significantly impact a trainee’s confidence and willingness to learn.
• Ask meaningful questions. Questions that encourage reflection or clarify understanding are essential in fostering growth.
• Receive and incorporate feedback. Training is not a one-way street; it is a dialogue. Trainers should be open to adjusting their methods based on input from their trainees.

Unfortunately, many trainers are thrust into their roles without receiving any training on how to train. This oversight can lead to awkward interactions or, worse, a trainee feeling unwelcome or unsupported.

Advance Preparation for Trainers

Another frequent issue arises when trainers aren’t given advance notice of their role. Imagine walking into work and being assigned a trainee without any prior warning. This not only catches the trainer off guard but also risks creating a suboptimal learning experience for the trainee. To address this, consider the following:

• Notify trainers in advance. For example, if there’s a position open, inform the trainer ahead of time: “We’re hiring for this role, and you will be responsible for training the new hire.” This allows them to mentally prepare and, if necessary, review the procedures they’ll be teaching.
• Identify backup trainers. Have a designated backup who can step in if the primary trainer is unavailable. Notify both trainers during the hiring process so they’re ready to fulfill their roles when the time comes.
• Ensure trainers volunteer for the role. In healthcare, it is common for people to be “voluntold” to train. While this can fill immediate gaps, it misses the opportunity to engage individuals who are genuinely interested in or suited for the role. By actively seeking out volunteers, you create a pool of trainers who are motivated and prepared to teach.

The Right People in the Right Roles

While there are people who excel at training, it is equally important to recognize that not everyone is suited for the role. Some individuals lack the interpersonal skills or patience required to guide others effectively. On the other hand, there are often untapped individuals who would thrive in a training role if given the chance. Actively engaging staff members and encouraging interest in training can expand the pool of qualified trainers while avoiding burnout among the usual go-to individuals.

Considerations: Patients

Considerations for Patient Communication and Consent

Building trust and rapport with patients starts with asking for consent—even for seemingly small actions. For instance, when approaching a patient’s room, consider saying, “Hi, I’m knocking at the door and standing in the doorway. Is it okay if I come in?” This simple request immediately establishes respect for their personal space and autonomy, setting a positive tone for the interaction. Asking for consent in these moments reinforces the idea that the patient is an active participant in their care, not just a passive recipient.

Encouraging Understanding Without Questioning

When explaining information to a patient, it is helpful to shift from yes/no questions about understanding to open-ended or declarative statements that encourage engagement. Instead of asking, “Do you understand?” (which might elicit a hesitant or automatic “yes”), try saying:

• “Please stop me if you have questions or need clarification.”
• “Let me know if I’m going too fast, and I’ll slow down.”
• “If something is not clear, feel free to ask me now, or you can let your nurse know, and they can reach out to me later.”

These statements remove the pressure of admitting confusion while still inviting dialogue. They empower the patient to take control of their learning process, making the conversation feel more collaborative.

Requesting Consent for Accompanied Visits

If you are entering a patient’s room with others—such as a student or another healthcare professional—always ask for consent. For example:

• “Is it okay if I come in? I also have a student with me who’s observing today.”

This approach respects the patient’s right to control who is present during their care. It contrasts with statements like, “We’re here, and this is my student,” which assume consent and may make the patient feel overlooked or pressured. Requesting consent in these situations protects both the patient’s comfort and the student's learning environment.

Including Family Without Shifting Focus

Family involvement in care can be valuable, but it is critical not to shift the spotlight away from the patient. This is particularly important when working with individuals with autism or mental health conditions, as it is not uncommon for providers to direct communication toward family members instead of the patient. For example:

• Rather than asking a caregiver, “What do you think is going on?” address the patient directly: “How are you feeling today?” or “Can you tell me what’s been going on?”
• You can include family members with statements like, “Let’s make sure we’re all on the same page about the care plan,” while keeping the patient at the center of the conversation.

This ensures the patient feels seen and respected, regardless of their condition, while valuing the family’s input as a secondary perspective.

Repeating Information in Different Ways

Patients may not always process information the first time it is presented—especially in stressful or unfamiliar settings. To support understanding:

• Use varied phrasing when repeating information. For example, if explaining a treatment plan, you might say, “This medication will help with your pain,” and later add, “The goal of this medication is to make you more comfortable while we work on your recovery.”
• Check in periodically: “Is this making sense so far?” or “Would you like me to go over anything again?”
• Provide written instructions or visual aids when possible, so patients and their families have something to refer back to after the conversation.

Always prioritize asking for consent, even for small actions such as entering a room or bringing additional people, like students or other staff members, into the space. These seemingly minor gestures build trust, respect the patient’s autonomy, and set a positive tone for the interaction. When explaining information, shift from yes/no questions to open-ended or declarative statements that encourage questions and engagement. This approach fosters better understanding and empowers patients to participate in their care actively.

Ensure the patient remains the central focus of all interactions, even when family members are present. While family input can be valuable, directing communication primarily toward the patient reinforces their agency and dignity, regardless of their condition. Additionally, consider repeating information multiple times and in different ways. This helps reinforce understanding, especially in stressful or unfamiliar situations. Pair verbal explanations with written instructions or visual aids whenever possible, giving patients and families a resource to revisit later. By incorporating these strategies, healthcare professionals can strengthen rapport, enhance patient-centered care, and contribute to better outcomes.

Non-Verbal Cues

Recognizing and Responding to Nonverbal Cues

Effective communication goes beyond words; nonverbal cues play a critical role in understanding and connection. If someone is nonverbal or struggles to articulate their thoughts, it is important to adapt your approach. For example, if you notice signs of discomfort or confusion, avoid pointing it out directly with statements like, “It seems like you do not understand.” Instead, rephrase your explanation or present the information in a different way. This allows the individual to remain in the loop without feeling singled out or embarrassed.

Pay close attention to nonverbal cues, as they often indicate whether someone is engaged or disconnected. Signs that you may have lost their attention or created discomfort include:

• Body language: Crossed arms, shifting in place, leaning away, or creating physical distance are all indicators that the person is disengaged or uneasy.
• Facial expressions: Frowning, pursed lips, raised eyebrows, eye rolls, or a shaking head can signal confusion, disagreement, or discomfort.
• Gestures: Fidgeting, tapping, or other closed-off gestures (such as clenching hands in pockets) may indicate frustration or discomfort.
• Eye Contact: Avoiding or limiting eye contact (if eye contact existed previously) may indicate hesitation or discomfort. Eye contact is particularly telling if it changes suddenly—though remember that cultural norms around eye contact vary.
• Tone of voice: A person’s tone can shift dramatically if they’re disengaged. Clear, steady speech may give way to mumbling, quieter responses, or even silence.

Understanding Minimal Encouragers

Minimal encouragers are subtle but essential nonverbal cues that show someone you are listening and engaged. These might include nodding, maintaining eye contact, or offering brief verbal affirmations like “Uh-huh” or “I see.” When these encouragers disappear—or are absent from the beginning—it could indicate that the person feels unheard, unvalued, or disconnected.

Tailoring Your Response

If you notice any of these cues, it is crucial to adjust your approach to bring the person back into the conversation. Here are some strategies:

• Rephrase and revisit: If you suspect they did not understand something, restate it in a different way. Instead of saying, “Let me explain that differently because I think you did not get it,” try, “Here’s another way to think about it,” or “Let’s go over this again from another angle.”
• Acknowledge and invite feedback: If you are unsure whether they’re following along, invite them to share: “Am I covering everything you need?” or “Did I miss something important?” This approach fosters collaboration and ensures they feel heard.
• Pay attention to their listening style: Some individuals might demonstrate understanding by maintaining prolonged eye contact, which can feel intense for some. If this makes you uncomfortable, address it gently: “I want to make sure I’m explaining things clearly—let me know if I missed anything.” This shifts the focus back to the conversation and reassures them of your engagement.

The Importance of Adapting

Everyone interacts with communication differently, shaped by their experiences, culture, and comfort level. By remaining attentive to nonverbal cues, adjusting your communication style, and inviting dialogue, you can create a more inclusive and understanding environment. These small but intentional efforts help ensure that both parties feel connected, respected, and aligned.

Considerations: ADA

Other Considerations: The ADA and Neurodiversity

it is important to note that the Americans with Disabilities Act (ADA) has not been updated since 2008 to reflect a broader understanding of neurodiversity. This lack of modernization is deeply problematic because the current framework primarily focuses on physical disabilities or accommodations like additional time for tasks. Neurodivergent conditions, which may require less conventional accommodations, often fall into a gray area within the ADA’s guidelines.

When we talk about reasonable accommodations, the term itself can be contentious. What is considered "reasonable" if the accommodation is not explicitly addressed by the ADA? This gap creates ambiguity for both employees requesting support and employers attempting to provide it.

Accommodations That Benefit Everyone

An important point to recognize is that accommodations designed for neurodivergent individuals often end up benefiting others as well. For example, I recently worked with an organization where an employee requested adjustments for light sensitivity. While replacing the lighting was not feasible, the company provided inexpensive, reusable tinted glasses instead. These glasses cost less than $2 each and ended up being useful for more than just the original requester.

This principle of universal benefit extends to many accommodations. Consider automatic doors: they were initially designed to help individuals using wheelchairs, but they’ve proven helpful for countless others. Parents juggling strollers and young children, shoppers carrying heavy bags, and older adults who struggle to open heavy doors all benefit from this innovation.

The same can be said for elevators in hospitals. Before elevators, staircases were the only option, creating significant barriers for individuals with mobility challenges. Today, elevators are a standard feature in nearly every multi-story building, benefiting people of all abilities.

Shifting the Lens: Equity vs. Equality

When thinking about accommodations, it is essential to approach them through an equity lens rather than an equality lens. Equality implies providing the same resources to everyone, while equity focuses on giving people what they specifically need to succeed. For neurodivergent individuals, this might mean personalized solutions that acknowledge their unique challenges.

it is also critical to acknowledge that not all accommodations are feasible. There may be instances where you have to say, “I’m sorry, we are unable to provide that accommodation right now.” This does not mean you have failed—it’s a reality of balancing resources and logistics. In these situations, it is important to give yourself grace. You cannot solve every issue, and recognizing your limits is part of creating a sustainable and thoughtful approach to accommodations.

The ADA’s outdated framework for neurodiversity highlights the need for broader societal and organizational efforts to address the unique needs of neurodivergent individuals. While not all accommodations are possible, many—such as inexpensive solutions or universally beneficial changes—are both doable and impactful. By thinking creatively and approaching these issues with an equity mindset, we can create environments that not only support individuals but also benefit entire communities.

Tips to Support

Social Etiquette and Creating Inclusive Workplaces

Understanding and fostering social etiquette in the workplace and in educational settings is vital for building an inclusive environment. Throughout my career, I have worked in diverse locations, including Detroit, Illinois, and Idaho. Moving to Idaho, however, felt like stepping into a different country—it was entirely unfamiliar. One notable experience stands out from my time in the ICU there.

Every day at 3 p.m., all the respiratory therapists would seemingly disappear. For months, I could not figure out where they went. As the only person in my department who looked like me, I hesitated to ask non-job-related questions. Eventually, I discovered that everyone was taking a collective snack break. While this was a normal routine for them, no one had thought to inform me or include me. It was not malicious—it was simply overlooked because it was ingrained in their culture.

This experience taught me the importance of explicitly sharing workplace norms, especially with new employees or students. Overlooking these small yet impactful social customs can unintentionally alienate others. For someone else, this situation could have led to feelings of not being liked or welcomed. By fostering open communication about workplace and social etiquette, you help others feel included and valued.

Addressing Stigma and Creating Safer Spaces

Many individuals, particularly those with neurodiverse conditions, hesitate to disclose their needs due to stigma. it is not required for anyone to share such personal details, but creating a safer space—a term I prefer over “safe space,” as true safety can only be governed individually—can encourage openness.

In my current job, I work on a team of five, and it was the quickest I have ever felt comfortable sharing my needs. Usually, it takes me six to nine months to open up about having ADHD and how it impacts my work. With this team, I felt safe enough to share within weeks. Their response was simple yet effective: “Okay. What do you need? How can we help?”

I explained that I struggle with abbreviations on video calls and meetings and that taking notes while leading a meeting or attending a webinar is difficult for me. They accommodated me by providing a pre-existing list of common abbreviations and even sending me Zoom messages in real-time with explanations when new ones came up. These accommodations were easy for them to implement and immensely helpful for me. Importantly, these changes weren’t formalized under the ADA—they were born out of an environment where I felt supported enough to ask for what I needed.

Understanding Different Definitions of Safety

Safety is a deeply personal concept that varies for each individual. For example, when I moved from Chicago to Idaho, many people commented, “I bet you are glad to be out of there.” For me, however, Idaho did not feel like a safe space. Safety, to me, meant being in a familiar environment surrounded by people who understood and supported me. Others may define safety differently, especially neurodiverse individuals, who may feel safest near those who have previously offered them understanding and support.

Providing advance notice about changes can also create a sense of safety. Notifying staff about upcoming fire drills, construction, or changes to routine helps them prepare physically and mentally. In healthcare, where such notice is not always possible, providing logic behind changes can help. If someone understands why something is happening, they may be more likely to accept and adapt to it.

Avoiding Assumptions

It is important not to make assumptions about people’s needs or goals. For instance, while encouraging someone to apply for a leadership role might come from a good place, it may not align with their aspirations. Some people find fulfillment in their current roles and do not seek additional responsibilities, and that’s perfectly valid. Share your observations and let them decide; do not push them into something they’re not ready for.

Similarly, avoid assumptions about what accommodations someone might need. Instead, foster open communication and allow them to share their preferences. Even simple accommodations, like addressing light sensitivity with inexpensive glasses, can make a significant difference.

Avoiding Sarcasm and Euphemisms

Lastly, be mindful of how sarcasm and euphemisms might be interpreted, especially by neurodiverse individuals or those unfamiliar with certain cultural norms. Sarcasm, while a common communication style, can be confusing or even hurtful if taken literally. For example, phrases like “That’s just great” in a sarcastic tone might be misunderstood. While avoiding sarcasm entirely can be challenging—especially for those who use it frequently—adopting clearer, more direct language fosters better understanding and connection.

Creating inclusive environments requires attention to both overt and subtle dynamics. From sharing workplace norms to fostering safer spaces and avoiding assumptions, these efforts build trust, encourage participation, and promote equity. By considering the varied needs and experiences of colleagues, staff, and students, we can work toward a culture where everyone feels valued and supported.

Common Euphemisms

The Importance of Direct and Thoughtful Language

Language carries weight, and the phrases we use—even those that seem harmless or commonplace—can have unintended consequences. Being direct and mindful of the words we choose not only reduces confusion but also helps avoid causing unintended harm.

Direct Language vs. Euphemisms

When discussing sensitive topics, it is important to prioritize clarity. For example:

• “They passed away” vs. “They died.” While "passed away" is often used to soften the reality of death, being direct by saying “they died” leaves less room for misinterpretation.
• “He is between jobs” vs. “He is unemployed.” The phrase “between jobs” can obscure the reality of unemployment, which may unintentionally downplay someone's situation. Being straightforward acknowledges their experience without unnecessary ambiguity.
• “She is feeling under the weather” vs. “She is sick.” While phrases like "under the weather" are commonly understood, their literal interpretation can spark confusion. A 19-year-old once pointed out to me, “If you think about it, everything is under the weather.” Technically, they’re not wrong, but this example highlights how being direct avoids unnecessary misinterpretations.

Phrases with Harmful Histories

Many common expressions have origins or implications that can be hurtful or harmful. For instance:

• “I’m gassed.” This phrase, used to express exhaustion, was pointed out in one of my conversations as having ties to the Holocaust. While not everyone may associate the phrase with this context, it is worth considering its potential impact.
• “Gone a bit baddie” or “That’s bonkers.” These terms, like "crazy," have historically been used to marginalize or demean people with mental health challenges. Even when used casually, they can reinforce harmful stereotypes or stigmas.

Recognizing Puzzled Reactions

Sometimes, people’s body language or expressions can indicate confusion or discomfort with a phrase you have used. If you notice puzzled looks or hesitation, take the opportunity to clarify. For example:

• If someone looks confused after hearing “He is between jobs,” you can follow up with, “I mean, he’s currently unemployed.”
• If you use a phrase with negative connotations and notice a reaction, acknowledge it: “I realize that phrase might not be the best choice—let me explain more clearly.”

Avoiding Harmful Expressions

Even phrases spoken lightly can have lingering effects. Words like “baddie,” “crazy,” or “bonkers” may seem innocuous but can sit with someone far longer than you realize. These terms, often weaponized against people with mental health challenges, can perpetuate stigma. The goal is not to be perfect but to strive for sensitivity and thoughtfulness in our speech.

Practical Tips for Mindful Communication

1. Be direct when possible. Use clear and straightforward language, especially for sensitive topics. This minimizes confusion and ensures your message is understood as intended.
2. Reflect on the origins of phrases. Many idiomatic expressions have negative or harmful histories. While you may not know every origin, being open to learning and adapting your language is key.
3. Pay attention to reactions. If you notice someone looks puzzled or uncomfortable, take it as an opportunity to clarify or adjust your phrasing.
4. Avoid stigmatizing terms. Words like “crazy” or “baddie” might feel casual, but they carry harmful connotations. Replace them with neutral or descriptive alternatives whenever possible.
5. Acknowledge mistakes. If you use a problematic phrase and realize it later, address it openly. This demonstrates a willingness to learn and grow.

Communication Tips for Workplaces and Interviews

Effective communication is the cornerstone of a supportive and inclusive environment. Patience is a critical component, even in fast-paced settings like hospitals. While time may be limited, making the effort to provide clear, concise instructions can prevent confusion and errors. For example, instead of saying, “Check everyone’s oxygen,” be explicit: “Check everyone’s oxygen using the pulse oximeter and document the readings.” Even if it feels overly specific, clear communication helps ensure tasks are completed accurately.

Job descriptions should also reflect clarity and modern standards. Use precise details such as shift times instead of vague terms like morning shift or afternoon shift. If weekend work is required, specify whether it is “every other weekend” or “every third weekend.” Additionally, reevaluate outdated requirements. For example, including phrases like “must lift 50 pounds” in office-based or non-physical job descriptions is unnecessary. Updating these descriptions ensures they accurately reflect the role’s demands and avoids perpetuating irrelevant or exclusionary criteria.

In interviews, move away from archaic definitions of professionalism that emphasize attire over qualifications. Judging candidates based on their clothing, particularly when the job involves wearing uniforms like scrubs, is both outdated and unfair. Focus on their skills, experiences, and responses rather than their outfit. It is also essential to ensure equity and relevance in interview questions. Regularly review and update questions to ensure they’re inclusive, free from bias, and directly related to the job’s requirements.

Creating inclusive and thoughtful interviews involves several steps. In group interviews, ensure the panel is diverse, with representation across genders and other identities. Mispronouncing a candidate’s name can cause disengagement, so practice names in advance and confirm pronunciation during the interview by asking, “Do I have this right?” If not, take the time to learn and use the correct pronunciation moving forward. Normalize sharing your pronouns and asking candidates for theirs to set a respectful and inclusive tone. Provide an overview of the interview process upfront, such as, “We’ll spend 60 minutes together, and I have 12 questions for you.” This helps candidates feel prepared and reduces anxiety.

Encourage candidates to take their time answering questions by saying, “You do not need to respond immediately—feel free to take a moment to think.” This fosters a more thoughtful and confident exchange. Additionally, remind candidates they can take notes during the interview. This small but meaningful gesture can help them organize their thoughts and feel more in control of the process.

By prioritizing clear communication, modernizing outdated practices, and fostering inclusivity, workplaces and interviews can become more equitable and supportive. These changes benefit individuals by creating a welcoming environment and enhance the organization by promoting fairness and collaboration.

Tips for Interviewing

During most interviews, it is common for the interviewer to take notes, so why shouldn’t the interviewee be allowed to do the same? Encouraging candidates to take notes during the interview helps them process questions and organize their responses. Additionally, a best practice is to provide interview questions in advance. While this suggestion often receives pushback from leaders—who worry it gives candidates an unfair advantage—it’s worth considering the benefits. Sharing common questions, such as “Tell me about your strengths and weaknesses” or “Describe a time when you faced a challenge and how you handled it,” allows candidates to prepare and present their best selves. This is not about providing clinical or technical questions in advance, but rather creating an environment where candidates can thoughtfully showcase their qualifications. After all, in most jobs, employees rarely need to respond to situations with the immediacy required in interviews, so giving them time to prepare aligns more closely with real-world expectations.

Another valuable question to ask during an interview is, “What makes a workplace feel safe or unsafe for you?” While you may not be able to fully meet their vision of a safer workplace, their response can offer insights into their values and needs. This information is useful not only for evaluating the candidate but also for shaping future policies and practices—even if they are not ultimately hired. Encouraging thoughtful responses and creating a supportive interview process fosters mutual respect and allows both parties to engage meaningfully.

Tips for Sensory

Supporting individuals with sensory needs involves practical solutions that promote comfort and inclusivity. For sound sensitivity, offering a quiet break space can make a significant difference. When quiet spaces aren’t feasible, providing noise-canceling headphones is an effective alternative. These headphones do not have to be expensive brands like Bose or Beats; affordable, reusable options are widely available, and many can be wiped clean for hygiene purposes.

For movement-related needs, allowing the use of fidget toys and offering flexible seating options, even briefly, can help individuals self-regulate. Healthcare environments often limit choices for seating or movement, but creating a comfortable space in break rooms can provide some relief. For instance, having chairs of varying heights ensures everyone can find a seat that suits them. Encouraging brief moments for physical movement outside of task-related rushing can also be beneficial.

Tactile accommodations might include allowing modifications to work uniforms, such as adding felt to scrub necklines for those with skin sensitivities. Providing tactile items like fidget toys in break areas is another simple yet effective solution. Many professionals, including mental health therapists, use fidget toys during their workday, and these items can be easily stored in pockets for convenience.

Lighting is another key consideration. Offering blue light screen covers or glasses can alleviate light sensitivity. Some organizations have even created sensory kits that include noise-canceling headphones, fidget toys, and light-filtering glasses. These kits can be purchased pre-made or assembled in-house at a lower cost, making them accessible for various settings. Sensory bags are increasingly common in workplaces, hospitals, hotels, and even retail environments, where they may be offered upon request.

Encouraging employees and students to take their breaks rather than skipping them is essential, especially in demanding fields like healthcare. Breaks aren’t just a luxury; they’re necessary for maintaining mental and physical well-being. While it is common for healthcare workers to skip breaks out of concern for burdening their colleagues, organizations should emphasize the importance of rest and recovery.

Neurodiversity Affirming Practice

• Core Principles
  • Intersectionality
  • Respecting autonomy
  • Validating differences
  • Presuming competence
  • Reframing expectations
  • Promoting self-advocacy
  • Rejecting neuronormativity
  • Prioritizing lived experience
  • Nurturing positive self-identity
  • Adapting systems and environments
  • Honoring all forms of communication

Watch Your Words!

Mindful language use is crucial in creating inclusive environments. Avoid using terms with stigmatizing or harmful connotations, particularly those related to mental health. For example, phrases like “this weather is so bipolar” misuse a serious condition and can deeply harm individuals who live with it. Similarly, casual remarks like “I’m a little OCD” or “take your happy pills” trivialize conditions like OCD and depression, which can be life-altering and debilitating for many.

In professional settings, it is especially important to avoid derogatory or dismissive terms. For instance, calling someone “psycho” or referring to a patient as “crazy” is not only disrespectful but also perpetuates harmful stereotypes. Such language can alienate colleagues or patients who may have experienced these terms as weapons against them or their loved ones. Even when used casually or jokingly, phrases like “bat-blank crazy” or “stop acting so schizo” are deeply problematic, particularly in healthcare or educational settings where trust and professionalism are paramount.

When communicating about a patient, stick to objective, clinical terms found in their chart or your observations. Avoid making assumptions or using colloquial terms, as these can harm your relationships with both colleagues and patients. It is impossible to know everyone’s personal history or how they may react to certain words. While true "safe spaces" may not exist, we can govern our own actions by being mindful of our language and fostering a more inclusive environment.

By implementing sensory accommodations and adopting mindful language practices, workplaces and educational settings can foster inclusivity and support individuals with diverse needs. Small changes, such as providing sensory tools, updating outdated language, and avoiding stigmatizing phrases, can have a significant impact on creating a respectful and welcoming environment for all.

Neurodiversity-affirming practices are rooted in principles that align closely with the framework of disability justice. There are ten principles of disability justice, and while all are significant, a few stand out as particularly relevant to this work. If you are interested in learning more, the QR code provided leads to additional information about the ongoing fight for disability justice in America.

Intersectionality

One critical principle is intersectionality, which is about recognizing that people have multiple, overlapping identities that shape how they experience the world. For example, I’m not just a person with ADHD—I’m also Black, queer, a woman, and I live in a fat body. All these parts of who I am come together in ways that influence how I move through life. Sometimes, certain spaces might feel safe or comfortable because of one part of my identity, but not for others.

For instance, as a Black person, I might face racial biases in certain settings, and as someone with ADHD, I might also deal with misunderstandings about how I work or communicate. Add in being queer and a woman, and it can feel like there are a lot of different layers to navigate at once. Living in a fat body adds yet another layer, especially when it comes to assumptions people make or the way healthcare is approached. All these identities do not exist separately—they mix and interact in ways that make my experiences unique.

Understanding intersectionality means keeping in mind that no one is just one thing. It is about seeing the whole person and recognizing how their different identities shape their experiences. For neurodivergent people, this is especially important because their challenges and needs might look different depending on the other parts of who they are. For example, a Black neurodivergent person might face both the stigma of neurodivergence and the impact of systemic racism, which creates a very different experience from someone who does not have those same layers.

When we think about inclusion, it is important to make room for all these different identities and how they overlap. It is not about treating everyone the same—it is about really listening to people and understanding how their unique mix of identities impacts their lives. That way, we can create spaces that feel welcoming and supportive for everyone, not just one part of who they are.

Prioritizing Lived Experience

Another key principle is prioritizing lived experience, which means valuing the voices of people who live with neurodivergence. While academic research and literature can provide useful information, there’s nothing more authentic than hearing directly from those who experience it firsthand. People with lived experience offer insights that no textbook or study can fully capture because they’re speaking from their day-to-day realities—their successes, challenges, and everything in between.

Resources created by neurodivergent individuals are incredibly valuable because they come from a place of personal understanding. They reflect real needs, practical solutions, and the nuanced ways neurodivergence impacts life. For example, a neurodivergent person sharing how they manage sensory overload or communicate at work provides actionable advice that feels relatable and grounded in reality. Whenever possible, we should prioritize learning from these voices rather than relying only on external analysis or theories written by people who do not share the experience.

It is not about dismissing academic research—it’s about balancing it with the perspectives of those who live it every day. By centering lived experience, we get a more complete, human understanding of what neurodivergence means and how to better support individuals in meaningful ways.

Recognizing Wholeness

Recognizing Wholeness is another essential principle. Neurodiversity is just one piece of a person’s identity, and it is important not to define someone solely by that one characteristic. People are complex, with many layers to who they are—interests, skills, values, and other parts of their identity that make them unique.

Recognizing wholeness means seeing and valuing the complete person—not just one part of their identity. It is about creating spaces where people can show up as their authentic selves without feeling like they’re being reduced to a single narrative or stereotype.

Sustainability

Sustainability is not just about protecting the planet—it is also about supporting people. To truly advocate for neurodivergent individuals, we need to adopt practices that prioritize their long-term well-being. This means understanding how neurodivergence affects them and making thoughtful changes to minimize stress and negative impacts in our interactions and shared environments.

Sustaining people goes beyond just meeting basic needs; it is about creating conditions where they can genuinely thrive. For neurodivergent individuals, this might include offering accommodations, fostering inclusive spaces, and ensuring that environments are flexible and supportive. Whether providing sensory-friendly workspaces or being mindful of clear communication, these efforts help people feel valued and empowered, not just tolerated.

Sustainability for people means moving past a survival mindset—where individuals are simply “getting by”—and instead focusing on helping them flourish in every aspect of life, whether at work, school, or within the community. By investing in practices that support long-term growth and well-being, we create a culture that uplifts everyone.

Collective Access

Collective access is vital. This principle highlights the importance of creating environments that support a wide range of needs, including cognitive, visual, auditory, motor, and speech-related accommodations. The idea is that accessibility is not just an individual responsibility—it’s a shared effort that benefits everyone. By working together to remove barriers and create inclusive spaces, we ensure that everyone has the opportunity to participate fully and equitably.

Collective access goes beyond meeting minimum standards. It is about recognizing that accommodations often serve more than just the individuals who request them—they enhance the environment for entire communities. For example, providing cognitive supports like clear instructions or sensory-friendly tools can improve focus and comfort for everyone in a workspace or classroom. Similarly, ensuring visual and auditory accessibility can make events or materials easier to engage with for a wider audience.

By embracing collective access, we take a proactive approach to inclusion, building environments that reflect the diversity of those who inhabit them. It reminds us that equity and justice aren’t one-time goals but ongoing commitments that require us to listen, learn, and act. When we prioritize accessibility and inclusivity, we create spaces where everyone feels valued, supported, and able to contribute their full potential.

Collective Liberation

Collective Liberation emphasizes that supporting neurodivergent individuals is not only about helping a specific group—it is about uplifting everyone. When we fight for equity and create spaces where neurodivergent individuals can thrive, the entire organization benefits. Inclusivity fosters collaboration, innovation, and mutual respect, making it easier for all employees to feel valued and supported, regardless of their identity.

By addressing barriers and implementing accommodations, we create a culture where diverse perspectives and strengths are welcomed and celebrated. This environment encourages people to bring their authentic selves to work, resulting in stronger teams and more meaningful contributions. The fight for equity is not just about fairness; it is about building a community where everyone benefits from understanding, respect, and shared success.

Sample of Neurodivergent Inclusion Policy

"This policy outlines our commitment to providing a workplace that embraces neurodiversity and challenges neuronormativity. Our workplace is dedicated to creating an inclusive environment for neurodivergent people where neurodivergent people feel welcome, accepted, and supported (livedexperienceeducator.com)."

Commitment to Inclusion and Support

• We strive to create a workplace where neurodivergent individuals can fully participate and thrive without facing stigma or discrimination.
• Accommodations are provided to ensure equitable opportunities for success, acknowledging that supporting one group often benefits the entire organization.
• We recognize the importance of learning from individuals with lived experience and incorporating their insights into our policies and practices

Guiding Principles

1. Embracing Neurodiversity:
   We challenge neuronormativity by recognizing and valuing the unique contributions of neurodivergent individuals. This means rejecting a "one-size-fits-all" approach and embracing diverse ways of thinking, working, and communicating.

2. Universal Benefits of Accommodations:
   Accommodations like flexible schedules, sensory-friendly environments, and clear communication practices often improve the workplace for everyone. By meeting diverse needs, we enhance productivity, collaboration, and employee satisfaction across the board.

Core Practices

1. Accessibility:

   • Provide accommodations for sensory, cognitive, and communication needs, including noise-canceling headphones, flexible seating, and quiet spaces.
   • Offer training to all staff to promote awareness and understanding of neurodiversity.

2. Clear Communication:

   • Use direct and inclusive language in all interactions.
   • Ensure transparency in processes like onboarding, meetings, and evaluations, with space for feedback and clarification.

3. Flexibility:

   • Allow for flexible work schedules and breaks to support individual productivity and mental well-being.
   • Provide tools such as sensory kits or assistive technology as needed.

4. Feedback and Collaboration:

   • Regularly seek input from neurodivergent employees to inform and improve policies.
   • Encourage open dialogue and create systems for anonymous feedback to ensure all voices are heard.

Implementation and Accountability

• Training: All staff, particularly managers and supervisors, will receive training on neurodivergent inclusion and best practices.
• Policies: Accommodations and inclusive practices will be clearly outlined and communicated during onboarding and revisited regularly.
• Monitoring: The effectiveness of this policy will be assessed through regular surveys, feedback sessions, and updates informed by lived experiences.

R.A.T.S. Framework for Inclusion

The R.A.T.S. framework—Relationship and Rapport, Accommodations, Time, and Sensory Support—offers a practical approach to fostering inclusion and accessibility in diverse environments. When in doubt, remember to focus on R, relationships, and rapport. Building strong connections with others provides valuable insights into their experiences, enabling you to identify ways to support them effectively and leverage your resources or privileges to help.

Relationship and Rapport Building

Strong relationships are the foundation of understanding and support. By taking the time to genuinely connect with others, you can gain deeper insight into their unique challenges and needs. This relationship-building allows you to move beyond assumptions and instead create meaningful, individualized solutions. Relationships are not just about listening—they’re about acting on what you have learned to make environments more inclusive and supportive.

Accommodations

The Americans with Disabilities Act (ADA) has not been updated since 2008, leaving many needs of neurodivergent individuals and others unmet. It is crucial to look beyond what the ADA defines as “reasonable accommodations” and instead focus on what is truly needed. When we move past the bare minimum and provide thoughtful accommodations, we make environments better for everyone—not just for those with neurodivergent conditions but for all individuals navigating shared spaces.

Time

Explicit communication about time, needs, and expectations is essential. Never assume someone “just knows” something because of their age, experience, or tenure. Share critical information early, repeat it often, and clarify as necessary. Clear and transparent communication ensures everyone has the tools they need to succeed.

Sensory Support

Sensory experiences play a significant role in accessibility. For example, at a recent AARC conference, I wore sunglasses indoors because of light sensitivity caused by the bright overhead lights. Similarly, sensory accommodations such as noise-canceling headphones, quiet spaces, or flexible seating can significantly improve accessibility for many individuals.

During my presentation at the same conference, I noticed an attendee with a service dog and a leading cane, indicating visual impairment. Recognizing the need for immediate adjustments, I modified my presentation on the spot. I announced that I would read more directly from the slides to ensure accessibility for everyone. The response was overwhelmingly positive—several people, including the attendee with the cane, stood up to thank me, sharing that this adjustment allowed them to participate fully for the first time. This experience highlighted the importance of anticipating and addressing accessibility needs, even when they aren’t immediately visible. While I made these changes on the fly, it reminded me of areas where I can improve and be more proactive in creating inclusive spaces.

The Importance of Accessibility and Understanding

For me, being diagnosed with ADHD in 2017 was a transformative experience. It gave me clarity and validation, enabling me to better understand the adjustments I had been making throughout my life. Despite being told that certain achievements were out of reach for me, I have built a meaningful career—first in respiratory therapy and now in mental health, where I run a private practice. My journey underscores an important truth: a diagnosis or condition does not define what someone can or cannot do. It might mean working harder or differently, but it does not mean the goal is unattainable.

As you interact with individuals with diverse conditions, remember that these conditions do not stop people from achieving their goals. Instead, they highlight the importance of support, understanding, and collaboration in fostering success. Advocating for neurodivergent inclusion and better clinical practices requires systemic change and individual action. By questioning outdated systems, choosing respectful language, and fostering collaborative communication with patients, we can create environments that support diverse needs and empower individuals to thrive. Every small adjustment we make contributes to a culture of inclusivity and care.

Questions and Answers

Thank you for sharing your personal examples of how neurodivergent individuals can advocate for themselves. How can we advocate more for inclusion, especially in clinical or workplace settings?

This is such an important question. Advocacy for inclusion begins with examining and questioning the systems already in place. For example, I once spoke with professors about challenges they faced in clinical settings, like students who struggled with social cues. These students were not harming patients but were seen as "different" in how they built relationships. One takeaway I shared was that we need to avoid boxing people into specific expectations—like assuming the ICU is the only viable path in healthcare. Not everyone wants to work in the ICU, and that's perfectly fine. We must create space for diverse skills and paths.

From a student perspective, creating safer spaces early on is key. For instance, I once attended a session where students asked questions about accommodations for exams, such as needing more time or using a standing desk. While the session leader provided information about accommodation forms, we later found significant barriers to accessing those accommodations, such as requiring doctor approvals or insurance. This underscores the importance of interrogating outdated systems: when were they last updated, and how can we make them better? Regularly seeking input from students and staff can lead to meaningful improvements.

On your slide about harmful phrases, you highlighted how language can create a silencing effect. Could you expand on why this is important?

Absolutely. Language has immense power, and harmful phrases—like using terms such as "bipolar" or "OCD" casually—can perpetuate stigma and silence individuals who live with these conditions. For example, jokingly saying someone is "so bipolar" trivializes a serious and life-changing condition. Similarly, calling medication "happy pills" dismisses the importance of treatment. In diverse settings, it is crucial to think critically about language and choose words that foster understanding rather than harm. This self-awareness can create a culture of respect and inclusivity.

In a clinical setting, how would you adjust your approach if a patient shows signs of sensory overload during suctioning or an ABG draw?

The first step is to acknowledge the situation and communicate openly. For example, you might say, “This might be uncomfortable or even painful—what can we do to make it a little easier for you?” Many patients, especially those who have undergone frequent procedures, may already have strategies that help them cope. Including them in the conversation gives them a sense of control. For suctioning, there may be fewer options due to its inherently uncomfortable nature, but for needle-related procedures, patients often have preferences that can reduce their discomfort.

Building on that, what about addressing sensory overload in the environment, such as bright lights or loud TVs?

That’s a great point. Creating a low-stimulus environment can significantly reduce sensory overload. When entering a room, I always try to explain what I’m doing: “It’s bright in here—I’m going to turn down the lights a bit. Does that work for you?” or “Let’s turn off the TV for more clarity during this conversation. Is that okay?” If the patient declines, I offer alternatives, such as writing things down or finding another way to communicate. Including the patient in these decisions is essential because hospital stays often strip individuals of their sense of control. Anytime we can return even a small measure of control to them, it builds rapport and trust.

References

Beatty, J. E. (2016). 10 principles of DJ-ing (2nd ed.). Squarespace. https://static1.squarespace.com

Bernstein, E. S. (2020, December 3). Why you need to stop using these words and phrases. Harvard Business Review. 

https://www.institute4learning.com/

Doyle, N. (2020, March 24). The world needs neurodiversity: Unusual times call for unusual thinking. Forbes. https://www.forbes.com.

Ngwagwa. (2021, December 15). Neuroexpansive™️ thoughts. Medium. https://medium.com/@ngwagwa

The following is a transcript of the live webinar An RT Overview of the Revised Pediatric Acute Respiratory Distress Syndrome (PARDS) Guidelines from PALICC II, presented by Evan Richards, BSc, RT.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Identify the key revisions in the Pediatric Acute Respiratory Distress Syndrome (PARDS) guidelines from PALICC II and understand their implications for clinical practice.
• Explain how to apply the revised PARDS guidelines in real-world scenarios, enhancing clinical decision-making and patient management skills in pediatric respiratory care.
• Discuss strategies to implement the updated guidelines effectively, aiming to improve patient outcomes through evidence-based respiratory therapy practices.

Introduction

I appreciate the opportunity to present this material, and I want to acknowledge that people take time out of their day to learn. That means a great deal to me. Everything I am about to share with you is based on clinical recommendations from evidence-based medicine, largely from randomized controlled trials or smaller individual trials. All content is evidence-based, and you will see why that matters when it comes to establishing guidelines.

Before going any further, let me simplify the terminology. Pediatric Acute Respiratory Distress Syndrome will be referred to throughout as PARDS, and the Pediatric Acute Lung Injury Consensus Conference will be called PALICC. The first consensus conference, PALICC 1, took place in 2015. The second, PALICC 2, was completed in 2023, and the revised guidelines it produced are the focus of this course.

I would like to acknowledge four colleagues whose contributions were essential to this presentation: Alex Rotta, MD, from Duke University; Robi Khemani, MD, the senior author of the PALICC 2 guidelines, from Children's Hospital Los Angeles; Ira Cheifetz, MD, from Rainbow Babies in Cleveland; and Martin Kneyber, MD, from Beatrix Children's Hospital in the Netherlands. I could not have assembled this content without them.

Why Children Are Not Small Adults

For many years, clinicians managed pediatric patients with ARDS by applying adult definitions and protocols to children. This approach is fundamentally flawed. Children are not small adults, and the physiological differences between children and adults have profound implications for how ARDS must be defined and managed.

Key physiological distinctions include the following.

• Airway cartilage formation is incomplete in children, whereas it is fully established in adults.
• Children have greater airway resistance due to smaller airways, making them more resistant to gas flow in both directions.
• Children have greater chest wall compliance because ossification of the rib cage is not yet complete, whereas the adult rib cage is solidified.
• Respiratory muscle reserve differs: children rely more heavily on the diaphragm than adults do.
• Pulmonary vascular resistance is a significantly greater problem in children, whose lungs are still growing and whose alveolar capillary proliferation is incomplete.
• Alveolar maturation differs dramatically: a child may have 20 to 50 million alveoli, resulting in a lower functional residual capacity, compared to approximately 500 million alveoli in a healthy adult.

These differences make it essential that pediatric ARDS be defined and managed on its own terms, not as a scaled-down version of adult ARDS.

What Is PARDS and Why Does It Matter?

Prior to 2015, there had never been a pediatric-specific definition of ARDS. Existing definitions, including the American-European Consensus Conference definition from 1994, the Murray Acute Lung Injury Score from 1998, the Delphi Consensus definition from 2005, and the Berlin definition from 2012, were all designed for adult populations.

Although PARDS affects only about 6 to 10 percent of patients in the pediatric intensive care unit, these patients consume approximately 80 percent of the unit's time and resources. They are, by definition, among the sickest children in any PICU. This clinical burden makes it essential to develop sound, evidence-based guidelines for their management.

The causes of PARDS are numerous. Sepsis and infectious pneumonia, bronchiolitis, aspiration, major trauma, pulmonary contusion, burns, inhalational injury, massive transfusions, transfusion-related acute lung injury, acute pancreatitis, fat embolism, envenomation, drowning, drug reactions, malignancy, and lung transplantation can all trigger PARDS. Regardless of the initiating cause, every one of these conditions presents a ventilation challenge that demands a carefully considered approach.

How PARDS Develops: Pathophysiology

In a healthy lung, each alveolus contains a layer of surfactant produced by type 2 pneumocytes. This surfactant maintains appropriate surface tension to keep the alveolus inflated. A basement membrane protects the alveolar wall. Capillaries remain close to the alveolar surface, enabling good ventilation-perfusion matching, and alveolar macrophages remain relatively quiescent.

When a patient becomes critically ill and requires mechanical ventilation, the shear forces generated by the ventilator can slough bronchial epithelium, denude the basement membrane, and create stress fractures in alveolar tissue. Interstitial flooding leads to protein-rich edema, which inactivates surfactant. Disrupted apoptosis impairs normal cellular renewal. Fibrin collects within alveolar walls, and gap formations develop in capillary walls under the pressure and volume delivered by the ventilator.

Once blood enters the air spaces or air enters the tissue spaces, an inflammatory cascade is triggered. Activated alveolar macrophages release interleukins and tumor necrosis factor, which act as chemoattractants for neutrophils. Neutrophils migrate into the lung from the bloodstream and, in attempting to contain the injury, release oxidants, leukotrienes, and proteases. The result is the full clinical picture of PARDS.

PALICC 1 (2015): The First Pediatric ARDS Consensus

In response to the absence of pediatric-specific ARDS guidelines, the first Pediatric Acute Lung Injury Consensus Conference convened. PALICC 1, completed in 2015, brought together 27 experts from eight countries. It was the first attempt to define ARDS specifically for pediatric patients. Over approximately three years, the group produced nine sections of guidance and more than 151 recommendations. The evidence base drew from both adult data and infant data, including studies conducted in neonatal intensive care units.

PALICC 2 (2023): An Expanded Effort

PALICC 2 was far more ambitious in scope. The consensus group expanded to 56 experts representing 15 countries across six continents. Forty-one percent of the participants were women, a significant increase from 2015. For the first time in either consensus conference, a respiratory therapist was included among the experts: Natalie Napolitano, MPH, RRT-NPS.

The process began in 2019 and was completed in 2023. The group conducted a systematic literature review to identify, assess, and combine all available evidence from adult randomized controlled trials, pediatric studies, and meta-analyses. Critically, no perinatal or neonatal data were included, reflecting the recognition that children are also not premature infants. The GRADE framework (Grading of Recommendations, Assessment, Development, and Evaluation) was used to classify each recommendation as either weak or strong. A strong recommendation required at least 96 percent agreement among participants after up to three rounds of voting. The final product comprised 11 sections and more than 160 recommendations.

Two new sections were added that had not existed in PALICC 1. The first addressed noninvasive respiratory support, reflecting the dramatically expanded use of noninvasive ventilation in pediatric critical care since 2015. The second addressed implementation in resource-limited settings, recognizing that not all centers have access to advanced equipment, full staffing, or the complete range of ventilatory options available in major teaching hospitals.

One inherent challenge for any PARDS guideline is the extraordinary range of patients it must cover. A pediatric patient with ARDS may be a young infant or a 17-year-old adolescent. Achieving consensus recommendations that apply meaningfully across this entire age spectrum is part of why strong recommendations require such a high level of agreement.

The Updated PARDS Definition

The core elements of the PARDS definition remained unchanged between PALICC 1 and PALICC 2. A patient with an oxygen index (OI) greater than 4, or an oxygen saturation index (OSI) greater than 5, should be considered at risk for PARDS. The major addition in PALICC 2 was the formal inclusion of a definition for noninvasive patients who cannot have an OI calculated because they do not have a measured mean airway pressure.

PALICC 2 also introduced an important change regarding the timing of diagnosis. Clinicians should not diagnose PARDS immediately upon a patient's arrival. Instead, the patient should be given four or more hours to stabilize with appropriate support before the diagnosis is made. The rationale is that modern therapists using modern equipment have become quite effective at rapidly stabilizing these patients. Premature diagnosis risks overloading a child with intervention before it is clear how sick that child truly is.

Severity Classification

PALICC 1 defined mild and moderate PARDS as separate categories. PALICC 2 combined them into a single category, because the data show very little difference in mortality rates between the two groups. Treating them separately created a false distinction in a population that is uniformly high-risk.

For intubated patients, mild to moderate PARDS is defined as an OI less than 16 or an OSI less than 12. Severe PARDS is defined as an OI of 16 or greater, or an OSI of 12 or greater. These thresholds are unchanged from PALICC 1.

For noninvasive patients, the PF ratio (PaO2 divided by FiO2) is used in place of the OI. A PF ratio greater than 100 indicates mild to moderate PARDS, while a PF ratio of 100 or less indicates severe PARDS.

To calculate the OI for an intubated patient, multiply the FiO2 (expressed as a decimal) by the mean airway pressure, divide by the PaO2, then multiply by 100. For example, a patient on 65 percent oxygen with a mean airway pressure of 16 and a PaO2 of 82 yields an OI of 12.5, placing that patient in the mild to moderate category. If that same patient deteriorates to 90 percent oxygen, a mean airway pressure of 19, and a PaO2 of 72, the OI rises to 24, indicating severe PARDS.

Resource-Limited Settings

PALICC 2 added guidance for resource-limited settings where full imaging, conventional mechanical ventilation, or adequate staffing may not be available. In these settings, a patient who requires supplemental oxygen to maintain an SpO2 of 88 percent or greater should be considered at risk for PARDS. Possible PARDS is defined by high-flow nasal cannula use at 1.5 L/kg/min or 30 L/min, or by a PF ratio of 300 or less, or an SF ratio of 250 or less in a patient on nasal noninvasive ventilation.

These patients are extremely high-risk. Approximately 50 percent of PARDS patients managed on noninvasive support ultimately require intubation, and those who do have very high mortality rates. Noninvasive ventilation in this population must be approached as a time-limited trial, with active monitoring for physiological stability including heart rate, respiratory rate, oxygenation, and work of breathing. If a patient with severe PARDS does not improve on noninvasive support, intubation should be pursued within one hour. For mild to moderate PARDS, a trial of four to six hours is appropriate before escalating to intubation. Resource-limited centers should also ensure they have a system in place for transferring patients who require a higher level of care.

Tidal Volume

PALICC 1 recommended a tidal volume (VT) of 5 to 8 mL/kg for patients with better respiratory system compliance, and 3 to 6 mL/kg for those with poor compliance. PALICC 2 updated this guidance based on a rigorous review of the evidence.

A landmark 1998 study by Amato and colleagues compared conventional ventilation using a VT of 12 mL/kg against a more protective strategy with a VT of 6 mL/kg. Patients on 12 mL/kg had a survival rate of approximately 28 percent. Those on 6 mL/kg had a survival rate of approximately 60 percent, demonstrating clearly that protective ventilation saves lives.

A subsequent multicenter randomized controlled trial by Dr. Khemani and colleagues found that 6 to 8 mL/kg produced the highest survival rates. Dropping below 6 mL/kg was associated with worse outcomes, possibly due to inadequate alveolar ventilation.

PALICC 2 revised the tidal volume recommendation to 6 to 8 mL/kg, with strong agreement at 98 percent. For patients in whom these volumes would cause plateau or driving pressures to exceed recommended limits, a VT less than 6 mL/kg should be used. In the most severely ill patients where survival is the primary concern, VT less than 4 mL/kg may be used with caution.

PEEP Recommendations

PALICC 1 recommended moderately elevated PEEP levels of 10 to 15 cm H2O, with higher levels considered acceptable in severe PARDS. PALICC 2 moved to a more structured approach.

PALICC 2 endorsed the Low PEEP/High FiO2 table from the ARDS Network protocol, which provides specific FiO2 and PEEP combinations to achieve adequate oxygenation. The target SpO2 range is 88 to 97 percent. Clinicians should use the table to guide their FiO2 and PEEP selections, recognizing that a PEEP lower than what the ARDSnet protocol specifies for a given FiO2 level is associated with higher pediatric mortality. There was strong agreement on this point at 96 percent.

The FiO2/PEEP table provides the following general pairings: FiO2 of 30 percent pairs with a PEEP of 5; 40 percent with 6 to 8; 50 percent with 8 to 10; 60 percent with 10; 70 percent with 10 to 14; 80 percent with 14; 90 percent with 14 to 18; and 100 percent with 18 to 24.

Importantly, PEEP should not be raised in isolation. As the patient's compliance, tidal volume, and hemodynamics change, PEEP should be titrated accordingly. As oxygenation improves and FiO2 is weaned, PEEP should be weaned in parallel to track the table. Conversely, when adjusting PEEP upward, clinicians must monitor that plateau pressure and driving pressure do not exceed their recommended limits. There was 100 percent agreement on this principle.

Evidence from large-scale studies supports elevating PEEP as the most effective single strategy for reducing the relative risk of death in ARDS. Research comparing three approaches, raising PIP without changing PEEP, raising both PIP and PEEP to maintain driving pressure, and raising PEEP while holding PIP stable, found that the last approach produced the most stable and favorable outcomes.

Driving Pressure: A New Addition in PALICC 2

Driving pressure is entirely new to PALICC 2; it was not addressed in PALICC 1. Driving pressure is defined as the difference between plateau pressure and PEEP. It is calculated by performing a brief inspiratory pause of two to three seconds. During this pause, pressure drops slightly as the lung and circuit absorb the delivered volume. The pressure at the end of that pause is the plateau pressure, not the peak inspiratory pressure. Driving pressure equals plateau pressure minus PEEP.

PALICC 2 recommends keeping plateau pressure at or below 28 cm H2O, with low agreement at 92 percent. In patients with reduced chest wall compliance, plateau pressures of 29 to 32 cm H2O may be necessary. These values are unchanged from PALICC 1.

The new addition is a specific limit on driving pressure: it should not exceed 15 cm H2O, as measured under static conditions. Although this recommendation achieved only 82 percent agreement and is therefore categorized as very low agreement in the GRADE framework, the clinical rationale is compelling. The lower the driving pressure, the lower the alveolar strain, and the better the patient's outcomes.

Consider a patient on a PEEP of 9 with a plateau pressure of 24: the driving pressure is 15, which is exactly at the recommended limit. If PEEP is then increased to 12 to improve oxygenation, the plateau pressure may rise above 28, pushing the patient into the lung injury risk zone. The appropriate response is to lower the tidal volume, which will bring the plateau pressure and driving pressure back within acceptable limits.

In practice, the three variables of PEEP, tidal volume, and driving pressure must be managed together. Increasing PEEP may require a corresponding reduction in tidal volume to stay within driving pressure limits.

Noninvasive Ventilation

PALICC 1 contained no guidance on noninvasive ventilation (NIV). PALICC 2 added a dedicated section reflecting the significant expansion of NIV use in pediatric critical care over the intervening years.

Meta-analytic data reviewed by PALICC 2 consistently showed that noninvasive approaches, including CPAP and high-flow nasal cannula, favor outcomes compared to standard oxygenation therapy. PALICC 2 recommends a time-limited trial of NIV, specifically CPAP or BiPAP, for patients who do not have a clear indication for immediate intubation. There was 88 percent agreement on this recommendation.

However, the time-limited nature of this trial must be taken seriously. If a patient on NIV does not demonstrate clinical improvement within four to six hours, or shows signs of deterioration, intubation should occur. There was 94 percent agreement on this point. The rationale is important: even patients who are never intubated can develop chronic lung disease if they struggle on noninvasive support for too long. Prolonged effort without adequate mean airway pressure to maintain an open lung strategy leads to ongoing injury through a different mechanism.

I recall a Canadian respiratory therapist describing a patient who was managed on NIV for 24 days before the team finally decided to intubate. The first post-intubation chest radiograph revealed chronic lung disease, despite the patient having never been on a conventional ventilator. Prolonged struggle on NIV had produced the injury.

For resource-limited settings, PALICC 2 suggests using CPAP or high-flow nasal cannula over standard oxygen therapy for patients at risk for PARDS (92 percent agreement), and CPAP over high-flow nasal cannula for patients with possible PARDS (83 percent agreement).

P-SILI: Patient Self-Inflicted Lung Injury

P-SILI, or patient self-inflicted lung injury, is another concept that is entirely new to PALICC 2. Unlike ventilator-induced lung injury, P-SILI is driven by the patient's own spontaneous breathing effort. When spontaneous breathing is intensely labored, large swings in transpulmonary pressure are generated. These pressure swings create alveolar stress even in the absence of mechanical ventilation. The worse the lung compliance, the more severe the problem.

P-SILI can occur in patients on conventional mechanical ventilation as well as those on noninvasive support. A patient taking large unassisted breaths through a poorly calibrated ventilator circuit is effectively injuring himself with each breath. This is why monitoring work of breathing is so important in every PARDS patient. Signs of excessive respiratory effort may indicate the need for sedation, neuromuscular blockade adjustment, or a reassessment of the ventilatory strategy itself.

Before proceeding to sedation or neuromuscular blockade, it is worth evaluating whether the ventilatory strategy itself can be adjusted to reduce the patient's drive to breathe. If a patient is working hard against the ventilator, it may be that the ventilator is not meeting the patient's needs. Modifying the strategy may reduce the work of breathing without requiring additional pharmacological intervention.

Putting It All Together

When a patient arrives in the PICU and is placed on noninvasive support, the clinician should begin calculating SF ratios and monitoring work of breathing immediately. Targeted sedation, adequate nutrition, and fluid management should be established as standard practice. Oxygenation targets on noninvasive support are an SpO2 of 92 to 97 percent.

If the patient requires intubation, the OI becomes the primary severity measure. On invasive ventilation, the PALICC 2 framework directs clinicians to maintain plateau pressure at or below 28 cm H2O, driving pressure at or below 15 cm H2O, tidal volume at 6 to 8 mL/kg, and PEEP according to the ARDSnet Low PEEP/High FiO2 table. The SpO2 target shifts to 88 to 97 percent to avoid exposing the patient to excessive oxygen toxicity.

As the OI worsens and the patient's condition deteriorates, additional interventions may be considered. Tidal volume may be reduced to 4 to 6 mL/kg. Neuromuscular blockade, inhaled nitric oxide therapy, prone positioning, and recruitment maneuvers may all be appropriate depending on the clinical picture. High-frequency jet ventilation (HFJV) or high-frequency oscillatory ventilation (HFOV), while not receiving a formal recommendation in PALICC 2, are available options when standard approaches are insufficient. If all conventional and rescue strategies are failing, extracorporeal membrane oxygenation (ECMO) must be considered before the window for safe cannulation closes.

Recruitment Maneuvers and High-Frequency Jet Ventilation

Recruitment maneuvers aim to open collapsed lung units and stabilize them at an adequate PEEP. An approach supported by evidence involves delivering a pressure 5 to 8 cm H2O above PEEP, no more than 15 cm above, and sustaining that pressure for 20 to 30 seconds, followed by a brief release, and then repeating the maneuver three times. On a conventional ventilator, this is approximated using two- to three-second inspiratory pause times. The underlying mechanism is pendulluft flow: when the inspiratory pause is long enough, air redistributes from better-ventilated alveoli to adjacent collapsed units, promoting gradual recruitment. This effect does not occur with the very short inspiratory times often used in standard ventilation.

PALICC 1 stated that HFJV could not be recommended for the routine management of PARDS but acknowledged it as a possible option in patients with severe pulmonary air leak syndrome, with 64 percent agreement. PALICC 2 made no recommendation for or against high-frequency ventilation of any type, despite the existence of multiple published studies. Research published in 2015 and 2020 as well as a 2021 study in the Respiratory Care journal demonstrated that HFJV improves oxygenation indices, normalizes pH, reduces FiO2 requirements, and may reduce the need for ECMO in PARDS patients. These studies also suggested that starting HFJV before the condition becomes too severe produces the best results.

The absence of HFJV from PALICC 2 reflects a gap in the evidence rather than evidence of harm. This represents an area where respiratory therapy researchers can make a meaningful contribution ahead of future consensus development.

The most important message from PALICC 2 was articulated simply by Dr. Cheifetz: back to basics and protective ventilation. How a patient is ventilated must be as protective as possible. Maintaining lower driving pressures, optimizing PEEP, delivering appropriate tidal volumes, and using longer inspiratory times at lower pressures all contribute to a safer ventilatory approach. High-frequency ventilation, conceptually described as CPAP with a wiggle, takes this principle to its logical extreme by delivering mean airway pressure without high-volume, high-pressure excursions.

Summary

PALICC 2 represents a rigorous, methodologically sound advance in the management of pediatric ARDS. Key achievements include the use of a larger and more diverse expert group, the exclusion of neonatal data to focus specifically on pediatric populations, the consolidation of mild and moderate PARDS into a single category, a four-hour observation window before diagnosis, and the formal extension of guidance to noninvasive patients and resource-limited settings.

The core recommendations that respiratory therapists should carry into practice are the tidal volume target of 6 to 8 mL/kg, PEEP management guided by the ARDSnet Low PEEP/High FiO2 table, plateau pressure at or below 28 cm H2O, driving pressure at or below 15 cm H2O, and active monitoring of work of breathing to detect P-SILI. Time-limited trials of noninvasive support with a clear threshold for escalating to intubation are also central to the revised guidelines.

Many recommendations carry only low or very low certainty of evidence, primarily because insufficient pediatric-specific research exists. This is an opportunity and a call to action for respiratory therapists who wish to engage in research. The areas with the weakest evidence, including high-frequency ventilation and several adjunctive therapies, are precisely where new data would have the greatest impact. If you are involved in PARDS research, you are contributing directly to the evidence base that will inform PALICC 3.

Questions and Answers

Given the broad age range of pediatric patients, from infants to adolescents, is it surprising that such a high level of agreement was required to achieve a strong recommendation?

That is an important point. The age range is precisely why strong recommendations are so difficult to achieve. The variability in patient size, developmental stage, and pathophysiology across the pediatric spectrum means that a recommendation which applies well to a one-year-old may not apply equally well to a fifteen-year-old. The requirement for 96 percent or greater agreement likely reflects this challenge. It is very hard to achieve near-universal consensus when the patient population is so heterogeneous.

What areas of PARDS research would you most encourage respiratory therapists to pursue?

The best strategy is to look at the PALICC 2 guidelines themselves and identify the sections where the recommendations carry the weakest evidence. Those are the areas where new research would have the greatest impact. High-frequency ventilation is a clear example: it received a strong recommendation in PALICC 1 only for air leak syndrome, received no consideration at all in PALICC 2, and yet multiple published studies suggest clinical benefit. That gap between available evidence and guideline inclusion represents an opportunity. More broadly, any section of the guidelines where the certainty of evidence is categorized as low or very low is a candidate for future study. Respiratory therapists who engage in this research will be among the heroes of PALICC 3.

References

References are provided in the course handout.

The following is an edited transcript of the course, Breathing Easy: Building Psychological Safety for Respiratory Therapists and Healthcare Teams, presented by Gabrielle Davis, MPH, MA, RRT, RRT-ACCS, RRT-NPS, TTS, LPC, NCC, FAARC.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Define psychological safety and explain its significance in healthcare settings, particularly for respiratory therapists and interdisciplinary teams.
• Identify common barriers to psychological safety in the workplace and their impact on communication, decision-making, and patient care.
• List strategies to cultivate a psychologically safe environment that encourages openness, collaboration, and continuous learning among healthcare professionals.

Psychological Safety

Psychological safety is the shared belief that individuals can speak up, take interpersonal risks, and voice concerns without fear of blame, ridicule, or retaliation. It is critical in complex, multidisciplinary settings such as healthcare, where open communication and trust are essential for effective teamwork and patient safety. Psychological safety allows us to ask questions, report errors, and share new ideas, fostering an environment where everyone feels valued and supported in contributing to high-quality care.

In simpler terms, psychological safety is the ability to speak up without fear of punishment. It encompasses the encouragement of varying ideas and feedback when appropriate, and places an emphasis on learning from mistakes rather than assigning blame. Punishment, it is worth noting, does not only mean formal consequences. It can also take the form of ridicule, embarrassment, or social exclusion.

I have thought about psychological safety in different contexts over my years as a respiratory therapist (RT), but I could not fully conceptualize it until I went to school to become a mental health therapist. Bridging the gap between healthcare and mental healthcare brought a great deal into focus.

Real-World Examples from Clinical Practice

To illustrate what psychological safety looks like in practice, I want to share a few scenarios from my own career.

The last time I worked bedside was in 2021. I was in a PICU helping out at a new hospital. The person assigned to orient me had been a therapist for about three or four years. At that point I had been a therapist for approximately ten years and had worked in multiple states. There was a child, twelve or fourteen years old, on the ventilator. The report indicated ventilator settings that I was unsure were appropriate, so I asked my preceptor whether we should speak with the physician.

She agreed it was a good idea. I approached the doctor, explained what I had observed, and said that in my experience those settings had not worked before and sounded potentially dangerous. I asked if he could say more about his reasoning. The doctor was visibly surprised that I was questioning him. He ultimately defended his position, but the next day the settings had been changed to what I had suggested. I found myself wondering: what if we could have had that conversation twenty-four hours earlier? Could we have mitigated harm more quickly?

What I also noticed in that moment was that my preceptor had privately agreed with my concern but was not comfortable voicing that agreement in front of the physician. She did not feel psychologically safe enough to speak up. That gap matters.

A second scenario involved me, a student, in 2008 during my final clinical rotation in the emergency room. A trauma came in, and the patient was a young woman who so closely resembled my sister that I froze. I could not function. My preceptor had to redirect me to the head of the bed by calling out to me. What brought me back was seeing the patient's mother enter the room, which reminded me that this was not my family.

After the patient was stabilized, my preceptor immediately moved on to the next room as if nothing had happened. I asked to use the restroom, went in, cried, and called my family. When I returned, my preceptor was irritated. There was no debriefing, no checking in, no acknowledgment of what had just occurred. What if there had been a psychologically safe space to say, "Do you want to talk about what just happened?" That conversation does not have to happen before the next patient. It can happen after. Any event can be debriefed at any time.

A third scenario took place during medical rounds. I was the only person of color in a group of ten medical professionals. The physician made a racially derogatory comment about the patient, who was also a person of color, and nobody responded. I asked the physician directly whether he had meant to say that aloud. He seemed surprised that anyone had challenged him. He eventually apologized. But I want to highlight something: nine other professionals were present, and not one of them said anything. Some were visibly uncomfortable and knew the comment was wrong. What would have happened if even one of them had felt safe enough to speak up?

These examples illustrate that psychological safety reaches beyond patient safety metrics and anti-bullying policies. It shapes every interaction in the clinical environment.

Outcomes of Psychological Safety

When healthcare teams operate in psychologically safe environments, the outcomes are significant. According to the Joint Commission, approximately 70% of medical errors are communication errors. If we create safer spaces for communication, we create safer outcomes for patients.

The benefits of psychological safety include:

• Safer patient care through reduced communication errors
• Enhanced collaboration and team learning, including input from dietary, environmental services, and other non-clinical roles
• Decreased errors and near misses
• Decreased compassion fatigue, which is the stress that comes from chronically caring for others, and is something every clinician experiences, whether they name it or not
• Decreased burnout

It is also worth noting that medical professionals are less likely to report their own mental health struggles. They may acknowledge that mental health challenges exist in the medical field broadly, but are far less likely to speak about their own. When the environment is not psychologically safe, this silence is reinforced.

Barriers to Psychological Safety

Several factors commonly work against psychological safety in healthcare settings.

Hierarchical Structures

Healthcare is structured around clear hierarchies: physicians, nurses, respiratory therapists, dietary staff, environmental services, and so on. These hierarchies affect who feels entitled to speak. In 2008, when I began my career, I lacked the confidence to challenge physicians. By 2021, after working in multiple states and building a reputation, I had more latitude. But that latitude came from privilege accumulated over time, not from a change in the hierarchy itself. Those structures exist whether we acknowledge them or not.

Fear of Blame or Punishment

Fear of blame or punishment does not always involve formal disciplinary action. It can be as simple as fearing ridicule, embarrassment, or a tense interaction with a colleague. If someone forgot to document a call-off and is afraid to admit it, the solution is not to hide the mistake. What would happen if the environment normalized saying, "I forgot to write that down"? Learning cannot happen in an environment of fear.

Time Pressures and High Workload

In the ER example I described earlier, there was almost certainly time to check in with me briefly after that traumatic event, but it was not prioritized. We tend to deprioritize emotional processing in favor of the next task. That breathing treatment for a patient could have waited a few minutes so we could have done a brief debrief. Beyond time, workload is an ever-present barrier. In my career, I have never worked at or consulted for a hospital without open positions. Short staffing makes everything harder, including creating space for psychological safety.

Bias, Discrimination, and Cultural Norms

Bias and discrimination within teams are real barriers. So are cultural norms that discourage vulnerability. Early in my career, I was taught to keep my feelings outside of the patient's room. For a while that seemed to work. Over time, I noticed that when I showed authentic emotion, it actually brought me closer to patients and families. Vulnerability in appropriate measure is not a weakness. Saying "I do not know" when you genuinely do not know is a form of professional integrity.

Power Distance, Privilege, and Intersectionality

Power distance refers to the degree to which societally perceived "less powerful" individuals accept and expect an unequal distribution of power. In healthcare, this concept is highly relevant. Those with high power distance have often been conditioned to know their place or have been minoritized by society. Those with lower power distance tend to be more comfortable addressing authority. If you are in a position of lower power distance, meaning you have more privilege in a given space, I encourage you to use it. If a colleague feels afraid to raise a concern because they fear losing their job, ask for their consent to raise it on their behalf.

Intersectionality, a term coined in the 1980s by Professor Kimberly Crenshaw, is a lens through which we can see where power comes and collides, where it interlocks and intersects. It is not simply that there is a race problem here, a gender problem here, and a class or LGBTQ+ problem there. Many times, that fragmented framework erases what happens to people who are subject to all of these things simultaneously.

I spent five years working in Idaho, where I was the only Black respiratory therapist in a seven-hospital system. Patients sometimes questioned whether I was really the person on my business card. Some asked if I was sure. I had to navigate, in real time, decisions about authenticity: when asked what brought me to Idaho, I had to decide whether to reveal that I had moved there because my wife had taken a job. I had already been asked to leave rooms because of my race. If I added being a queer person to that disclosure, what would happen? These are decisions people with marginalized identities make constantly. If that is the calculation someone must run in every interaction, it is not a psychologically safe environment.

Identity dimensions that can affect psychological safety include, but are not limited to: race and racism, sexual identity, gender identity, body size, ageism, educational background (both formal and experiential), geographic location, visible and invisible disability, socioeconomic status, literacy, mental wellness and access to resources, and personal history. These factors compound and intersect in ways that affect every interaction in a clinical setting.

Recognizing Safe and Unsafe Environments

Signs of a Safer Environment

In psychologically safe environments, staff feel comfortable raising concerns without fear of retaliation. Constructive feedback is both given and received. Diversity of thought is welcomed and encouraged rather than suppressed. For example, in my COPD and nicotine cessation program, I built a team primarily composed of students and newer RTs, despite pressure from colleagues to use only senior staff. Those newer voices brought value. Diversity of thought is not just about demographics. It includes professional experience, clinical setting, and role.

Red Flag Environments

Several behaviors and patterns can signal that an environment is not psychologically safe:

• Unusual silence during meetings and huddles, particularly from team members who are normally engaged
• Defensive responses when concerns are raised, which make it unlikely that the person will raise a concern again
• Chronic interruptions, particularly affecting women, younger professionals, and newer clinicians. I spoke with one department in which the women tracked how often they were interrupted over an hour and found that, collectively, they completed only 6 sentences during that period.
• Lack of accountability: a culture where errors are attributed to others rather than owned
• Changes in nonverbal communication, which I consider the most immediately observable signal

Nonverbal Communication as a Signal

Nonverbal cues can tell you a great deal about whether someone feels safe. Crossed arms, leaning away, creating physical distance, and shifts in posture all indicate disengagement or discomfort. Facial expressions such as frowns, pursed lips, eye rolls, or a head shaking with disappointment signal that something is wrong. Gestures like fidgeting, foot tapping, or clenching hands can indicate anger or anxiety.

Eye contact is culturally variable and should not be used as a universal marker. However, if someone who previously made eye contact suddenly stops, that shift is meaningful. Similarly, a sudden drop in vocal tone, giving only short responses, or the absence of minimal encouragers all suggest a person has withdrawn from the interaction.

Minimal Encouragers

Minimal encouragers are verbal and nonverbal cues that signal to a patient or colleague that you are actively listening and that they can continue sharing. Most people use them instinctively without knowing there is a name for them. They foster an environment where patients feel safe to tell their story, and stories yield more clinically useful information than closed-ended yes-or-no questions.

Verbal minimal encouragers include phrases such as "I see," "Go on," "That sounds difficult," "Mhm," and "Tell me more." These signals communicate that you are present, that you hear what is being said, and that the person should continue. The specific phrasing can be adjusted for the audience. With a pediatric patient, "That is tough" may feel more natural than "That sounds difficult." The goal is authenticity, not formula.

Nonverbal minimal encouragers include nodding, maintaining eye contact (where culturally appropriate), leaning forward slightly, and using facial expressions that convey concern or empathy. I have found in my mental health practice that allowing myself to have genuine reactions, including surprise or visible concern, actually helps patients open up more than a trained neutral expression does. People need to see that you are human.

Minimal encouragers help patients feel heard and understood, promote sharing of critical health information, demonstrate genuine care and attentiveness, lead to better understanding of patient needs, and contribute to more accurate diagnoses and treatment plans.

Case Study: Minimal Encouragers and COPD Management

I had a patient with COPD, whom I will call Mary, who had been managing well through a program we developed together with her daughter. She had stopped coming in. Then, shortly before COVID emerged, she was readmitted and described by staff as non-compliant with her medication regimen.

Because I had a relationship with her, I asked simply: what was going on? She mentioned that her daughter was not with her. I asked where her daughter was. Through that conversation, I learned that her daughter had fractured her femur and had been bedridden for forty days. Her daughter's husband, overwhelmed by caring for everything, had not been getting Mary's medications to her. She was not non-compliant. She did not have access to her medication.

The fix was simple: arrange for the medication to be mailed. But we never would have reached that solution without asking open-ended questions and listening for the story behind the symptom.

Case Study: A Patient Refusing Discharge

Another patient was ready for discharge but was refusing to leave. Staff were frustrated and described her in negative terms. Because I had an established relationship with her, I approached her directly and asked why she wanted to stay. In conversation, it came out that her daughter would be paroled in two weeks and released to her home. She was afraid.

All it took was a conversation with the social worker. The social worker contacted the parole officer, the daughter was discharged to a halfway house instead, and the patient went home the next day. Relationships built on genuine listening and rapport resolve problems that checklists and protocols cannot.

Best Practices for Using Minimal Encouragers

Be fully present during patient and colleague interactions. Avoid overusing verbal encouragers, as they can feel like interruptions when used excessively. Combine verbal and nonverbal cues for greater impact. Avoid colloquialisms and euphemisms, which can mean different things to different people or fall into unintended meanings. One time I returned to a patient's room and said "I am back like a bad rash," and the patient was startled because she was covered in a rash. We cannot always anticipate every context, but we can be thoughtful.

Creating Safer Environments

Creating a psychologically safe environment involves four interconnected practices: building trust, reducing fear, promoting openness, and fostering mutual respect.

Building Trust

Trust is built through consistent communication using varied formats, demonstrating humility and integrity, showing care and empathy, and checking in proactively rather than only reactively. You do not have to wait for a death or a critical incident to check in with a colleague. You can check in about everyday stressors, organizational changes, or just how someone is doing.

Do what you say you will do. If you cannot, be honest about it. Shift the idea of 'leader' to 'leadership': leadership is not a title. Everyone has the capacity to practice leadership behaviors. When people understand that leadership is a practice available to all, it creates a safer environment because the hierarchy feels less absolute.

There is no such thing as cultural competency, despite how often the term is used. We only know what we know. We should always be on a path toward learning more. Humility is the posture; cultural humility is the ongoing practice.

Reducing Fear

One of the most powerful fear-reducing practices is normalizing "I do not know." In healthcare, where knowledge is associated with authority and credentialing, admitting uncertainty is difficult. But it is far better to say "I do not know" electively than to pretend you know emergently. I have even said "I do not know" when I did know, specifically to invite a patient or colleague to teach me something. It creates space for others to contribute.

Encourage question-asking and model it yourself. When someone asks me a question in a group setting, I sometimes answer and then turn it back to the group: what do others think? This moves away from the idea that one person holds all the answers and toward a shared learning environment.

When errors occur, the response should focus on learning rather than on admonishment, where appropriate. This is why near-miss reporting programs exist. Refraining from mistakes as learning opportunities rather than grounds for punishment encourages team members to report issues promptly.

Promoting Openness

Be mindful of your tone when collecting information after a mistake is made. An interrogative tone shuts people down. Be aware of your own nonverbal communication. Share your own stories about mistakes made. I tell my mentees about failing a certification exam by six points. That six-point margin stung more than the failure itself. Sharing that story out loud normalized failure for them in a way that abstract encouragement never could.

Active listening is the cornerstone of openness. One evidence-based framework for active listening is O.A.R.S., drawn from motivational interviewing. O.A.R.S. stands for:

• Open-ended questions, such as "Tell me how you believe your life is impacted by your smoking."
• Affirmations, such as "I appreciate you sharing that with me."
• Reflections, such as "It sounds like no one has really paid attention to this issue for you before."
• Summarize: briefly paraphrase what you have heard to confirm understanding. You do not have to repeat everything, but enough to demonstrate that you received what was said.

Fostering Mutual Respect

Avoid interrupting and dismissing. Recognize and celebrate contributions from all team members, particularly those from minoritized identities who may not have been recognized in similar ways before. Establish shared goals and values. Learn how teammates prefer to receive both feedback and recognition. Some people find public recognition mortifying. If you are in a leadership role, ask new hires early on: how do you want to receive feedback, and how do you want to be recognized when you do something well? Then honor that.

Clinical Scenarios

Scenario 1: Wrong Equipment During Emergency Intubation

During an emergency intubation, an RT notices that the wrong-sized endotracheal tube is being prepared but hesitates to speak up, fearing backlash from the lead physician. The patient develops complications, leading to more difficult airway management.

If the RT had felt secure enough to raise concerns, the appropriate equipment could have been used from the outset, avoiding complications and improving patient outcomes. Open communication in high-pressure scenarios is critical for effective teamwork and patient safety. This is exactly the kind of situation where pre-established psychological safety pays off. If a newer RT or younger clinician has been told that their voice matters, they are far more likely to speak up when it counts.

Scenario 2: Medication Protocol Error

An RT realizes they administered the wrong oxygen therapy protocol but avoids reporting the mistake due to fear of reprimand. This delay in addressing the error leads to prolonged hypoxia for the patient.

In a psychologically safe environment, the RT could report the mistake promptly, allowing for a swift corrective response, minimizing harm, and framing the error as a learning opportunity for the team.

Scenario 3: Conflict Between Orders and Patient Directives

An RT is asked to continue aggressive ventilation on a terminally ill patient despite the patient's advanced directives. The RT feels conflicted but fears repercussions for questioning the order.

In a psychologically safe workplace, the RT could discuss their ethical concerns without fear, leading to a reassessment of the care plan in alignment with the patient's wishes and ethical practices. This is where leadership is especially important. People with formal titles have the responsibility to lead by example and demonstrate that ethical questions are welcome.

Strategies for Leaders and Teams

Leadership Strategies

Leaders set the tone for psychological safety. When you make a mistake in front of a group, correct it in front of the group. If you realize after the fact that you gave incorrect information, send a follow-up email to the whole team. When you make errors visible and correctable, you model that it is safe for others to do the same.

Create clear expectations for behavior and communication. Provide educational resources that support team development. Psychological safety resources are widely available, many of them free, and can be incorporated into huddles. The huddle does not have to be only about census and staffing. Small, consistent touchpoints around team culture accumulate over time.

Feedback Strategies

Use "I" statements when giving feedback. Ensure feedback is specific and actionable. If you are pointing out a missed step or a problem, pair it with a suggestion for what could be done differently. Do not deliver a complaint without a path forward.

If you are a colleague rather than a supervisor, ask for consent before offering feedback. I recently said to a colleague, "I have some feedback specific to you. Are you willing to hear it?" She said yes. I offered it. She received it well. But asking for consent is what made that possible. It shifts the power dynamic and demonstrates respect.

Addressing Challenges to Change

When organizations push back with "this is how it has always been done, and it has worked," I always ask: has it, though? If there is a need for this conversation, something has happened. The fact that something has persisted does not mean it is working well. Resistance to change is best addressed through gradual implementation rather than sweeping mandates.

Time constraints are real, but they can be addressed by integrating psychological safety practices into existing workflows rather than adding separate programming. Hierarchy concerns can be mitigated by intentionally involving leaders in modeling desired behavior so that change is visible at the top.

Takeaways

Psychological safety enhances patient outcomes. In environments where team members feel safe to speak, there are fewer medical errors, earlier identification of patient risk, and higher-quality care. Additionally, patients lose a sense of control when they enter the hospital. Building rapport early in a patient's stay is not just a relational nicety. It is a clinical strategy.

Leadership sets the tone. How leaders respond to questions, errors, and dissenting voices tells the entire team what is and is not safe to bring forward. Building trust is a deliberate act, not a passive outcome. It requires consistent communication, modeling of vulnerability, and follow-through.

Errors are opportunities for learning. Reframing mistakes in this way changes a team's entire culture. When people do not fear punishment for mistakes, they report them. When they report them, those mistakes can become the basis for improved protocols and processes.

Inclusion of all voices matters. Psychological safety relies on valuing every team member's contribution regardless of role, experience level, or identity. Inclusion is not passive. It is something you do on purpose. You have to actively invite voices in. I was not the most diverse hire at the Idaho hospital system, where I worked for five years, but I was included. My ideas were sought, heard, and sometimes acted upon. That distinction, between diversity and inclusion, is meaningful. Inclusion is the mechanism that creates the conditions for psychological safety to exist.

Questions and Answers

How do I recover mentally after making a mistake in patient care?

The first thing to recognize is that you are not the only person who has ever made a mistake. You are not alone, even though it feels that way in the moment. There is a model called the CLAIM model that can be helpful to review after a clinical error.

The most important step in the immediate aftermath is to own the mistake and apologize. Not a prolonged apology that shifts focus to your distress, but a clean one: acknowledge what happened, apologize, and ask if there is anything else the patient or colleague needs. Do not fill the apology with explanations. The explanation does not serve the person harmed in that moment.

Later, in private, reflect on what you can do differently in the future. The most important ongoing practice is to give yourself grace. A mistake is not the last mistake you will ever make. What changes over time is the rate and the severity, and your capacity to catch yourself earlier. Do not measure your career against other people's benchmarks. We set goals based on external comparisons that often do not serve us. You get to define what success means, and that definition can evolve.

References

References are provided in the course handout.

Editor’s note: This text-based course is an edited transcript of the webinar, MAP vs. NAP: The Impact of Mechanical Ventilation on Hemodynamics, presented by Evan Richards, Advanced Practice Clinical Consultant, BSc, RT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Describe areas of potential physiological interaction with positive pressure ventilation
• Identify the safest of the five techniques for increasing MAP
• Describe the impact of non-invasive ventilation on hemodynamics
• List ventilator strategies that may reduce the negative impact of positive pressure

 The Impact of  Ventilation on Hemodynamics

I always look forward to these sessions. I have done this for 35 years, and not once have I taken for granted the fact that people take time out of their day to learn. I really respect the fact that you are here, and I am going to try to pay you back with something that might be immediately relevant to your clinical practice. The effect of mean airway pressure (MAP) on pulmonary blood flow and systemic blood flow can be observed in various ways. In this discussion, I will address the consequences of MAP, focusing on both its impact and the strategies to mitigate its negative effects. Additionally, I will briefly explore what I consider the most effective approaches to recruiting and stabilizing lungs. Finally, I will share an anecdote about how a trip to the produce section with my wife provided unexpected insights into pulmonary mechanics, and that is how I will conclude today's presentation.

Areas of Potential Physiological Interaction with MEAN Airway Pressure

• Define MAP and NAP
• Methods of increasing MAP
• MAP and pulmonary blood flow
• Address the consequences of MAP
• Best way to recruit and stabilize lungs
• Learning pulmonary mechanics from the produce section of the grocery store

The 60/90 Rule

Before I end, I want to remind you of the 60/90 rule, which I first learned about on NPR. Hearing it was a sobering moment, as I realized I am often the biggest culprit. According to the rule, 60 minutes after a lecture, people forget 90% of what was said—just like that, it is gone. This isn't about placing blame; it is simply human nature. I empathize because I, too, struggle to retain everything shared during a presentation. After each section, I will summarize the key take-home message. That way, you'll have the 10% of what I said that truly matters. This presentation covers a lot of information, and my goal is to ensure you leave with the most important insights.

Updated Definitions

First, let's begin with MAP versus NAP. I will introduce you to these updated definitions, which I coined myself—they may be entirely new to you. MAP emphasizes the word "mean," referring to any potentially counterproductive pressure applied to the airways. I call it "mean" airway pressure because, quite frankly, it is not very nice. In contrast, NAP stands for Nice Airway Pressure. NAP is the lowest amount of pressure possible, tailored to the patient’s specific pathophysiology.

This distinction may seem like a playful alliteration—with all those P's—but it is also a serious concept. Our goal is to apply just the right amount of airway pressure to avoid harm while still effectively ventilating the patient. As we proceed, we will aim to identify the optimal Nice Airway Pressure (NAP) and steer clear of the counterproductive Mean Airway Pressure (MAP).

What Is the Most Dangerous Component of Mechanical Ventilation?

As I prepared for this talk, I asked myself: What is the most dangerous component of mechanical ventilation? Initially, I was convinced the answer had to be volume. After all, volume trauma is a well-documented risk, and its dangers are emphasized frequently. I also recognized the peril of inspiratory time (or "I-time") for patients with air leaks, where prolonged pressures can exacerbate the damage.

Despite my assumptions, my research revealed a surprising consensus: the most dangerous component of mechanical ventilation is not volume, pressure, or time—it is the act of intubation itself. This realization reframed my perspective on ventilator-induced lung injury (VILI). If we aim to prevent such injury, the best strategy is often to avoid intubation altogether. A patient cannot experience ventilator-induced harm without a ventilator in the first place.

Of course, non-invasive ventilation has its own complexities, but the damage associated with mechanical ventilation begins with the endotracheal tube. The moment that the tube is placed, the dynamics between the patient and the ventilator fundamentally change. Intubation inherently increases mean airway pressure and, with it, the risk of elevated intrathoracic pressure. These pressures, regardless of how carefully they are managed, alter the physiology of the lungs.

The most challenging aspect of mechanical ventilation, however, is not just mitigating pressure or volume—it’s achieving effective gas distribution within the alveoli. Positive pressure ventilation can unevenly inflate the lungs, leading to regions of overdistension while others remain under-ventilated. This uneven distribution not only complicates oxygenation but also increases the risk of lung injury over time.

In summary, mechanical ventilation is a powerful tool, but it comes with inherent risks. While volume, pressure, and timing are all critical considerations, the act of intubation itself sets the stage for potential harm. As clinicians, we must remain vigilant in balancing these factors, seeking opportunities to minimize invasive interventions whenever possible.

This is why so many patients sustain harm during mechanical ventilation. In an attempt to ventilate the poorly compliant or collapsed alveoli—the “bad guys”—we often overventilate the healthy ones. This uneven volume distribution increases the risk of stretch injury to the functional alveoli, compounding the damage.

Stretch injury occurs when the alveoli are forced to expand beyond their physiological limits. This can lead to stress fractures in the delicate capillary-alveolar interface, disrupting the integrity of the lung’s microarchitecture. For example, stress fractures in the capillaries allow red blood cells to leak into the air spaces, triggering an inflammatory cascade. This process can progress to conditions like interstitial emphysema, where air infiltrates tissue spaces, exacerbating inflammation and further impairing lung function.

Overinflation can also compress the pulmonary capillary beds, reducing blood flow and impairing gas exchange. Conversely, underinflation may cause capillaries to become extravascular, disrupting the balance needed for effective ventilation and perfusion. Either scenario—overinflation or underinflation—disrupts pulmonary capillary blood flow, further complicating patient management.

In my experience working in an animal lab with Dr. Kurt Albertine at the University of Utah, I observed how sensitive the lungs are to ventilation-perfusion (V/Q) mismatches. The body has mechanisms to detect and respond to suboptimal V/Q matching, but when mechanical ventilation exacerbates these mismatches, the result is often detrimental. It is a delicate balance, and achieving proper ventilation without causing harm remains one of the greatest challenges in respiratory care.

When alveoli are not in contact with open, compliant neighbors, the body naturally redirects blood flow to areas with greater potential for gas exchange, optimizing ventilation-perfusion (V/Q) matching. However, both overinflation and underinflation can disrupt this delicate balance, impairing pulmonary capillary blood flow and creating further complications.

This phenomenon has been vividly demonstrated in research labs, such as Gary Neiman’s lab in Syracuse, New York. Using advanced imaging techniques, they have shown how a conventional ventilator breath can disrupt pulmonary capillary blood flow. These disruptions, visible as interruptions in the "sparkling" patterns of blood flow around the alveoli, illustrate how even a single ventilator breath can interfere with microcirculation. This effect, though unavoidable to some extent, should be minimized to reduce harm.

One critical component of lung function affected by ventilation is surfactant, a substance essential for reducing alveolar surface tension. When ventilation damages the alveolar walls, or when protein-rich edema fluid accumulates, surfactant becomes inactivated. This breakdown in surfactant function leads to further alveolar instability and exacerbates lung injury. In neonates and infants, who often produce surfactant in limited quantities, this disruption can be particularly catastrophic.

Beyond the lungs, mechanical ventilation can have systemic effects. Excessive mean airway pressure compresses the heart, reducing venous return and impairing cardiac output. The relationship is simple: the heart can only pump as much blood as it receives. Elevated pressures can also impact other organs, including the liver, kidneys, and brain, underscoring the far-reaching consequences of improper ventilator management.

The take-home message is clear: ventilation is an incredibly powerful tool, but it must be used judiciously. While it can save lives, mechanical ventilation has the potential to cause significant harm if not carefully managed. By understanding and addressing these risks, we can improve outcomes and minimize injury to our patients.

Least Invasive Method of Ventilating

When placing a patient on a mechanical ventilator, it is important to remember that this is not how we were naturally designed to breathe. This realization led me to reflect: if mechanical ventilation is not natural, how are we meant to breathe? The answer lies in negative pressure ventilation.

Unlike mechanical ventilation, which uses positive pressure to force air into the lungs, our bodies are designed to breathe by creating negative pressure. When we inhale, the diaphragm contracts and drops, while other respiratory muscles activate. This action expands the chest cavity, creating a pressure gradient that draws air into the lungs to equalize thoracic pressure. It is an elegant, efficient system.

Historically, negative-pressure ventilators like the iron lung mimicked this natural process. One well-known example is the iron lung, which was developed in the mid-20th century at Sick Children’s Hospital in Toronto, Canada. These devices encased the patient’s body and created a vacuum that allowed the chest to expand and air to flow into the lungs. They were remarkably effective and far less invasive than modern positive-pressure ventilation.

So why don’t we still use iron lungs if they align more closely with our natural physiology? The simple answer is practicality. Iron lungs are cumbersome, require specialized environments, and lack the versatility of modern ventilators. While they were lifesaving during their time—especially during the polio epidemics—they have been largely replaced by more portable and adaptable technologies.

Still, the principle behind the iron lung serves as a reminder of how our bodies are designed to function. Understanding the natural mechanics of breathing can inform how we approach mechanical ventilation, helping us to minimize harm and support patients in the safest way possible.

A Brief Tribute to the Iron Lung

Managing patients in an iron lung was notoriously challenging, but I want to take a moment to acknowledge the remarkable legacy of Paul Alexander, a man who lived most of his life in an iron lung. Paul passed away on March 11, 2024, at the age of 78. His life was nothing short of extraordinary.

Despite the limitations of living in an iron lung, Paul taught himself to breathe outside the device for up to three hours at a time. His determination and resilience were unmatched. He earned two master’s degrees, authored three books, and became an inspiration to many. Paul often expressed his appreciation for the iron lung, noting that it breathed the way humans are naturally meant to—with negative pressure.

For those unfamiliar with the iron lung, it is a fascinating device. The patient's body is encased inside the cylindrical chamber, with only their head protruding. The design includes portholes for caregivers to access and manipulate the patient as needed, as well as a window to visually monitor the patient. At its core, the iron lung uses a motor-driven piston to create alternating pressure within the chamber. This shift between negative and positive pressure allows the diaphragm to move, mimicking the natural mechanics of breathing.

The Iron Lung and Negative Pressure

Paul’s story is a powerful reminder of the iron lung’s significance in medical history. While it is no longer practical for modern use, the device served as a lifeline for many, enabling a natural form of breathing that aligns with our physiology. It also stands as a testament to human ingenuity and the resilience of the human spirit.

The iron lung even included a mirror so patients could see themselves, a small but meaningful touch for those who spent much of their lives inside the device. For those who relied on it, the iron lung was remarkable—it allowed them to breathe the way nature intended, with negative pressure. While it may seem unimaginable to live in such a device, patients often expressed gratitude for its ability to sustain their lives in a way that mimicked natural respiration.

I once encountered an unexpected illustration of this principle while working in a lab. An engineer had modified a standard laboratory flask by cutting off the bottom, inserting a tube through a cork, and attaching a Y-connector with two balloons. Curious, I commented, “You have reinvented the iron lung.”

The engineer looked puzzled and asked what I meant. I explained that his setup was essentially a negative-pressure breathing model. The rubber glove stretched across the open end of the flask represented a diaphragm. When the glove was pulled downward, the balloons inside inflated, just as the lungs do when the diaphragm contracts to create negative pressure.

When the rubber glove at the base of the flask is pulled downward, it simulates the diaphragm contracting, creating negative pressure inside the flask. This causes air to rush through the tube and inflate the attached balloons, mimicking how the lungs expand during natural breathing. When the glove is pushed back up, the pressure inside the flask increases, forcing air out of the tube, much like the process of exhalation.

Spontaneous vs. Mechanical Breathing

This mechanism mirrors how human beings breathe. Fortunately, our lungs maintain enough functional residual capacity (FRC) to prevent collapse at the end of exhalation, unlike the simulated system. If you have ever experienced having "the wind knocked out of you," you understand how crucial this reserve air is for maintaining breathing stability.

Negative pressure breathing offers significant physiological benefits. During inspiration, it assists venous return by reducing intrathoracic pressure, which facilitates blood flow back to the heart. It also reduces pressure on the pulmonary capillaries, promoting better circulation and gas exchange.

In contrast, positive pressure ventilation increases intrathoracic pressure during inspiration. This has the opposite effect: it restricts venous return, decreases right ventricular output, and makes it more challenging for blood to flow through the lungs. By effectively compressing the heart and pulmonary vessels, positive pressure ventilation can impair pulmonary blood flow and place additional strain on the cardiovascular system.

Despite these physiological drawbacks, positive pressure ventilation is widely used because it is far more practical and adaptable than negative pressure systems like the iron lung. Understanding these differences allows us to better manage ventilation and minimize potential harm to patients. 

This simple experiment highlighted the elegance of natural respiration and served as a hands-on demonstration of the principles behind devices like the iron lung. it is fascinating how even the most basic tools can mirror complex physiological processes and remind us of the ingenuity of early medical devices.

Ventilation and Hemodynamics

• In normal breathing, the negative pressure phase of inspiration: 
  • Assists venous return
  • Alleviates pressure on the pulmonary capillaries
  • Encourages good blood flow
• In PPV, the intrathoracic pressure increases during inspiration, causing:
  • Decreased venous return
  • Decreased right ventricular output
  • Restricted pulmonary blood flow

Let’s take a moment to discuss ventilation and hemodynamics. Hemodynamics, as we know, is the study of blood flow and its properties. Maintaining stable hemodynamics is critical because any disruption can compromise blood flow and, ultimately, organ function. Two key components of hemodynamics are venous return and cardiac output. Venous return refers to the amount of blood returning to the heart, while cardiac output is the volume of blood the heart pumps out. Both of these processes depend on two critical factors: preload and afterload.

Preload

• The amount of blood in the heart just before it contracts
• Depends on how much is coming back (Venous Return)
• Decreased pressure on the heart from MAP
• Reduced preload will tend to decrease cardiac output
• Increased preload is good

When I first started exploring this topic, I realized I needed a better understanding of preload. Like many, I found it a challenging concept at first, so I did some research. Preload is the volume of blood in the heart at the end of diastole, just before the heart contracts. It is directly influenced by venous return—how much blood is flowing back to the heart—and can be reduced by factors that apply pressure to the heart, such as excessive mean airway pressure from mechanical ventilation.

Interestingly, managing preload can significantly impact cardiac output. By optimizing preload—ensuring the heart is not overloaded or underloaded with blood before contraction—you can improve cardiac output. However, cardiac output may suffer when preload is decreased by external pressures, such as those caused by positive pressure ventilation.

When preload is reduced, cardiac output decreases because the heart simply doesnot have enough blood to pump effectively. Factors like excessive mean airway pressure from mechanical ventilation can compress the heart, reducing venous return and subsequently decreasing preload. This disruption impairs the heart’s ability to maintain adequate cardiac output.

Conversely, increased preload is beneficial. It ensures the heart receives more blood, allowing it to send more oxygenated blood to the body. The key takeaway is that reduced preload is generally detrimental, as it leads to reduced cardiac output, while increased preload supports efficient circulation.

For example, turning up the mean airway pressure too high can "squeeze" the heart, particularly the right side, making it harder for blood to return to the heart. Since cardiac output is directly dependent on venous return—essentially, the heart can only pump out as much blood as it receives—disrupting venous return disrupts the entire system.

Preload plays a vital role in maintaining cardiac output. Managing ventilatory pressures to avoid excessive compression of the heart and ensuring adequate venous return are key strategies for optimizing preload and supporting overall cardiovascular function.

Understanding Increased Afterload

• The pressure the heart must overcome to eject blood to the rest of the body
• Increases when blood vessels are compressed or restricted (e.g., excessive MAP)
• Reducing afterload will tend to improve cardiac output
• Increased afterload is bad

Afterload, unlike preload, refers to the resistance the heart must overcome to pump blood into circulation. It is the pressure against which the heart works to eject blood. Increased afterload occurs when blood vessels are compressed or restricted, which can happen with excessive mean airway pressure.

Reducing afterload generally improves cardiac output because it decreases the resistance the heart has to overcome. Here's a simple rule to keep in mind: increased preload is beneficial, but increased afterload is detrimental. Increased preload ensures more blood returns to the heart for pumping, while increased afterload creates more resistance to blood flow out of the heart, reducing efficiency.

Increased afterload can manifest in different ways. On the left side of the heart, it might result from high resistance in the systemic circulation, such as compression of the aorta or other vessels due to elevated mean airway pressure. While a cardiologist might point out that squeezing the heart can improve ejection fraction, the heart still struggles to push blood against narrowed or restricted vessels, which increases afterload.

On the right side of the heart, increased afterload often results from elevated pulmonary vascular resistance. This can happen when alveoli are overinflated, compressing pulmonary capillaries and creating resistance to blood flow. Conversely, underinflation of alveoli can also increase pulmonary vascular resistance, as the body may shut down blood flow to vessels that aren’t in contact with adequately inflated alveoli.

Balancing Pulmonary Vascular Resistance

Both overinflation and underinflation of alveoli can disrupt pulmonary vascular blood flow. Overinflation compresses pulmonary vessels, while underinflation fails to provide adequate contact between blood vessels and open alveoli. As a respiratory therapist, your job is to find the “sweet spot” in ventilation—a balance where alveoli are optimally inflated without overdistension or collapse. This balance ensures maximum surface area for gas exchange, with the greatest number of vessels in contact with open alveoli.

The Goldilocks Approach

The take-home message is that hemodynamics can be compromised by either too much or too little mean airway pressure. As respiratory therapists, we excel at finding this balance because we are attentive and meticulous. Think of it as the "Goldilocks principle": too much or too little of something is not ideal, but when it is just right, the lungs function optimally. By carefully optimizing mean airway pressure, we ensure the best outcomes for our patients, providing stable hemodynamics and efficient gas exchange.

How Is MAP Increased?

To effectively manage mean airway pressure (MAP) during mechanical ventilation, it is essential to understand the various strategies available and their physiological implications. Here are five key methods to increase MAP:

1. Shortening the Rise Time: By accelerating the time it takes to reach peak inspiratory pressure, you can enhance MAP. This rapid attainment of pressure allows for more immediate recruitment of alveoli, improving oxygenation. However, caution is necessary, as overly aggressive rise times may lead to patient discomfort or barotrauma.
2. Increasing Peak Inspiratory Pressure (PIP): Elevating PIP directly raises the pressure delivered to the lungs, thereby increasing MAP. While this can improve oxygenation, it is crucial to monitor for potential lung injury due to higher pressures, especially in patients with compromised lung compliance.
3. Extending Inspiratory Time (I-time): Prolonging the duration of inspiration maintains the lungs at a higher pressure for a longer period, which increases MAP. This strategy can enhance gas exchange but may also reduce the time available for exhalation, potentially leading to air trapping or hyperinflation if not carefully managed.
4. Increasing Respiratory Rate: Raising the number of breaths per minute reduces the time allocated for exhalation. This can elevate MAP by maintaining higher average pressures. However, an excessive respiratory rate may cause incomplete exhalation, resulting in air trapping and increased intrathoracic pressure, which could adversely affect hemodynamics.
5. Raising Positive End-Expiratory Pressure (PEEP): Elevating PEEP prevents alveolar collapse at the end of expiration, thereby increasing MAP. This method is often considered the most effective and safest way to enhance oxygenation, as it promotes alveolar recruitment and improves functional residual capacity. Nonetheless, excessive PEEP can lead to overdistension and impede venous return, so it must be titrated carefully.

A pivotal study by Dr. Marcelo Amato and colleagues (2014) examined the impact of ventilator management strategies on patient outcomes. The study introduced the concept of relative risk of death associated with different ventilatory approaches:

• Raising PIP without Increasing PEEP: This approach was associated with a significant increase in the relative risk of death. Elevating PIP alone can lead to overdistension and ventilator-induced lung injury, especially when PEEP is not adjusted to maintain alveolar stability.
• Raising Both PIP and PEEP: Combining increases in PIP and PEEP showed a moderate improvement in outcomes compared to raising PIP alone. However, in patients with severe illness, this strategy still poses substantial risks. Maintaining an appropriate driving pressure (the difference between PIP and PEEP) was crucial in mitigating potential harm.
• Raising PEEP Alone: This method resulted in the most significant reduction in the relative risk of death. Elevating PEEP alone provided a stable and protective pressure, enhancing alveolar recruitment without the detrimental effects associated with high PIP.

The study underscores the importance of driving pressure as a critical determinant of patient outcomes. Driving pressure, calculated as the difference between PIP and PEEP, reflects the cyclic stress applied to the lungs during ventilation. Maintaining a lower driving pressure has been associated with improved survival in patients with acute respiratory distress syndrome (Amato et al, 2014).

In clinical practice, the goal is to optimize MAP to improve oxygenation while minimizing the risk of ventilator-induced lung injury. Among the strategies discussed, adjusting PEEP is often the most effective and safest method. However, individual patient factors must be considered, and ventilator settings should be tailored to achieve the best possible outcomes.

In summary, while several methods exist to increase MAP, careful consideration of their physiological impacts is essential. Elevating PEEP stands out as a particularly effective strategy, but it should be implemented judiciously within the context of a comprehensive ventilatory management plan.

Impact of MAP on Cerebral Circulation

Positive end-expiratory pressure (PEEP) is a critical component in mechanical ventilation, particularly for patients with acute respiratory distress syndrome (ARDS). By maintaining alveolar recruitment and improving oxygenation, PEEP plays a vital role in patient care. However, its application requires careful consideration due to potential systemic effects, especially concerning cerebral circulation.

Impact on Cerebral Circulation

Elevated PEEP levels can increase intrathoracic pressure, which may impede venous return from the brain, leading to elevated intracranial pressure (ICP). This rise in ICP can reduce cerebral perfusion pressure (CPP), potentially compromising cerebral blood flow and increasing the risk of hypoxic or ischemic injuries. Studies have shown that while moderate PEEP levels may have minimal impact, higher levels can significantly affect ICP and CPP.

Clinical Considerations

In patients with brain injuries or compromised cerebral autoregulation, the application of PEEP necessitates meticulous monitoring. The balance between optimizing oxygenation and maintaining stable cerebral hemodynamics is delicate. Adjustments to PEEP should be individualized, taking into account the patient's respiratory mechanics, intracranial dynamics, and overall clinical status. Continuous monitoring of ICP and CPP is advisable when applying higher levels of PEEP in such patients.

Recommendations for Practice

• Individualized PEEP Titration: Tailor PEEP levels to the patient's specific needs, considering both pulmonary and cerebral parameters.
• Monitoring: Employ invasive monitoring techniques to assess ICP and CPP in patients at risk of cerebral complications.
• Interdisciplinary Approach: Collaborate with neurology and critical care specialists to optimize ventilatory strategies for patients with concurrent respiratory and neurological concerns.

Understanding the nuances between hypoxic and ischemic brain injuries is crucial for accurate diagnosis and treatment.

Hypoxic Brain Injury

This occurs when the brain receives blood that is inadequately oxygenated. Despite sufficient blood flow, the reduced oxygen content leads to cellular dysfunction and damage. Common causes include respiratory failure, carbon monoxide poisoning, and high altitudes. Depending on the duration and severity of oxygen deprivation, symptoms can range from mild cognitive impairments to severe neurological deficits. 

Ischemic Brain Injury

In contrast, ischemic injury arises when there is an obstruction or reduction in blood flow to the brain despite the blood being oxygen-rich. This deprivation prevents brain tissues from receiving necessary oxygen and nutrients, leading to cell death. Causes often include blood clots, strokes, or cardiac arrest. The resulting damage can lead to motor deficits, speech difficulties, and other neurological impairments.  Both types of injuries can result in significant neurological impairments, and their management requires precise monitoring of both oxygenation and perfusion.

Near-Infrared Spectroscopy (NIRS)

NIRS is a non-invasive monitoring technique that offers real-time insights into tissue oxygenation and perfusion. By emitting near-infrared light into tissues and measuring the absorption spectra, NIRS can determine the balance between oxygenated and deoxygenated hemoglobin. This provides continuous data on both oxygen delivery and utilization in specific regions, making it invaluable in settings like cardiac surgery and critical care. 

The NIRS device operates by placing sensors on the skin's surface. A light source emits near-infrared light, which penetrates tissues and is absorbed by hemoglobin. Two detectors measure the intensity of light after it has traversed the tissue:

• Shallow Detector: Captures light that has traveled a shorter path, providing information about superficial tissue layers.
• Deep Detector: Measures light that has penetrated deeper, offering data on underlying tissues and organs.

By analyzing the differential absorption at these depths, NIRS calculates regional oxygen saturation and assesses tissue perfusion. This dual capability distinguishes it from standard pulse oximetry, which primarily measures arterial oxygen saturation without providing direct information on tissue perfusion. 

In clinical practice, NIRS has proven beneficial in various scenarios:

• Cardiac Surgery: Monitoring cerebral oxygenation to prevent neurological complications.
• Neonatal Care: Assessing brain oxygenation in preterm infants to detect and prevent hypoxic-ischemic injuries.
• Critical Care: Evaluating tissue perfusion in patients with circulatory shock or traumatic brain injuries.

By providing continuous, real-time data, NIRS aids clinicians in making informed decisions to optimize patient outcomes. In summary, distinguishing between hypoxic and ischemic brain injuries is essential for targeted therapeutic interventions. Utilizing advanced monitoring tools like NIRS enhances the ability to assess and manage these conditions effectively, ultimately improving patient care.

This device is remarkable because it monitors both oxygen delivery and perfusion simultaneously, providing critical real-time insights into a patient’s condition. Its utility lies not just in what it measures but in how it empowers clinicians to act proactively. Unlike many diagnostic tools—such as X-rays, CT scans, MRIs, or ultrasounds—this device doesn’t simply confirm whether harm has occurred. While these technologies are invaluable for diagnosing existing issues, they are typically reactive, informing clinicians only after an injury or complication has already taken place.

What sets this device apart is its ability to alert clinicians to potential harm before it happens. Rather than waiting for signs of an adverse event to appear, it provides early warnings, enabling timely interventions that can prevent injury altogether. This proactive functionality represents a significant shift in how we approach patient care, moving us closer to truly preventive medicine. By identifying and addressing risks in real-time, clinicians can reduce complications, improve outcomes, and potentially save lives.

The device monitors critical metrics related to organ saturation, such as how well oxygen is reaching the kidneys and brain—two organs particularly vulnerable to oxygen deprivation. These metrics are essential because they reflect how effectively the body is maintaining vital functions. A decline in saturation values signals potential organ dysfunction, allowing clinicians to act immediately, whether by adjusting oxygen delivery, optimizing perfusion, or addressing other underlying issues.

In one instance, a drop in both cerebral and renal saturation levels was identified within a few hours. The clinical team traced the issue to excessive mean airway pressure. They responded by suctioning the patient and switching from a device that utilized higher mean airway pressure to one that used less. This change led to a rapid improvement in oxygenation, preventing brain injury before it occurred. The ability to detect and address such problems early highlights the profound impact of this technology.

What’s remarkable is how this device facilitates real-time monitoring of both cerebral and renal saturations. By providing continuous feedback, it bridges the gap between reactive diagnostics and preventive care, offering precision and foresight that redefine patient safety standards. This capability ensures that clinicians can make informed, timely decisions in critical care settings, where even slight delays can have serious consequences.

The key takeaway here is that mean airway pressure can significantly impact cerebral circulation, making its careful management critical. Another takeaway is more general but equally important: attention to detail matters, whether you’re managing a clinical device or inflating a raft. Small adjustments can have big impacts, and proactive care can make all the difference in patient outcomes.

Consequences of MAP

I have personally experienced lightheadedness when blowing up something for my grandkids, which serves as a reminder to be cautious. Overexertion, even in seemingly simple tasks, can have consequences—similar to the clinical risks associated with excessive mean airway pressure. Understanding this concept is critical because the implications can be significant, as highlighted in a fascinating study.

This study, titled Cardiovascular Effects of HFOV with Optimal Lung Volume Strategy in Term Neonates with ARDS (Acherman, R.J., Siassi, B., deLemos, R., Lewis, A.B., & Ramanathan, R.), examined the cardiovascular effects of high-frequency oscillatory ventilation (HFOV) using optimal lung volume strategies. The collaboration included notable figures in the field: Dr. Reuben Acherman, a cardiologist; Dr. Ramanathan, the inventor of the RAM cannula; and the late Dr. deLemos, known as the "grandfather" of the SensorMedics oscillator. This team was based at LA Children’s Hospital, a hub for groundbreaking pediatric care.

Dr. Acherman, intrigued by the team's approach, visited Dr. deLemos to discuss their use of high mean airway pressures during oscillation. Dr. deLemos explained that using HFOV allowed for higher mean airway pressures with improved safety compared to conventional ventilation methods. The reduced risk of overdistension, as confirmed by X-ray imaging, supported their strategy.

However, Dr. Acherman, ever cautious, expressed concerns about the potential effects of mean airway pressure on the cardiovascular system. He proposed using his ultrasound machine to investigate further. The team welcomed his input, as they had not observed evidence of overdistension on imaging but were open to additional insights. 

The primary challenge with oscillation and jet ventilation lies in their mechanics. Both devices essentially function as CPAP systems with added oscillatory movement, often referred to as “CPAP with a wiggle.” They operate at higher mean airway pressures while maintaining lower peak inspiratory pressures, which can obscure traditional signs of overdistension. For example, on a conventional ventilator, overinflation often causes visible changes like diaphragm flattening or rib expansion on X-rays. These indicators are typically absent in oscillatory ventilation, making it harder to detect underlying issues.

Dr. Acherman became concerned when he observed that patients on these devices, particularly at higher mean airway pressures, were showing signs of systemic cardiovascular stress. Despite interventions to maintain blood pressure and cardiac output, these patients continued to exhibit troubling symptoms. Using his ultrasound machine, Dr. Acherman investigated further and made a critical discovery: many of these patients had a significantly dilated inferior vena cava (IVC), elevated central venous pressure (CVP), and widespread edema.

His findings were striking. While the heart and lungs initially appeared normal on imaging, the inferior vena cava below the diaphragm was dilated, in some cases up to three times its normal size. This indicated that venous return to the heart was being obstructed. Both the superior and inferior vena cava were affected, contributing to increased intracranial pressure, which can have severe neurological consequences. Additionally, the hepatic veins, which drain blood from the liver, were also significantly dilated—approximately three times their normal size. This systemic venous congestion confirmed that elevated mean airway pressure was creating significant hemodynamic strain.

Dr. Acherman concluded that the elevated mean airway pressures were not just ventilating the lungs but also exerting pressure on the heart and pulmonary vasculature. This compression impaired venous return and increased resistance within the pulmonary and systemic circulations. These findings were critical because they highlighted a hidden risk of oscillatory ventilation that could not be readily detected with traditional methods like X-rays.

The study conducted at LA Children’s Hospital brought together several pioneers in neonatal and pediatric care, including Dr. Acherman, Dr. Ramanathan (inventor of the RAM cannula), and the late Dr. deLemos, known as the "grandfather" of the SensorMedics oscillator. Their work illustrated the complex interplay between ventilation strategies and cardiovascular physiology. While HFOV was deemed safer than conventional ventilation in certain cases, Dr. Ackerman’s findings underscored the importance of monitoring not just pulmonary parameters but also cardiovascular effects.

One of the most illustrative demonstrations of HFOV mechanics involved placing a pig or sheep lung inside a sealed bottle. When high mean airway pressures were applied, the lung inflated while maintaining low internal pressures, a feature often touted as an advantage of HFOV. However, Dr. Acherman noted a critical limitation of this model: it did not account for the constraints of an intact thoracic cavity. In a living patient, the rib cage, diaphragm, and surrounding structures limit lung expansion. This restriction is especially pronounced in adults but can also affect pediatric patients. Consequently, the pressures that seemed safe in an isolated lung model could, in practice, result in significant hemodynamic consequences when applied in vivo.

At LA Children’s Hospital, the clinical team observed that patients with high mean airway pressures did not exhibit traditional signs of overdistension, such as diaphragm flattening or rib spacing changes, commonly seen on X-rays. However, the elevated pressures were compressing the heart and pulmonary vasculature, leading to increased CVP, venous congestion, and impaired cardiac function. These effects were subtle yet profound, illustrating the need for advanced diagnostic tools like ultrasound to detect and address such complications.

This study demonstrated the importance of interdisciplinary collaboration in improving patient care. By combining the expertise of cardiologists, neonatologists, and pulmonary specialists, the team was able to identify and mitigate risks associated with HFOV. It also highlighted the need for careful consideration of mean airway pressures, even when using “safer” ventilation strategies. The findings emphasize that while advanced technologies can offer significant benefits, they also require a thorough understanding of their potential systemic impacts.

In clinical practice, this case serves as a reminder to monitor not just respiratory parameters but also the broader physiological effects of ventilation strategies. The insights gained from this study continue to inform how we approach high-frequency ventilation, emphasizing the importance of vigilance, comprehensive assessment, and early intervention to prevent complications.

Consequences of Too Much MAP

Managing mean airway pressure is critical, whether using a conventional ventilator or a high-frequency ventilator because elevated pressures can have serious consequences. The question then becomes: what can be done to address the problem? At Children’s Hospital Los Angeles, under the guidance of Dr. Philippe Friedlich, an experienced neonatologist, the team approached this challenge with innovation and collaboration. Dr. Friedlich and his team worked closely with biomedical technicians to design practical solutions that address real clinical needs, not just theoretical ones.

During a visit to speak with his group, I discussed the process of developing medical devices, emphasizing that they must solve real problems in the ICU, NICU, or PICU. Before my talk, Dr. Friedlich and I discussed a pivotal study conducted at his hospital (Marked Reduction in MAP and OI Using HFJV in Neonates with Severe Refractory Hypoxemic Respiratory Failure). This study focused on addressing mean airway pressure and overdistension in neonates, particularly those who had failed conventional ventilation and were deteriorating on oscillators after missing their ECMO window.

The Problem: Overdistension and Gas Trapping

In these cases, the neonates were experiencing gas trapping and hyperinflation, which contributed to elevated mean airway pressures. These pressures, in turn, exacerbated issues like barotrauma—or as Dr. Friedlich coined it, "mapotrauma." The team hypothesized that gas trapping was the primary cause of the elevated pressures, leading to poor oxygenation and ventilation. They realized that conventional ventilators with a 1:2 inspiratory-to-expiratory (I:E) ratio were not sufficient to alleviate this problem. This led them to revisit high-frequency jet ventilation (HFJV) to explore its potential in these critical cases.

The Solution: Extending Expiratory Time

Using HFJV, the team was able to adjust the I:E ratio to as much as 1:6 or 1:12, significantly increasing the time available for exhalation. This approach helped to minimize gas trapping and, subsequently, reduce mean airway pressure. The goal was to resolve hyperinflation, improve oxygenation, and ultimately stabilize these fragile patients.

The Results: Rapid Improvement

The first ten patients in the study had failed conventional ventilators and oscillators. These neonates were critically ill, with oxygen indexes (OI) averaging 30, indicating severe respiratory failure. Over 50 days, they had been stuck on oscillation without significant improvement. Once switched to HFJV, the results were striking:

• Reduction in Mean Airway Pressure: Within four to five hours of starting HFJV, the mean airway pressure dropped from 14 to below 10 cm H₂O
• Improved Oxygenation: As mean airway pressure decreased, the fraction of inspired oxygen (FiO₂) could be weaned from nearly 90% to below 50%
• Improved Oxygen Index: The OI, which reflects the severity of respiratory failure, fell from 30 to 10 within hours and remained low over the next several days

This rapid improvement allowed the team to extubate the patients and eventually send them home. Of the ten initial patients, nine survived and were discharged. Tragically, one patient suffering from sepsis did not survive. However, the surviving neonates—all with chronic lung disease at the time of intervention—were able to leave the NICU and go home on oxygen.

The Impact: Better Outcomes and Reduced Costs

While some neonates required supplemental oxygen at discharge, Dr. Friedlich emphasized that sending them home was a success. Each day a patient spends in the NICU costs $10,000 to $20,000. By reducing the time spent on mechanical ventilation and in the NICU, the team not only improved patient outcomes but also reduced financial burdens for families and healthcare systems. On average, after the intervention, patients were on mechanical ventilation for just seven more days before being weaned.

Lessons Learned

Dr. Friedlich and his team concluded that lowering mean airway pressure was the key to success. By resolving hyperinflation and gas trapping, they achieved better oxygenation and reduced the risk of complications. The study also highlighted the importance of avoiding hyperinflation in the first place. Prolonged expiratory times, achieved through HFJV, proved to be a critical strategy for minimizing barotrauma and reducing mean airway pressures.

MAP During Noninvasive (NIV) 

Mean airway pressure has long been a focus of discussion in mechanical ventilation, but I had initially thought it wasn’t an issue during noninvasive ventilation (NIV). My reasoning was simple: during NIV, patients typically breathe in a way that mimics natural physiology. Humans are designed to breathe with negative pressure, not positive pressure. Unlike invasive ventilation, which requires mechanical assistance, NIV generally relies on the patient’s normal breathing mechanisms unless supplemental breaths are delivered. Because of this, I assumed mean airway pressure wouldn’t play a significant role in NIV. I was wrong.

Over time, I began to question what might be better for patients: delivering breaths through the nose using noninvasive positive pressure ventilation (NIPPV) or maintaining continuous positive airway pressure (CPAP) through the nose. Which approach was more effective? Was one safer than the other? To answer this question, I turned to a pivotal study by Dr. Haresh Kirpalani, a Canadian physician who researched this topic during his time in Washington, D.C. The study, published in The New England Journal of Medicine in 2013 (A Trial Comparing Noninvasive Ventilation Strategies in Preterm Infants), sought to compare these two strategies in preterm infants.

Key Findings of the Study

Dr. Kirpalani’s study explored whether NIPPV—delivering breaths through the nose—or CPAP—maintaining a continuous positive pressure—offered better outcomes for preterm infants. The findings were intriguing. There was no substantial difference between the two strategies in terms of preventing complications. There was a slight advantage for avoiding breaths through the nose, but the difference was minimal, just a few percentage points. Importantly, the rates of bronchopulmonary dysplasia (BPD) were nearly the same in both groups.

This was surprising to me. BPD, a chronic lung condition, is commonly associated with invasive mechanical ventilation and prolonged exposure to high oxygen concentrations. These preterm infants, however, had never been intubated. How could they develop BPD? This challenged my understanding of the condition and highlighted the complexity of its underlying mechanisms.

Rethinking Assumptions

Dr. Marty Kessler once made a thought-provoking observation about our attachment to terminology in respiratory care. He said, “I think we’re misled by these terms.” Terms like continuous positive airway pressure, high-flow nasal cannula, and noninvasive ventilation create an impression of minimal intervention. They suggest that these methods are inherently safer or less likely to cause harm compared to invasive approaches. Yet, as this study demonstrated, even noninvasive techniques can contribute to conditions like BPD.

The Implications

The findings of this study—and my reflections on it—serve as an important reminder of the nuanced nature of respiratory support. While NIV strategies like NIPPV and CPAP are invaluable tools, they are not without risks. Mean airway pressure, even during noninvasive support, can play a critical role in patient outcomes. it is not just about delivering the right therapy; it is about understanding the potential consequences of each approach and tailoring care to the individual needs of the patient.

Dr. Marty Kessler made an important observation during a conference we attended together. He pointed out that regardless of the terminology we use—whether it is CPAP, high-flow nasal cannula, or noninvasive ventilation—all these techniques share three critical components: pressure, flow, and ventilation. Even in noninvasive strategies, maintaining sufficient pressure and flow is essential to adequately ventilate the patient. Without these, complications can arise.

The Challenge of Maintaining Pressure

Dr. Kessler emphasized that a CPAP level must be sufficient to keep the lung open, even when the patient is not intubated. This principle ties into the concept of lung protection. If the lung collapses, particularly in a surfactant-deficient state, reopening it becomes more challenging and can cause injury. Dr. Jack Emerson, an early pioneer of the iron lung, referred to this phenomenon as “sticky lung syndrome.” He described how surfactant-deficient alveoli tend to stick together when they collapse. Reopening these collapsed alveoli can result in shear stress and lung injury, even with noninvasive techniques.

Dr. Emerson’s insight underscores an important reality: just as patients can experience ventilator-induced lung injury (VILI) with invasive strategies, they can also suffer lung injury from noninvasive methods if pressure and flow are inadequate. Persistent attempts to maintain noninvasive support in a struggling patient can sometimes do more harm than good.

When to Transition to Intubation

One of the key lessons from these discussions is knowing when to transition from noninvasive to invasive ventilation. Dr. Kessler explained that while noninvasive strategies are often preferable, there are cases where intubation and low-pressure, low-volume lung-protective ventilation may be the safer and more effective option. Administering a dose of surfactant in such scenarios can help stabilize the lung, making it easier to extubate the patient later.

A colleague in Canada shared a compelling example of this principle in action. They had a 24-week-old preterm infant who was started on nasal prongs immediately after birth. Initially, the infant responded well and defied the odds, maintaining stability on noninvasive support. However, over time, the team struggled to maintain adequate ventilation. Despite their best efforts—repositioning the prongs, switching systems, and adjusting the patient—they couldn’t achieve stability. After 24 days of noninvasive ventilation, they decided to intubate the infant.

What was striking was the infant’s first chest X-ray post-intubation, which revealed chronic lung disease (CLD). This was surprising, as the patient had never been intubated prior to that point. The cause? Insufficient or unstable mean airway pressure during noninvasive support. The lesson was clear: sufficient mean airway pressure is critical to maintaining functional residual capacity (FRC) and alveolar inflation. Without it, the lung remains unstable, even in a noninvasive strategy.

Noninvasive Ventilation: Not Always "Noninvasive"

Dr. Kessler’s reflections challenge the notion that noninvasive ventilation is entirely “noninvasive.” While it avoids the physical invasiveness of endotracheal intubation, it can still cause harm if mean airway pressure is insufficient to maintain stable lung function. In this way, “noninvasive” can be a misnomer. The absence of an endotracheal tube doesn’t negate the physiological invasiveness of inadequate support.

The take-home message is this: noninvasive strategies are highly effective when applied correctly, but they require careful attention to mean airway pressure. If mean airway pressure is too low or unstable, noninvasive ventilation can fail, leading to lung injury and complications like CLD. Achieving therapeutic outcomes hinges on delivering adequate pressure, flow, and ventilation. Noninvasive may be better in many cases, but it is only truly noninvasive if it provides sufficient support to maintain stable lung function.

Recruitment Maneuvers and Optimal MAP 

Ventilating patients effectively requires an open lung strategy. For noninvasive ventilation to work, the lungs must remain open, which often involves recruitment maneuvers. However, if mean airway pressure is critical and too much or too little can be problematic, the question becomes: how do you optimize it? What is the best way to recruit and stabilize the lungs while avoiding injury?

Learning from a New Perspective

I recently discussed this topic with Dr. Molly, a physician I admire greatly who works at a hospital in Winnipeg, Manitoba. She is not only a colleague but also a friend, and I had the pleasure of having dinner with her during a visit to her hospital. Our conversation drifted to a pivotal moment we shared years earlier at the PAS conference in Washington, D.C., where Molly attended a lecture that left a lasting impression on both of us.

At that conference, Molly was intrigued by an anesthesiologist’s perspective on lung recruitment strategies. She recalled how she had initially planned to challenge the presenter, confident in her own NICU experience. Yet, after hearing his approach, she found herself rethinking some deeply held beliefs. The anesthesiologist argued that many ICU and NICU patients, particularly babies, are recruited improperly. He explained that high-pressure, short-duration breaths, often used in the ICU, can push the lungs into the injury zone, increasing the risk of barotrauma and other complications.

A Different Recruitment Strategy

The anesthesiologist described his approach to recruiting patients during surgery when their lungs had collapsed. Instead of giving a short, high-pressure breath, he advocated for a longer-duration, lower-pressure breath. For example, he would hold a breath 5 to 8 cm above PEEP (and no more than 15 cm in extreme cases) for 20 to 30 seconds. After releasing the pressure for four to five seconds, he would repeat the maneuver two or three times. In nearly all cases, this method restored lung function without causing injury.

Molly relayed this to me with a big smile, admitting she had been skeptical at first. “We cannot give 20- or 30-second breaths in the ICU,” I said. She agreed but suggested we could modify the strategy with one- to three-second breaths at lower pressures. “It’s safer than it sounds,” she explained. “The anesthesiologist emphasized that longer inspiratory times are far less dangerous when pressures are kept low. it is the combination of high pressure and long inspiratory time that increases the risk of injury.”

Optimizing Mean Airway Pressure Safely

Molly explained how her team applies these principles in their unit. After optimizing PEEP to ensure the lungs remain open, they often transition to high-frequency ventilation. This approach allows them to maintain higher mean airway pressures safely, as the oscillatory nature of high-frequency ventilation (CPAP with a wiggle) minimizes the risk of overdistension and injury.

She emphasized the importance of keeping the lungs open while using the gentlest means possible. “The take-home message,” she said, “is to optimize mean airway pressure to open the lungs and keep them open, but to do so gently. Recruitment maneuvers should be tailored to the patient, using lower pressures and longer durations to avoid harm.”

The Future of Recruitment Research

Inspired by these discussions, Molly’s team and others have begun exploring the best ways to recruit and stabilize lungs effectively. Preliminary studies suggest that a longer inspiratory time with lower pressures is more effective and less injurious than shorter, high-pressure recruitment strategies. Additional research is underway to examine whether simply raising PEEP or mean airway pressure alone can achieve the same results or whether recruitment breaths are necessary for optimal outcomes.

The hope is that these studies will provide clear evidence for the safest and most effective recruitment methods, ensuring better outcomes for patients in the ICU, NICU, and PICU. As Molly put it, “We need to find the balance—enough pressure to open the lungs but not so much that we cause harm. And we need to use every tool and strategy at our disposal to get it right.”

This ongoing research represents an exciting opportunity to refine our understanding of lung recruitment and improve how we manage mean airway pressure. I look forward to sharing more about these findings as they develop, but for now, the key takeaway is clear: recruitment and stabilization must be done with care, precision, and a focus on gentle, patient-centered strategies.

MAP vs NAP in the Produce Section

Ventilation, like grocery shopping, requires balance, observation, and attention to detail—at least that is how I see it. My wife, who’s far better at navigating grocery stores, loves to remind me how chaotic I find them. On Mother’s Day, she convinced me to join her on a grocery run. How could I refuse on her special day? Reluctantly, I agreed, thinking I could survive one trip. Little did either of us know how the produce section would ignite my respiratory therapist brain.

When we got to the produce section, I couldn’t help myself. Suddenly, I saw lung dynamics everywhere. “Look at these vegetables,” I exclaimed. “That is a great example of a good distribution of tidal volume. Over there, hyperinflation! And here, underinflation.” My wife, a fellow respiratory therapist, stared at me, baffled. “What are you talking about? We’re here to shop!” But I couldn’t stop. This was too exciting.

I pointed out the divine ripened tomatoes. “These are perfect! They represent optimal lung inflation. See how balanced they are?” Then I held up the heirloom tomatoes and explained how their irregular shapes resembled overinflated alveoli, with their stems acting like pulmonary capillaries. “And look at these habanero peppers,” I continued. “When insufficient PEEP lets the alveoli collapse, they look just like this—uneven and deflated.”

As we moved through the store, I found more metaphors. A broken bag of frozen peas scattered on the floor became pulmonary interstitial emphysema. Clumps of ruptured alveoli spilling into tissue spaces came vividly to life through the imagery of scattered peas. My wife rolled her eyes, begging me to move on. But I was having too much fun.

By the end of the trip, she was regretting bringing me along. “Never again,” she declared, assigning me errands elsewhere in the store whenever we shop together. Despite her exasperation, the trip reminded me of something profound: ventilation, like selecting produce, requires care. Too much pressure, and you risk damage; too little, and the lungs fail to function. Each lung, much like each tomato, has unique needs that must be respected.

The Take-Home Message: Individualized Care

This playful metaphor brings us back to a critical point about ventilation: no two patients are the same. As respiratory therapists, our job is to assess, adapt, and respond to each patient’s unique pathophysiology. My colleague, Marty Kessler, often says, “It is very important to tailor your strategy to the pathophysiology. Choose the right strategy for the right disease.” To that, I would add: “It is equally important to change the strategy as the pathophysiology evolves.”

This is what makes our profession so rewarding and vital. Our expertise lies in our ability to understand pulmonary dynamics and hemodynamics, identify what each patient needs, and continuously adapt. We don’t take a cookie-cutter approach because the same strategy that worked for one patient might fail for another. This adaptability is what makes us the experts in pulmonary care.

Critical Thinking: The Heart of Respiratory Therapy

Our role as RTs demands critical thinking—skills that grow with every shift, patient, and case. Bedside care is dynamic, requiring us to make real-time decisions and adjust as conditions change. Sessions like those offered by Continued are invaluable in honing our knowledge and keeping us at the forefront of respiratory care.

So, the next time you’re in the produce section, maybe you’ll think of tomatoes, peppers, and peas in a new light. More importantly, remember the delicate balance required to ventilate and protect the lungs. By optimizing mean airway pressure—finding that sweet spot between too much and too little—we ensure better outcomes for our patients. And if nothing else, let this story serve as a reminder: never take a respiratory therapist grocery shopping!

Thank you for allowing me to share my thoughts on mean airway pressure, its impact on pulmonary dynamics, and the parallels we can draw from everyday life. It is these connections and insights that make our profession both challenging and deeply rewarding. Now, let’s dive into the questions you have for me.

Questions and Answers

You mentioned in your talk about the importance of PEEP. Why do you think we don’t give enough PEEP, and why is that significant?

that is an excellent question. My colleagues and I use a term we jokingly call “PEEPophobia.” For some reason, many clinicians are more apprehensive about increasing PEEP than they are about mean airway pressure (MAP). I have seen this repeatedly, particularly with high-frequency ventilation. For example, on devices I worked with, we displayed both PEEP and MAP. Over time, we noticed people were much more hesitant to increase PEEP.

Why? It could be that MAP is calculated—it’s an average of several variables and doesn’t have a direct adjustment knob. On the other hand, PEEP is tangible; you turn a knob, and the change is immediate. This directness may make it feel riskier. I’ll admit, I was once “PEEPophobic” myself. But we must overcome that fear. Properly optimizing PEEP is critical for patient care and stability, especially when trying to prevent lung collapse and ensure proper oxygenation.

Regarding noninvasive ventilation (NIV), what adjustments or precautions would you recommend when NIV doesn’t seem to provide sufficient MAP for a patient with hemodynamic concerns?

that is a great question. One key thing to remember is not to assume the pressures displayed on the NIV device are entirely accurate at the patient’s airway. Resistance in the system, such as prongs or mask interfaces, can significantly affect delivered pressure. A doctor once told me about a case where they set a pressure of 6 cmH₂O on a patient, but when the prongs were laid on the bed, the device still displayed 4 cmH₂O—clearly inaccurate.

If a patient is not responding well to NIV, start by ensuring the prongs or mask are positioned correctly. Next, verify that you’re delivering enough pressure to keep the lungs open. I would err on the side of providing slightly more pressure rather than less. Remember, noninvasive systems are prone to under-delivering pressure compared to invasive systems. that is why careful monitoring and adjustments are crucial when managing patients on NIV.

You discussed near-infrared spectroscopy (NIRS) for monitoring cerebral and renal tissue oxygenation. Is this technology frequently used in practice, especially in the pulmonary and RT fields?

Unfortunately, no, it is not as widely used as it should be. Years ago, I worked at a hospital that was an early adopter of this technology, and I saw its benefits firsthand. However, in many newborn intensive care units (NICUs) and pediatric ICUs I visit, I don’t see it being implemented as often. NIRS has immense potential—not only for monitoring but also for preventing injuries by giving clinicians a real-time “heads up” before harm occurs.

Technologies like NIRS and electrical impedance tomography (EIT) could significantly improve decision-making in patient care, but they haven’t fully caught on yet. it is a great question, and I hope to see more widespread adoption of these tools in the future, as they align perfectly with our goal of proactive, rather than reactive, care.

To wrap things up, what’s the overarching takeaway from your presentation on MAP and its role in ventilation?

The key takeaway is this: get the lungs open and keep them open. Optimizing MAP is crucial in achieving this balance. Too much MAP can cause overdistension and injury, while too little leads to alveolar collapse and inadequate oxygenation. We must tailor ventilation strategies to each patient’s unique physiology and needs.

Critical thinking is essential, and we cannot use a one-size-fits-all approach. Every patient’s condition evolves, and we must adapt accordingly. As RTs, our role is to assess, identify the pathophysiology, and apply strategies that maximize outcomes while minimizing risks. With ongoing education and tools like NIRS, EIT, and careful PEEP adjustments, we can elevate our care standards.

References

Acherman, R. J., Siassi, B., deLemos, R., Lewis, A. B., & Ramanathan, R. (n.d.). Cardiovascular effects of HFOV with optimal lung volume strategy in term neonates with ARDS. USC School of Medicine, Division of Neonatology, and Children's Hospital of Los Angeles, Division of Cardiology, Los Angeles.

Amato, M. B. P., Meade, M. O., Slutsky, A. S., Brochard, L., Costa, E. L. V., Schoenfeld, D. A., Stewart, T. E., Briel, M., Talmor, D., Mercat, A., Richard, J. C. M., Carvalho, C. R. R., & Brower, R. G. (2014). Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine, 372(8), 747-755. https://doi.org/10.1056/NEJMsa1410639.

Friedlich, P., Subramanian, N., & Garg, M. (n.d.). Marked reduction in MAP and OI using HFJV in neonates with severe refractory hypoxemic respiratory failure. Children’s Hospital Los Angeles, Division of Neonatology, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Fu, Z., Costello, M. L., Tsukimoto, K., Prediletto, R., Elliott, A. R., Mathieu-Costello, O., & West, J. B. (1992). High lung volume increases stress failure in pulmonary capillaries. Journal of applied physiology (Bethesda, Md. : 1985), 73(1), 123–133.

Kirpalani, H., Millar, D., Lemyre, B., Yoder, B. A., Chiu, A., & Roberts, R. S., for the NIPPV Study Group. (2013). A trial comparing noninvasive ventilation strategies in preterm infants. New England Journal of Medicine, 369(7), 611-620.

Editor's note: This text-based course is an edited transcript of the webinar Developing Staff Through All Stages of a Career, presented by Carrie Coffman, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Recognize the different stages of a respiratory therapist career
• Identify various strategies for development opportunities
• Identify issues facing respiratory leaders regarding staffing

First Stage - New Graduate

I am delighted to be here today to discuss the vital topic of staff development. If I were to ask everyone on this webinar—or even walk into any respiratory therapy department across the country—what the top three challenges are, I am confident I would hear the same things. The issues of staff retention, recruitment, and burnout would undoubtedly be on everyone's list, if not at the top.

Speaking from my own experience as a respiratory therapist for over 26 years, with 20 of those years in leadership, I have never seen the staffing crisis reach the level it is at now. While there are no easy solutions to these complex problems, I firmly believe that one essential part of the solution is developing your staff throughout all stages of their careers.

Let's start with the first stage: the new graduate. This group is typically full of energy and enthusiasm, eager to dive into the field and put their newly acquired skills into practice. Their excitement for learning and growth is palpable, as they are ready to tackle challenges, take on new tasks, and immerse themselves in patient care. For leaders, this is a rewarding stage to witness, as these fresh graduates bring a sense of renewal and vitality to the team.

One of the biggest hurdles with new graduates is helping them channel their enthusiasm into focused learning. They are often so eager to excel that they can become overwhelmed by trying to master too many things simultaneously. As a leader, we are responsible for guiding them through this initial phase by helping them focus on one task at a time, allowing them to build a solid foundation of skills before moving on to the next challenge. While this can be a challenge, it is certainly a good one to have—managing enthusiasm and eagerness rather than apathy.

For example, take Antonio—a new graduate on our team. After completing his NICU training, He is already making significant strides and delivering exceptional care. His eagerness to learn and grow has made him a standout, and it is gratifying to see how much potential he has. This phase of development is exciting not only for the new hires but also for the entire team. Their enthusiasm is contagious and can even reignite passion in more experienced team members, including leaders. Working alongside new grads reminds us of why we entered the profession in the first place—seeing their fresh perspective and genuine excitement brings back the drive and inspiration that sometimes fades after years in the field.

It is essential to provide new graduates with structured guidance and mentorship during this stage. They need clear expectations and consistent feedback to build their confidence and competence. Early successes—like mastering key procedures or navigating challenging patient cases—serve as important milestones that keep them motivated and engaged. As they start to find their footing, they gain technical skills and a deeper sense of responsibility and connection to their patients and the team.

However, while new graduates are full of potential, they face steep learning curves. This can lead to self-doubt or frustration as they encounter situations they have not mastered yet. That is where leadership plays a crucial role—being present, offering encouragement, and fostering a safe learning environment where mistakes are treated as growth opportunities rather than setbacks. It is important to remind them that perfection is not expected at this stage and that every challenge they overcome is a step toward becoming a more competent and confident clinician.

What makes this phase so fulfilling for leaders is witnessing the rapid growth and transformation of these individuals. New graduates tend to develop quickly, and with the right support, they can move from nervous beginners to competent professionals in a relatively short time. It is a phase of development where every effort invested in their growth pays off, both for the individual and the department.

Overall, the new graduate phase is a period of high energy, potential, and growth. These new hires are the future of the profession, and by nurturing their development, we are not only helping them thrive but also strengthening the team and enhancing patient care. This stage is about laying the foundation for a long and successful career, and for leaders, it is an opportunity to inspire, guide, and shape the next generation of healthcare professionals.

Second Stage - The Proficient Stage

• The stage our team is going to spend the majority of their career in.
• This proficiency can lead to stagnation.
• Stagnation can lead to disengagement. 

The second stage could be called the "proficient stage," where most of our staff will spend the majority of their careers. In this phase, employees have fully mastered their core job skills and can execute their responsibilities with confidence and precision. They are no longer learning the basics but have instead become experts in their day-to-day tasks. Whether delivering patient care, managing complex equipment, or making critical decisions in fast-paced environments, they do it with ease and expertise.

While those in the proficient stage have a firm grasp of their duties, healthcare is an ever-evolving field. They may still need to occasionally learn new equipment, adapt to updated best practices, or master a new charting system. But even when faced with these changes, they are able to incorporate new information without losing the high level of competence they've developed. Their ability to adapt and apply new knowledge to their existing skill set is a hallmark of this stage.

These are the professionals who form the backbone of our departments. They reliably handle the demands of the job, having honed their skills over time through hands-on experience and consistent practice. Because they have moved beyond the learning curve of a new graduate, they are efficient and can manage their workload without constant supervision or direction.

However, it is important to recognize that while this group is highly competent, they may face the risk of becoming stagnant over time. Without opportunities for further growth or development, even the most skilled professionals can lose motivation. That is why, as leaders, it is essential to continue providing new challenges, learning opportunities, and ways for them to remain engaged—whether it is through mentorship roles, leadership training, or specialty certifications. By doing so, we ensure they stay at the top of their game and avoid the disengagement that can come with being in the same role for a prolonged period.

This stage is critical not only for maintaining the quality of care within a department but also for fostering a culture of reliability, consistency, and excellence. These proficient staff members are the ones you can count on during busy shifts or in high-pressure situations. Their experience and knowledge often serve as a resource for newer staff members, and their contributions are vital to the overall success of the team.

Stagnation and Disengagement

• "U.S. employee engagement took another step backward during the second quarter of 2022, with the proportion of engaged workers remaining at 32% but the proportion of actively disengaged increasing to 18%. The ratio of engaged to actively disengaged employees is now 1.8 to 1, the lowest in almost a decade."
• And that proficiency can lead to stagnation. And that stagnation can lead to disengagement. Now, as mentioned, I am located here in beautiful southern Oregon, and we have this beautiful creek here in southern Oregon. And as I was working on this presentation, what it really reminded me of sort of was a metaphor for me of how we get to this second stage, this proficient stage, and what can happen (Harter, 2022).

Imagine a beautiful creek, its water flowing swiftly along, full of energy and movement. Suddenly, it opens up into a wide area where small pools of stagnation begin to form. This image mirrors the progression of our careers. In the beginning, we are fast-moving—not necessarily in a physical sense, though that can be part of it. We are quickly learning, growing, and developing, navigating new skills and responsibilities with excitement and momentum.

Then, like the creek, our career path can widen. In these wider areas, pools of stagnation can appear. Without realizing it, we may slow down, fall into routines, and stop seeking out new challenges. What we need at this stage is something to pull us out of that stagnation—some force that pushes us back into the fast-moving current—back into the center of the stream where we can continue rolling forward, learning, growing, and developing, and most importantly, avoiding stagnation.

We all know that stagnation leads to disengagement, which can be dangerous for our personal growth and the quality of care we provide. For years, as leaders, we have discussed disengagement—what many have referred to as stagnation. Disengagement was the buzzword for quite a while. However, in recent years, we have seen a new term emerge: "quiet quitting." This refers to employees who show up, do the bare minimum required to keep their jobs, and then check out mentally and emotionally. Unfortunately, this is not limited to respiratory therapy. It is a growing phenomenon across the entire workforce.

A September 2022 Gallup article highlighted this trend. In their poll, 32% of the workforce reported being engaged, which does not sound too bad at first glance. However, 18% admitted to being actively disengaged—a number that has been steadily rising across industries and is now nearing the highest level in over a decade. This trend is expected to continue.

As leaders, both in respiratory care and across other fields, we must pay attention to this growing problem of disengagement, stagnation, and quiet quitting. Combating these issues will clearly require focused time, energy, and effort. This brings us back to the second stage—the proficient stage. It is in this stage that disengagement can creep in, and if we are not careful, it can lead to stagnation.

Third Stage - The Late Part of a Career

The final stage, often referred to as the "late-career stage," presents its own set of unique challenges and opportunities. By this point, respiratory therapists have accumulated a vast amount of knowledge and experience, having witnessed and managed countless situations throughout their careers. These professionals are invaluable assets to any department, as they have likely encountered almost every scenario the field has to offer. Their deep understanding of the profession, combined with their practical know-how, makes them an essential resource for both patient care and the ongoing development of the team.

At this stage, one of our primary goals as leaders is to tap into that reservoir of wisdom and ensure it is passed down to the next generation of practitioners. Late-career professionals often possess insights that cannot be learned in a classroom or found in textbooks—they know the nuances of patient care, how to navigate complex cases, and how to handle the pressures that come with high-stakes environments. Their wealth of experience can help guide newer staff members through situations that may seem overwhelming at first.

However, the challenge lies in finding ways to effectively harness this expertise. We must ask ourselves: How do we engage these seasoned professionals and encourage them to share their knowledge with those at the beginning of their careers? One solution is creating formal or informal mentorship programs that provide late-career therapists with the opportunity to serve as mentors or preceptors. Through these programs, they can pass on their hard-earned wisdom, guiding younger staff members in areas like critical thinking, advanced procedures, and even the softer skills of patient communication and teamwork.

Yet, while it is crucial to tap into their expertise, we also need to be mindful of the physical realities that come with the later stages of a career. Respiratory therapy is physically demanding work, and over time, some may find it harder to keep up with the physical demands of bedside care. It becomes a delicate balancing act—how do we honor their desire to continue contributing while ensuring they are not overexerted?

This requires thoughtful and personalized leadership. We must have open conversations with late-career staff members about what they still want to contribute and where they feel most effective. Some may wish to step back from the physically demanding aspects of the job, such as high-intensity critical care or emergency response, but still want to remain involved in teaching, training, or administrative roles. Others may want to focus on areas where they feel they can make the most impact, such as complex patient cases or new hire orientation.

Finding ways to offer flexible roles for late-career professionals is key. This might mean transitioning them into roles that involve more teaching, quality improvement projects, or protocol development, where they can apply their knowledge without being on the front lines 24/7. By giving them ownership over projects that allow them to use their expertise in meaningful ways, we can help them continue to feel valued and fulfilled, even as their physical role evolves.

Engaging late-career therapists in this way benefits them and strengthens the entire team. When newer staff members see that experienced colleagues are still learning, growing, and contributing in different ways, it sets a powerful example of lifelong learning and adaptability. It also helps bridge the generational gap that can sometimes arise between more seasoned and younger staff members. By fostering intergenerational communication and collaboration, we create a more cohesive and well-rounded department.

Additionally, retaining late-career professionals in mentoring or advisory roles can have a profound impact on department culture. Their leadership—whether formal or informal—instills a sense of continuity, tradition, and pride in the profession. It can be deeply motivating for younger therapists to have the opportunity to learn from someone who has dedicated decades to the field, reinforcing the importance of commitment, perseverance, and excellence in patient care.

Ultimately, managing the late-career stage requires flexibility, empathy, and creativity. It is about acknowledging the incredible contributions these therapists have made throughout their careers and finding ways to continue benefiting from their experience, even as their roles evolve. The goal is to keep them engaged and appreciated while allowing them to shift their focus in a way that suits both their physical needs and professional desires. By doing so, we not only honor their legacy but also ensure that the next generation of respiratory therapists can learn from the best, contributing to a stronger, more resilient profession as a whole.

Career Ladder

As we consider our employees at each stage, we must ask: What is the gold standard for developing our teams? The answer is a career ladder. And regardless of its structure, any effective career ladder must have two essential components.

First, the career ladder must be fluid. Second, we as leaders must be fluid in our approach. Our staff members will move through different stages at their own pace, and we need to recognize and support that. This flexibility is key to fostering continuous growth, no matter what the career ladder looks like.

I would like to share a snapshot of our current career ladder, which is currently under review as we work on making improvements. Essentially, it looks like this: our first level, RCP I, is our "floor care" role. This is typically where new graduates begin their journey. At this stage, we want our therapists to focus on honing their assessment skills—especially the critical "sick or not sick" judgments. We also expect them to utilize our therapist-driven protocols to the fullest extent.

Once they have mastered these skills, they can move up. Here is where that fluidity comes into play—there is no set timeline. For one therapist, this transition might happen in two months; for another, it could take six months. It all depends on their individual growth and development.

Once our therapists have mastered the RCP I level, they advance to RCP II. At this stage, we train them to work in our adult critical care units, including the emergency department. This is where the mandatory portion of our career ladder ends. Our expectation for every new hire is that they at least reach the RCP II level.

As mentioned, I am with Asante Health System in southern Oregon, a three-hospital system. At our regional center, we offer an RCP III level, which branches into specialized areas. Staff can apply to either the Adult Critical Care Specialist (ACC) team or the Neonatal Pediatric Specialist (NPS) team. However, this specialization is available primarily at the regional center. At our two smaller sister hospitals, RCP III might be a leadership role, but those opportunities are limited, making it more challenging for staff at those facilities to reach RCP III.

Recently, we added another level to the ladder for transport therapists, offering further advancement beyond RCP III. Each level—RCP I, II, III, and Transport—comes with its own pay scale. While there is some overlap between them, they remain distinct, which provides a financial incentive for staff to reach the next level. Currently, we have a NICU transport team in place, and we are actively working on developing an adult critical care transport team.

As I mentioned earlier, flexibility is crucial when it comes to career development. Throughout each stage of a career and within each level of the career ladder, our staff members are navigating their personal lives. They may be getting married or divorced, welcoming children, caring for elderly parents, or dealing with health issues of their own. Any of these life events can significantly impact their ability to focus on their own professional development or contribute additional time and energy to the department.

That is why it is important for us as leaders to meet our staff where they are. Understanding their personal circumstances and adjusting our expectations accordingly is key to helping them succeed. I would like to share some examples to illustrate what I mean by "meeting them where they are."

Let me start with my first example. We had a team member on our RCP III NPS transport team who was incredibly passionate about neonatal care, as many neonatal therapists are. Unfortunately, he experienced a partial loss of vision in his left eye, which significantly impacted his depth perception. This loss affected his ability to consistently and successfully intubate neonates—an essential skill for our NPS team.

As heartbreaking as it was for him—and for us as his leaders—we had to make the difficult decision to move him from RCP III back to RCP II since intubation was a critical requirement at the higher level. The challenge for us as leaders was not just addressing the technical aspect but also finding a way to keep him engaged and motivated in his new role. We had to ask, "Now what? What can we do to help you stay passionate and fulfilled as an RCP II?"

It would have been easy—almost understandable—for him to fall into disengagement and stagnation after such a setback. However, through persistent encouragement and support, we worked with him to find new areas where he could contribute. He took ownership of several key projects and gradually re-engaged in his role at the RCP II level. I am proud to say that, despite the challenges, he found renewed purpose in his work and remained engaged until his retirement.

That first example was challenging, but this second example highlights a different kind of situation. We had a new graduate passionate about respiratory therapy and floor care. She was a real go-getter, and we were confident she would quickly rise up the career ladder. She had all the signs of someone destined for success.

However, just as she was transitioning into the RCP II role, life threw her a curveball. She went through a divorce, and the change in her personal circumstances drastically affected her childcare situation. Unfortunately, this meant she could no longer work the bedside hours required in our department. Despite our best efforts to accommodate her schedule with different shifts, none fit her new reality. Ultimately, she had to leave bedside care and step away from the inpatient respiratory therapy department altogether.

We found her a position in our outpatient setting, where the 9-to-5 hours worked much better for her childcare needs. She thrived in that role for the next seven years. Fast-forward to the present—her childcare situation was no longer a pressing concern, and she came to us excited about returning to bedside care. She was ready to return to the work she loved: bedside floor care.

We started her back at the RCP I level, despite her seven years of experience in respiratory therapy, because that time did not directly translate to the career ladder. However, she quickly moved to RCP II, took on a charge therapist role, and eventually expressed interest in joining the Adult Critical Care Specialist (ACCS) team. She applied, was accepted, and is now excelling in that position.

I am thrilled that we brought her back into bedside care, where her passion lies. These two examples highlight how a career ladder must remain fluid, adapting to both the stages of a therapist's career and the life events that happen along the way. This is what makes it a gold standard for developing your team. However, as leaders, we know there are countless approaches and tactics for fostering growth and development in our teams. Here, I would like to share a small snippet of strategies we use to help our staff grow and succeed.

Other Approaches

• A level: Our solution to allowing a staff member to contribute regardless of level
• Obtaining credentials
• Mentorship with leadership
• Teaching opportunities
• Jobs within the system
• Unit councils leading to project/team leadership
• Journal Club
• Leadership training
• Conferences
• Outside education
• Professional development funds

Let me take a moment to explain what we mean by an "A level" because I know it may sound a bit confusing. An "A level" is our solution for enabling any staff member, regardless of their position on the career ladder, to contribute meaningfully to the department. Whether an RCP I or higher, you can take on a leadership role in a project or initiative that benefits the team.

The key is that the contribution must be both meaningful and measurable. it is not enough to say, "I am going to be the best therapist I can be." While That is important, it is not considered an A level contribution. An A level requires taking charge of a project, leading a team, or driving an initiative that has a tangible impact on the department.

The A level also comes with a financial reward. It adds an extra dollar per hour to the staff member's base wage—not just when they are actively working on a project but across the board. This financial incentive, combined with the personal fulfillment of contributing to the department meaningfully, makes the A level especially rewarding for those at the RCP I level and beyond.

In addition to leading projects, obtaining new credentials and taking on teaching opportunities are excellent ways to keep staff engaged and help them avoid falling into that stagnant pool. Offering leadership training, hosting educational conferences, and encouraging outside education are strategies I strongly advocate for. I have seen firsthand how attending conferences can reignite passion and spark creativity in our team members. These events allow them to come back with fresh ideas, eager to share what they've learned with the department and other teams. it is a fantastic way to get those creative juices flowing and keep staff energized and engaged.

Professional development funds are something I want to highlight because I have seen how impactful they can be. Leadership training, obtaining new credentials, or pursuing outside education can sometimes present financial barriers for our staff. Even though these tools are essential for growth, the cost can prevent team members from taking advantage of them.

If your facility offers professional development funds, it can significantly reduce—or even eliminate—those financial barriers. By providing access to these resources, we empower our teams to take full advantage of leadership training, conferences, and educational opportunities. These tools are invaluable in helping our staff continue to grow, develop, and remain engaged in their roles.

Nursing Career Ladder Pathway to Excellence

The career ladder I shared with you, along with these other strategies, is not only relevant to respiratory therapy. As we have already discussed, the issue of quiet quitting is not unique to our field—it affects many departments within the hospital setting, including nursing. These challenges are widespread, and it is important to apply these development approaches across the board to keep our teams engaged and motivated.

Now, let me give you an example of our nursing career ladder, part of a program called Pathway to Excellence. This program operates on a point-based system and is built around six key standards: shared decision-making, leadership, safety, quality, a culture of well-being, and professional development.

The program is structured annually, and nurses are responsible for accumulating and tracking their points, with proof, across at least three of these six standards. Over the course of the year, they must meet a certain point threshold by engaging in activities that fall under these selected standards. This ensures that they stay on track with their professional growth while contributing to the hospital's goals for excellence.

Nurses gather all their points and supporting documentation throughout the year and submit them annually, qualifying for a bonus based on their total number of points. I like this approach for many reasons. In fact, when we were designing our respiratory therapy career ladder, we seriously considered using a point system before ultimately deciding on levels instead.

One aspect I particularly admire about the nursing program is the inclusion of well-being activities. I would love to find a way to incorporate similar well-being components into our respiratory therapy career ladder. I truly believe that prioritizing well-being activities could be a powerful tool in addressing staff burnout. If we could help our respiratory therapists find ways to better care for themselves, it would have a tremendous impact on both their personal and professional well-being.

Guiding the Process

• Quarterly rounding
• Yearly evaluations
• Performance feedback

We have established the stages, the approaches, and the strategies for developing our teams. But how do we guide our staff through these processes? This is where gathering feedback becomes crucial.

One effective method is through quarterly rounding. As leaders, we sit down with our staff members every few months to have a candid discussion about what is working well and what is not. When they bring up issues, we encourage them to also come up with possible solutions. This not only engages them in problem-solving but also fosters a sense of ownership and accountability. What better way to motivate and empower them than by having them contribute directly to the solutions they have identified?

Encouraging staff to take ownership of an issue—whether a minor pet peeve or a significant challenge—is one of the best ways to engage them in meaningful solutions. When they are involved in fixing what bothers them, they feel more invested in the outcome.

Of course, we have the yearly evaluations, where we sit down with staff and ask those often dreaded words: "What are your goals for the upcoming year?" For new graduates, the list is endless—they are bursting with excitement and have 1,000 goals. In those cases, our task is to help them focus on just the top three.

However, this conversation can be much more challenging for the proficient group or those in the later stages of their careers. They may not have as many clear goals, or they might feel less certain about what is next for them professionally.

Often, as leaders, we need to think outside the box when guiding staff through goal-setting, especially for those in the proficient or later stages of their careers. This is where performance feedback becomes essential. Let's break down the two types of performance feedback and how we can apply them effectively, starting with the more challenging one: constructive feedback.

Imagine we are preparing for yearly evaluations, or perhaps we have received consistent, credible feedback about a staff member—let's say, Bob. The feedback indicates that Bob is struggling with his communication skills, something you yourself may have noticed or even experienced firsthand.

So, we sit down with Bob and say, "Based on the feedback we have received, it seems communication is an area where you face some challenges. What do you think? What steps do you think we can take to help you improve in this area?"

My recommendation to Bob might be a specific class, a book, a course, or even a leadership program—because leadership courses often include valuable communication training. There are a variety of tactics we can use, depending on the situation and the person. Ultimately, as leaders, our goal is to inspire Bob to actively work on improving his communication skills. In an ideal scenario, Bob returns excited about his learning. He is eager to share his newfound knowledge with his team, coworkers, and you, creating a win-win situation for everyone involved.

Now, That is constructive feedback, which can be challenging. But when done right, it can lead to real growth. On the other hand, positive feedback is something I love to give. it is a win on so many levels. When I sit down with someone and say, "Paul, I have heard nothing but great things about your knowledge of Nitric Oxide in the NICU," it is an easy, rewarding conversation.

"You have become everyone's go-to person for Nitric in the NICU. How would you feel about taking on a bigger role—maybe providing education on Nitric, handling the supply orders, or even becoming the lead for Nitric in the NICU?" By offering this, not only are you acknowledging Paul's expertise and showing your appreciation, but you're also rewarding him with ownership—something he can truly take pride in, especially in an area where he already excels.

This idea of ownership is key, particularly when discussing creating opportunities for late-career professionals to share their extensive knowledge with younger colleagues. Sometimes, there is a significant generational gap in communication, and you're absolutely right—it can be a challenge. In my experience, bridging that gap often requires leadership guidance on how to facilitate these knowledge transfers effectively.

Absolutely—creating mentorship opportunities is key. Take Deb McFarland, the RT who's been with us for 42 years. She faced challenges with the generational communication gap, but at her core, her heart was always in the right place. She wanted to help others become the best they could be in the critical care units. Once my co-leaders and I encouraged her, we coined the phrase, "Take them under your wing." We empowered her to mentor younger colleagues by teaching them everything she knew.

When Deb had concerns or faced challenges, I would guide her on how to approach the situation—offering suggestions on how to communicate feedback effectively or share constructive input. We also shared examples of how others had successfully navigated similar communication barriers.

I think sometimes it really comes down to offering clear examples and providing guidance rather than taking a completely hands-off approach. It is about finding that balance between generations and helping them communicate effectively with one another. This generational gap can go both ways. Take a new grad, for example—someone who has no patience for anything written on paper because they are used to everything being electronic. It is important to help them understand that while we may not expect them to adopt the paper methods of their mentor, they should still recognize the value of learning from someone who relies on those systems because that person may not trust computers as much.

As their leader, I do not expect them to carry on those practices forever, but I do ask them to absorb as much as they can while being precepted. Utilize the paper method to the best of their ability, and once they are on their own, they can adapt their approach—whether that means going fully digital or leaving the paper behind. it is about helping them see the value in both perspectives and how they can use that to move forward. When we talk about the stages of a career, all our tactics, approaches, and strategies for development ultimately come down to guiding our team in a way that fosters engagement and growth.

Development Is Not a Magic Solution

Imagine we all now have a magic wand at our disposal. Suddenly, no more staffing issues—our staffing crisis, retention challenges, recruitment difficulties, and burnout problems are all solved. Magic wand, the problem is completely resolved? If only it were that simple. Unfortunately, development alone is not the magic solution, as much as I wish it were.

Let me give you a snapshot of where we are right now. Despite all our efforts, approaches, tactics, processes, and policies, our current vacancy rate is 14.8%, and our turnover rate is 6.7%. Development cannot solve everything. It is not the magic answer we wish it could be.

We all know that COVID certainly did not help our staffing situation. In 2020, our vacancy rate was 6.2%. So, while things have worsened, I cannot imagine where we would be today if we had not implemented all these strategies. It makes me even more determined to keep asking: What is next? What else can we learn, improve, and develop to keep moving forward?

Forbes published an article in July 2023 titled Why Personal Development is the Solution to Quiet Quitting—there is that catchphrase again. In the article, they emphasized that to retain top talent, boost productivity, and drive innovation, it is crucial to offer more professional development opportunities for employees. This applies across all industries, not just ours. We are not facing these challenges alone—we are in good company. What is becoming clear is that many industries recognize that developing their teams is key to retaining top talent and attracting new talent. Professional development is an essential part of the solution.

What Are Your Areas of Opportunity?

As we have been discussing, what are your areas of opportunity? Do you have a career ladder in place? If not, what could it look like for your team? It could take the form of a point system, a level-based approach, or other career ladder models. There are multiple versions out there, and if you do not currently have one, I strongly encourage you to do your research.

Explore what is available and consider what might work best for your organization. A well-structured career ladder can make all the difference in developing your team, retaining talent, and fostering growth.

As a leader—often pulled in a million different directions—do you have projects that could be handed off as an A-level project or whatever version you might use? Think about what that could look like for your team. Would it involve a bonus or an increase in wages? What form of recognition or reward would make sense for your facility?

I am sure there is something you could delegate. We all have tasks we could pass on. But the key question is: How would that reward your employee? Would it provide personal recognition, increase engagement, or give them a sense of ownership? Or could it be all of those things plus a financial incentive?

Do you also offer professional development funds? I know that, especially during a financial crisis, like many facilities are facing right now—it can be tempting to cut those funds when trimming the budget. But if at all possible, I urge you not to. The benefits of keeping your staff engaged, learning, growing, and developing far outweigh the short-term savings.

What opportunities exist within your system? Do you have relationships with schools or mentorship programs in place? It is important not to overlook those opportunities. For example, we had a traveler come to our system.

She was a wealth of knowledge, having been a traveler and a respiratory therapist for many years. When she came to our facility, she found that she really enjoyed our therapist-driven protocols and the way we operated. As a result, she decided to join us as a full-time employee. We brought her on as an RCP II, given her level of experience.

Shortly after, she applied for the ACCS team and was quickly successful in securing that role. She thrived in it for some time, but then, as life and career stages shifted, she decided it was time to slow down. She came to us and said she wanted to step back from ACCS and return to an RCP II role. We fully supported her decision.

At that very moment, a job opportunity opened at one of our smaller sister hospitals. It was an RCP II position that included PFT (pulmonary function test) responsibilities, and she expressed a strong interest in it. She wanted more time to connect with her patients and felt this role would allow her to do that.

I am incredibly proud of her because she not only took on the role but quickly developed a passion for PFTs. She helped us further develop our cardiopulmonary program and even launched her own Better Breathers Club as part of that program.

This is a perfect example of how meeting your staff where they are—personally and professionally—can help you retain them, even if it means supporting them in a different role or at a different facility. By staying flexible and listening to their needs, they continue to contribute meaningfully to your system as a whole.

Summary

• Better clinicians
• Recruitment
• Retention
• Ongoing development of your staff is an important part of the solutions to the current  issues facing our profession
•  

We can all agree that when you invest in developing your staff, you will see better clinicians every time. By preventing stagnation, disengagement, and quiet quitting—where someone only does the bare minimum—you're setting your team up to deliver the high-quality care we all strive for. Engaged therapists provide excellent patient care, and That is something each and every one of us on this webinar is committed to. Not only does development improve patient care, but it also helps with recruitment. For example, we serve as a clinical site for a school in northern California, even though we are in southern Oregon.

The school sends its students to us for their NICU rotation, and every time we welcome a new group into our NICU, we introduce them to our career ladder. We show them exactly what we are willing to do to help them become the best respiratory therapist they can be. We always aim to support their growth and development, and we want them to reach their full potential.

Often, the NICU captivates them during their clinical rotation, though we do have a few who gravitate toward ACCS as well. Do they stay with us forever? Sometimes not. Some are only with us for a handful of years. But I take immense pride in knowing that I have played a part in helping them become the best RTs they could be, even if it means they take those skills to another facility—perhaps even one of yours.

I truly believe that when we focus on developing quality therapists, it makes us stronger as a profession. When we have only the best therapists, it benefits all of us. It also plays a critical role in retention. When your staff sees you as a leader, going out of your way to support them—no matter what stage of their career or the career ladder they are on—builds trust and loyalty. By finding ways to utilize each person's skills to their fullest potential, you create an environment where they can be proud of their work every shift.

This is why I am so passionate about the ongoing development of our staff. It is a key part of the solution to the challenges we face in our profession today, from retention to engagement to overall quality of care.

Questions and Answers

What metrics do you use to measure the success of your onboarding process, such as new hire retention and performance?
While I do not have the hard data in front of me, I can share that we closely monitor several key metrics. For new hire retention, we track how long a staff member stays with us and analyze the reasons for their departure when they leave. In terms of performance, we assess where each employee stands during their yearly evaluations, including the goals they set, and evaluate whether we were able to help them achieve those goals in the following year.

How do you account for differences in new hires' backgrounds, such as those from bachelor's programs versus shorter respiratory therapy programs?
We do see clear, measurable differences between new hires from bachelor's programs and those from shorter 14-month programs. In general, bachelor's degree graduates tend to progress more quickly through our career ladder compared to those from shorter programs. The discrepancy is often due to the type of clinical experience they have been exposed to. For example, some graduates from 14-month programs have not performed tasks like arterial blood gas analysis, which can result in a steeper learning curve compared to bachelor's graduates who come in with more hands-on experience.

How do you handle onboarding challenges for new hires who are not familiar with your therapist-driven protocols?
There can be a significant learning curve for new hires who have not worked under therapist-driven protocols, where therapists are responsible for decisions like bronchial hygiene treatments or bronchodilator dosages. Our goal is to get them up to speed with these protocols. However, we recognize that it is not always possible to achieve this with every new hire.

How does having a union affect your ability to move staff through the career ladder?
Having a union can significantly impact how fluidly we can move staff up or down the career ladder. Before our department unionized, we had more flexibility to make those decisions as respiratory leaders. Now, those decisions are more constrained by union agreements.

References

Harter, J. (2022, September 6). Is quiet quitting real? Gallup. https://www.gallup.com

Arruda, W. (2023, July 5). Why personal development is the solution to quiet quitting. Forbes. https://www.forbes.com
 

Editor’s note: This text-based course is an edited transcript of the webinar, Bridging the Gap: From Student to Professional, presented by Jessica Hewitt, MSOL, RCP, RRT. 

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Identify the different ways a gap between student knowledge and professional practice may appear.
• List the factors contributing to the disparity in readiness between respiratory therapy school and clinical practice.
• Identify personal strategies for participants to help bridge this readiness gap.

Memory Lane

Let’s begin by reflecting on your time as a student. Think back to when you were first learning about the respiratory therapy profession. I have a few key questions to help guide this reflection. How well did you understand the role of a respiratory therapist before entering the field? Did your education fully prepare you for the hands-on realities and challenges of the job? What specific experiences or skills do you wish you had developed before stepping into the role of an RT? As you think about these questions, consider the gap that often exists between academic training and clinical practice. We’ll use this reflection to discuss how we can better prepare new graduates for the field by strengthening their transition from education to real-world practice.

Reasons for Choosing Respiratory Therapy

Student Perspectives

To begin, let’s explore why students choose respiratory therapy as a career. I look at it from two perspectives: the student viewpoint and insights from the American Association of Respiratory Care (AARC). From my experience as an educator and through interviews with incoming students, many of them are drawn to this field after working in other healthcare roles. Some come from positions like phlebotomists or certified nursing assistants (CNAs), bringing with them valuable experience, but often with limited understanding of the specific demands of respiratory therapy.

These students often choose respiratory therapy because it offers a hands-on, patient-centered career with opportunities to make a direct impact on patient outcomes. The promise of specialized skills and the ability to work across diverse healthcare settings—like emergency departments, ICUs, and neonatal care—makes it a unique and appealing profession.

Sometimes, students are motivated by personal experiences as patients. For example, I had one student who chose respiratory therapy after being hospitalized with COVID-19. That experience gave her firsthand insight into what respiratory therapists do, from patient care to the critical role of ventilation.

For others, it is family connections. Many students have family members with respiratory illnesses, which introduces them to the profession early on. Then there are those who do not have direct contact with RTs but are drawn to the profession for its job stability and increasing demand. Post-COVID, the need for respiratory therapists has escalated, and we have gained more visibility in the news. The competitive compensation that has followed also makes it an attractive option for many.

Despite being a relatively short program—typically about two years, sometimes even less with accelerated options—respiratory therapy offers strong career prospects. In some cases, students can complete their associate's degree in respiratory therapy in under two years and still enter the workforce with competitive wages.

Another appeal of the field is the potential for a good work-life balance. Many respiratory therapists work three 12-hour shifts per week, which allows for flexibility—something that is especially valuable for parents or those with other family responsibilities.

Student and AARC Perspectives

A common theme I hear from students is how rewarding this career can be. They are motivated by a desire to help others, find purpose in their work, and know they are making a real difference in someone’s life. From the AARC perspective, this sentiment remains consistent.

The AARC emphasizes that respiratory therapy is a solid and growing career. According to their projections, the demand for respiratory therapists is expected to increase significantly in the coming years. Many of us have heard about the looming shortage of RTs, driven in large part by a wave of retirements. This will create a critical need for new graduates to enter the field and keep the profession thriving.

It is more important than ever to ensure that these new graduates are well-prepared and strong in their practice. By doing so, we can maintain the stability of our profession and continue making a meaningful impact on the lives of our patients.

Respiratory therapy also offers a path for lifelong learning. Many of us will continue to grow in our careers by exploring different areas of the hospital, working with various patient populations, and staying current with continuing education units (CEUs). These ongoing challenges contribute to making the career even more rewarding.

In fact, I recently spoke with a prospective student who mentioned that she was specifically drawn to the idea that high stress leads to high rewards. This mindset speaks to the heart of what many of us seek—a career that is challenging but deeply fulfilling.

At its core, respiratory therapy is about service to others. Making patient needs the top priority and showing genuine care allows us to truly make a difference in people’s lives.

RT School and The Gap

RT School: CoARC

First, let’s examine the structure of respiratory therapy programs. A significant aspect of this is the role of the Commission on Accreditation for Respiratory Care (CoARC). Students must graduate from a CoARC-accredited program to sit for their board exams and earn their credentials, making this accreditation crucial.

CoARC sets the standards to ensure that RT schools provide a high-quality education. These standards help guarantee that graduates are not only well-prepared for the profession but are also equipped with strong practical skills, a solid academic foundation, and the ability to engage in research. Ultimately, this accreditation ensures that new respiratory therapists can provide excellent patient care and contribute meaningfully to the healthcare field.

CoARC also ensures that schools maintain their accreditation through continuous improvement. To keep this accreditation, programs must undergo regular audits and follow several processes to ensure their curricula stay current and relevant.

A key part of this is the professional development of faculty and administrators. This often involves regular meetings to review and update the curriculum as needed. If evidence-based medicine evolves, those changes are integrated into the program to ensure students receive the most up-to-date education.

Quality assurance is a critical component of the accreditation process. Schools are required to track and report several key performance indicators, ensuring transparency and accountability. The three primary metrics I will focus on are graduation rates, credentialing rates, and job placement rates.

We consistently monitor the number of students who begin and successfully complete the program, the number of graduates who go on to earn their credentials—both Certified Respiratory Therapist (CRT) and Registered Respiratory Therapist (RRT)—and the number who secure employment in the field after graduation. These metrics are not just numbers; they reflect the program's effectiveness in producing competent and hireable respiratory therapists.

Programs are also held accountable to ensure students are not only graduating but are fully prepared for the profession's demands. High credentialing and placement rates demonstrate that graduates are ready to pass board exams and succeed in clinical environments. This continuous tracking helps identify areas for improvement, ensuring that the education provided is aligned with industry needs, emerging trends in healthcare, and the evolving standards of evidence-based practice. Additionally, these indicators offer valuable feedback for faculty, allowing them to adjust teaching methods and curricula as needed to maintain high performance and meet accreditation standards.

CoARC also plays a crucial role in ensuring that best practices are being taught and that any developments in respiratory care are incorporated into the curriculum. They are strong advocates for the respiratory therapy profession, helping to shape its future. In fact, CoARC has been instrumental in the creation and expansion of bachelor’s and master’s programs in respiratory therapy, which are gaining increasing attention.

I have noticed a growing interest from students asking about master’s programs—something that was not even an option when I was in school. This reflects the evolving nature of the profession and the drive for continued academic advancement within respiratory care.

Beyond advancing degree options, CoARC is committed to maintaining a student-centered focus. Their goal is to ensure that each student receives a high-quality education, fully preparing them for their careers. This dedication helps guarantee that students graduate not only with the necessary credentials but also with the skills and knowledge to thrive in the field.

What Is “The Gap?”

What is this gap I keep referring to? It is the difference between what is taught in RT school and what is commonly practiced at the bedside, including the emotional intelligence required to work in a clinical setting. Many students are surprised—and sometimes even frustrated—when they learn that what is in the textbook does not always match what they see in the real world. This variation comes from different hospital protocols and varying scopes of practice depending on the facility or region.

One major aspect of this gap is the challenge of applying textbook concepts to real-world scenarios. Learning from books and passing exams is one thing; being confronted with a live patient is another. Even when students have the necessary knowledge, putting it into practice can be difficult.

Another critical aspect of the gap is emotional preparedness. This is often overlooked in education and can be a tough conversation to have. As respiratory therapists, we work in high-stress environments, and our work carries significant emotional weight—not only for us but for our patients and their families. The ability to relate to patients, manage emotions, and cope with the stress of critical care situations can be incredibly challenging for new graduates transitioning to bedside care.

The Emotional Gap

Building on this emotional gap, a significant challenge for many new graduates is the transition to working independently. The shift from a supervised learning environment to the autonomy of being on your own can be overwhelming. I actually had a former student reach out to me after starting their first job in the field, asking, "How do you get rid of imposter syndrome?"

This student was incredibly intelligent—at the top of their class—and felt well-prepared academically. However, once they were faced with the reality of making decisions on their own, the weight of responsibility hit them hard. They experienced a sense of panic, realizing they were now responsible for managing high-stress situations and severe illnesses. This feeling of not being ready, despite their training, is a common experience and adds to the emotional challenge of transitioning from student to practicing professional.

A significant challenge for new graduates is managing the emotional trauma that comes with coping with patient loss. This aspect of the job can be incredibly difficult, and teaching students various coping techniques is essential to bridging this emotional gap. Coping skills cannot be entirely taught from a textbook, but they need to be discussed and developed throughout their education.

An area I did not anticipate as a student but now make a point to address in my classes is navigating complex family dynamics. As respiratory therapists, we often provide care not just to the patients but also to their families. In some situations, particularly when patients are critically ill or unable to communicate, our interactions with families can be even more intense. Helping families understand medical interventions, managing their emotions, and offering support during critical moments are all parts of the job. In some cases, the ability to guide families through end-of-life situations with empathy and compassion becomes just as important as the technical aspects of care.

Encouraging students to build strong personal and professional support systems is critical. These systems help them manage the emotional demands of the profession and foster resilience. Peer networks, mentorships, and even mental health resources can be invaluable as new graduates adjust to the pressures of working in such a high-stress, emotionally charged environment.

Personally, I do not have any family in the healthcare field. While my family has always been incredibly supportive, they could not fully understand or relate to the challenges I was facing. What ultimately helped me find the best coping strategies and feel more secure in my role was finding a support system of people who truly understood the demands of the job.

Helping students understand the importance of finding these support systems—whether through coworkers, mentors, or even their current classmates—is critical to easing their transition into the respiratory therapy world. Having a network of individuals who can relate to what they are experiencing can make a huge difference in navigating the emotional and professional challenges they will face.

Reasons for the Educational to Clinical Gap

What are the reasons for this gap I have been discussing? A significant factor is that each institution and setting has its own priorities and focus. Respiratory therapy schools emphasize foundational knowledge, critical thinking, and meeting accreditation standards, ensuring students are prepared for their credentialing exams. However, a trauma hospital may prioritize rapid, life-saving interventions, quick decision-making, and managing high-acuity cases in a fast-paced environment. In contrast, home healthcare focuses more on long-term patient care, rehabilitation, and chronic disease management. Each of these settings requires different skills, and the divergence between academic preparation and real-world practice becomes more evident based on the focus of each institution.

The gap between academic and clinical settings is often substantial. In school, the goal is often to ensure that students understand theoretical concepts and protocols, while clinical settings require them to apply this knowledge in dynamic, real-world scenarios. We will explore these differences in more detail shortly.

A contributing factor is the varied expectations between the classroom and the bedside. In an academic environment, students are evaluated primarily on their ability to memorize information, pass exams, and perform in controlled simulations. In contrast, at the bedside, they are expected to apply this knowledge in unpredictable, high-pressure situations. They must navigate not only the medical complexities of patient care but also interpersonal dynamics, emotional intelligence, and decision-making in real-time. This is where the gap widens—bridging the transition from textbook learning to patient-centered care can be a challenge.

The healthcare landscape is constantly evolving. New technologies, updated protocols, and emerging evidence-based practices are introduced regularly. Schools may struggle to keep up with the rapid changes in clinical practice, meaning that by the time students enter the workforce, they may encounter new methods or tools they had limited exposure to during their education. This creates another layer of difficulty when transitioning from the classroom to the clinical environment.

Focuses of RT Education

Let’s talk about the focus on the education side of respiratory therapy. One of the primary emphases in RT programs is preparation for the board exams. As I mentioned earlier, credentialing rates are tracked as part of CoARC’s accreditation requirements. We place a heavy emphasis on ensuring students are fully prepared to pass these exams because this is essential for maintaining accreditation.

This focus is critical, as passing the board exams is the gateway to becoming a licensed respiratory therapist. Without these credentials, students cannot enter the field. Therefore, much of the curriculum and academic effort is geared toward equipping students with the knowledge and skills they need to succeed on these exams. Whether it is through test simulations, practice questions, or in-depth reviews of core concepts, we do everything we can to help students reach that goal.

A key part of the educational focus is hands-on competency. Students need to demonstrate their practical skills through hands-on assessments, which might involve working with simulated patients or practicing with each other. These exercises help prepare them not only for the real-world scenarios they will face but also for the multiple-choice Therapist Multiple Choice (TMC) exam, which is required to earn their CRT credential.

In addition, we emphasize developing critical thinking skills, which are essential for passing the RRT credential. This is assessed through the Clinical Simulation Exam (CSE), where students must demonstrate their ability to think critically and make sound decisions in complex clinical scenarios. We work hard to prepare them for both exams by simulating real-life challenges as much as possible.

• Focuses of RT Education: Focuses on individual subjects
  • Educational programs and instructors determine the integration of topics based on curriculum design
• Balancing act of mitigating content overload
  • Balances depth of learning to prevent memorization without understanding

One challenge in RT education that can make it difficult for students to apply their knowledge to real-world situations is the way subjects are taught in a very compartmentalized manner. Most schools break down topics into distinct categories, like pulmonary anatomy and physiology, therapeutics, and mechanical ventilation, each taught separately. However, in practice, all of this knowledge needs to come together to treat a single patient.

Initially, students tend to think of these subjects as isolated areas of learning. While this may change as they progress through the program, it often leads to difficulty connecting concepts from one class to another—and, ultimately, applying them in a clinical setting. This disjointed approach can result in students struggling to integrate what they learned in different courses when faced with real patients.

Students may experience content overload, trying to absorb a vast amount of information in a short time. One of the most common issues we see is what we call "memorize and dump"—students memorize information for exams but quickly forget it afterward rather than retain and understand the material deeply enough to apply it effectively in practice. This can create a significant gap between what they know in theory and what they can actually do in a clinical environment.

This "memorize and dump" cycle is incredibly difficult to combat, largely because students are bombarded with a vast amount of information in a short period. As soon as they finish one class, they move on to the next, often forgetting much of what they just learned. By the time they have completed a final exam, their focus shifts to the next set of material, and the knowledge from the previous class starts to fade.

The challenge is finding a balance—helping students truly understand and internalize the material so that it sticks, rather than just memorizing it for a test. We need to ensure that students recognize the long-term importance of what they are learning rather than simply focusing on short-term retention for exams. It is crucial to foster a deeper understanding so that the knowledge stays with them as they progress through the program and into their clinical practice.

Positives and Challenges of RT Education 

• Promotes critical thinking
  • May be difficult to teach
• Addresses the importance of evidence-based medicine and patient-centered care
  • Difficult to evaluate and score in the classroom

There are several challenges in RT education, but they often go hand in hand with the positives. One of the key strengths of RT school is that it promotes critical thinking, which is essential for success in the field. However, teaching critical thinking is not easy. Each student approaches situations differently, and no two clinical scenarios are exactly the same. For critical thinking to be effective, students need to integrate their knowledge with personal insights—yet, as students, they often lack the real-world experience to fully develop this skill.

This is where the challenge arises. Critical thinking improves with time and practice, and experienced therapists benefit from drawing from personal experiences—whether successes or mistakes—to guide their decision-making. Students, on the other hand, have not yet had the opportunity to build that reservoir of experience, which can make developing strong critical thinking skills more difficult in an academic setting.

That being said, the promotion of critical thinking in RT education remains a major positive. While it takes time to develop fully, students are introduced to the importance of problem-solving and learning to approach complex patient situations with a critical, analytical mindset. As they gain more clinical exposure and experience, their ability to think critically will naturally grow, building a strong foundation for their professional careers.

As new graduates, they have not yet developed the depth of insight that comes with experience. They rely heavily on their academic knowledge, trying to piece together everything they have learned to care for their patients. This is where the challenge lies—being able to synthesize and apply their knowledge effectively in real-world situations.

A critical aspect of thinking through patient care, which is often overlooked from the student's perspective, is the presence of subconscious biases. These biases, whether cultural, social, or emotional, can significantly influence how a therapist approaches patient care. Factors such as a patient's race, socioeconomic status, gender, or lifestyle choices can unintentionally affect how care is delivered. It is crucial to make students aware that biases exist in healthcare and to help them recognize their own subconscious biases as much as possible.

By acknowledging these biases, students can begin to reflect on how these influences might shape their interactions with patients, whether through assumptions about a patient’s condition or judgments regarding their behavior. Once students recognize these biases, they can learn how to set aside emotional or biased barriers and focus on delivering patient-centered, objective care that aligns with the best clinical practices.

Understanding and addressing these subconscious biases is an essential, yet often underestimated, part of developing as a healthcare professional. Healthcare providers, including respiratory therapists, frequently interact with patients from diverse backgrounds, and their ability to recognize and mitigate these biases directly affects the quality of care. Helping students to confront and manage these biases early on not only improves patient outcomes but also equips students to be more compassionate, culturally competent, and effective therapists. It fosters an environment where patients feel seen, heard, and understood, which is vital for building trust and ensuring that care is equitable for all patients.

RT school also emphasizes the importance of evidence-based medicine and patient-centered care, which ties directly into addressing subconscious biases. The goal is to help students make decisions based on the best available research while also keeping the individual needs and preferences of the patient at the forefront. However, applying evidence-based medicine can be challenging because it is constantly evolving. What we know today may change tomorrow, and students must learn to adapt to this ever-shifting landscape.

A clear example of this was during COVID-19, when we all witnessed the scientific method in real-time. Guidelines, treatments, and protocols were rapidly updated as new evidence emerged. This experience reinforced the idea that learning in healthcare is never static. In RT, everything builds on prior knowledge, and no matter how long we have been in the field, we are always learning and adapting. Evidence-based medicine is a lifelong commitment, and understanding this early on prepares students to be more flexible and responsive to new developments in the profession.

While we can emphasize the importance of evidence-based medicine in RT education, its rapid evolution makes it difficult to keep up with—and even harder to evaluate in the classroom. The fast pace of medical advancements creates challenges in ensuring students not only understand the current best practices but are also able to apply them effectively in a real-world setting.

This makes it particularly difficult to assess and score in a traditional classroom environment. While we can stress the significance of evidence-based practice, testing its real-world application is much more complex. The dynamic nature of healthcare means students must continuously adapt, and measuring their ability to do so can be challenging. Ultimately, while we can provide the foundation for evidence-based medicine, the true test comes when they are on the job, continually learning and integrating new knowledge into their practice.

• Ample class time, less clinical exposure
  • Leading to a lack of understanding of how to triage, time management, and scope of practice
• Difficulty in keeping instructors up-to-date
  • Exposure to new equipment and technological advances

One challenge we face in RT education is that it is primarily classroom-focused. While every program provides students with some clinical exposure, the majority of their time is spent in the classroom, leaving less opportunity for hands-on learning in real-world environments. The classroom setting is essential for teaching foundational knowledge, particularly when it comes to preparing for board exams. However, clinical exposure is critical for developing the practical skills that are necessary for success at the bedside.

In clinical settings, students have the chance to apply their theoretical knowledge, but more importantly, it is where they learn to manage real patients. This exposure allows them to practice key skills such as triaging patients, refining their time management, and making quick decisions in high-pressure situations. These experiences also provide a clearer understanding of the full scope of practice for respiratory therapists, including how to collaborate with interdisciplinary teams and navigate complex patient cases.

The limited time spent in clinical settings can make it challenging for students to fully grasp these practical aspects before graduation. Furthermore, clinical experiences vary based on location, meaning some students may not have exposure to certain patient populations or care environments. For example, a student might get a lot of exposure to emergency care but little experience with long-term or home care settings. This variance can leave gaps in their practical experience, which may take time to fill once they enter the workforce.

The challenge, then, is finding the right balance between academic knowledge and clinical experience. Programs must ensure students are not only equipped to pass their exams but also prepared to handle the complexities and unpredictability of patient care in real-life scenarios.

Another layer of complexity is that clinical practices and available resources can vary significantly depending on where you are in the country or even around the world. This variability can affect the kind of experiences students have during their clinical rotations, further contributing to the gap between education and real-world practice.

Additionally, keeping instructors up to date with the latest advancements in technology and care practices is an ongoing challenge. While educators can stay informed through conferences, online forums, and continuing education units (CEUs), including programs like this one, many of us do not have the opportunity to work directly with new equipment or technologies on actual patients. This limits our ability to fully integrate cutting-edge tools and techniques into our teaching.

Without firsthand experience using newer technologies in clinical settings, it becomes harder to share personal stories or offer insights into how these advancements are applied in real life. This gap makes it even more difficult to bridge classroom learning with what students will encounter in hospitals, particularly as healthcare continues to evolve rapidly. Ensuring instructors have access to hands-on experience with the latest technologies is essential for preparing students to handle the realities of modern respiratory therapy.

Focuses of RT Profession Cont'd. 

• Implementation of respiratory-therapy driven protocols
  • Hospital specific
  • Focused on evidence-based medicine and patient centered care
• Emphasis on maintaining certifications, credentials, and licensing

Shifting away from the classroom setting, let’s talk about the clinical side of the RT profession, where a significant focus is on the implementation of respiratory therapy-driven protocols. These protocols guide the care provided by RTs and play a crucial role in how respiratory therapists operate within hospital settings. However, these protocols can vary widely depending on the institution or geographic location, making them highly specific to the hospital or healthcare system in which you work.

For example, one hospital may have a protocol that allows RTs to manage ventilator settings independently based on patient needs, while another facility might require close collaboration with physicians for every change. Similarly, protocols surrounding oxygen therapy, nebulizer treatments, or weaning from mechanical ventilation can differ greatly depending on the hospital’s policies, the patient population they serve, and the resources available.

These differences are often based on a variety of factors, such as the hospital’s culture, regional regulations, and the specific needs of its patient demographic. This makes it important for RTs to adapt quickly when transitioning between facilities or even between departments within the same hospital. What works in one institution may not apply in another, and part of the RT’s skill set involves learning the protocols unique to each clinical environment.

Furthermore, respiratory therapy protocols are often developed and updated based on the latest evidence-based practices, making it essential for therapists to stay informed of new research and advancements in the field. This constant evolution of clinical protocols emphasizes the importance of adaptability and continuing education for RTs, as they must balance standardized practices with the flexibility to adjust to new information and different clinical environments.

This variability in protocols can be particularly challenging for new graduates, especially those who work at multiple hospitals, or even for seasoned professionals transitioning between different facilities. Each hospital may have its own set of protocols, and adapting to these differences can be overwhelming at first. For both new and experienced respiratory therapists, it is essential to remain flexible and quickly learn the specific practices of each institution.

In addition to navigating these varying protocols, there is also a strong emphasis in the RT profession on using evidence-based medicine to provide the highest quality care for patients. While RT schools focus heavily on helping students achieve their certifications, credentials, and licenses, the professional environment shifts the focus to maintaining and building on those qualifications. Respiratory therapists are expected to participate in continuing education (CEUs), in-services, and other professional development opportunities to stay current in the field. This commitment to lifelong learning ensures that RTs are not only keeping their credentials up to date but also growing in their knowledge and advancing in their career ladder.

The specific focus of an RT’s role can also change dramatically depending on the setting in which they work. For example, the skills required for a rehabilitation setting are vastly different from those needed in a pulmonary function testing (PFT) lab or an intensive care unit (ICU). Each environment demands a unique set of competencies, whether working with long-term, recovering patients in rehab or managing critically ill patients on mechanical ventilation in the ICU. This diversity in clinical settings is one of the key aspects of respiratory therapy, making it both challenging and rewarding as therapists continuously adapt their skill sets to meet the needs of various patient populations.

Comprehensive training across hospital areas

• Including but not limited to:
  • Observation units
  • ICUs
  • ER
  • Sleep lab
  • Rehabilitation
  • Home health
  • PFT lab

As new graduates enter the field, their transition can be particularly challenging if they are hired to work in multiple hospitals. I have had several students who secured per diem positions at more than one facility, and this situation can make the adjustment even more difficult. In these cases, they are not only learning different protocols for each hospital, but they are also managing different areas of patient care. For example, they might be working in the emergency room at one hospital and in a PFT lab at another. Juggling these roles can make it hard for new graduates to gain confidence, as they are constantly shifting between protocols, settings, and patient care expectations.

This challenge is not limited to new graduates—seasoned respiratory therapists can also find it difficult to move between hospitals or switch care settings. Even with years of experience, transitioning to a new environment with different protocols and priorities can feel overwhelming. Whether it is a move from one hospital to another or a switch from an ICU setting to rehab, adapting to new practices and expectations can take time and can impact the confidence of even the most experienced RTs.

Variances in RT Professional Practice

• Scope of practice
  • Variances observed across states and hospitals
• Diverse equipment and protocol standards
  • Impacting operational efficiency
• Disparity in workloads
  • Influencing clinical practice and resource allocation

There are several variances in RT practice that contribute to these challenges. Even RTs who have been in the field for a while may feel like they face a gap when moving to a new facility or region. Being a new hire anywhere can be intimidating, and much of that comes from differences in the scope of practice. For example, respiratory therapists in Texas may be performing tasks that are not allowed in California or vice versa. These variations make it difficult for instructors to stay current with what is allowed in each state, and it can be challenging for students to build confidence in their skills before transitioning to the bedside.

The equipment and protocols can vary widely from one facility to another. For instance, one hospital may use a specific model of BiPAP machine, while another hospital uses a completely different brand or model. Learning new equipment with each job change adds another layer of difficulty to the already steep learning curve. This can exacerbate the existing gaps in knowledge, especially when transitioning between facilities that use different technologies or have distinct approaches to patient care.

Moreover, there are disparities in workloads and resources between facilities. Some hospitals may have more staff, allowing for lighter patient loads and more manageable time constraints. Others may have fewer resources, requiring RTs to handle more patients with less support. These differences can impact clinical practice and significantly influence how RTs manage their time and balance their workload. Adapting to a new facility’s workflow and expectations can be challenging for both new graduates and seasoned professionals, as it requires not only mastering new equipment and protocols but also adjusting to different time management strategies.

Merging the 2 Ways of Thinking

• Skills
• Critical thinking
• Time Management
• Empathy
• Compassion

To help students and new graduates feel more confident at the bedside, we need to find a way to merge the clinical setting with the educational side. Bridging these two worlds is essential to preparing students for the realities of patient care. It is not just about ensuring they have the necessary theoretical knowledge; it is also about equipping them with the practical skills and emotional intelligence they will need to succeed.

One key focus should be on helping students develop their critical thinking skills. In the classroom, they learn the basics of decision-making, but in the clinical setting, they need to be able to apply that knowledge in unpredictable, high-pressure situations. By integrating more clinical scenarios and simulations into education, we can help students better prepare for the complex decision-making they will face in real life.

Time management is another critical skill that requires attention. In the classroom, students may have time to work through problems thoroughly, but in clinical practice, they will need to make decisions quickly and prioritize tasks effectively. Incorporating time management training into their education—through case studies, simulations, and clinical rotations—can help them build the skills necessary to manage real-world patient care more efficiently.

Equally important is teaching empathy and compassion, not just for the patient but also for the families present in the room. Clinical care is not just about treatment; it is about communication and emotional support. By emphasizing patient-centered care and teaching students how to engage with families compassionately, we can help them develop soft skills that are just as vital as clinical knowledge.

By merging these aspects of education and clinical practice, we can create a more holistic approach that prepares students not only for their exams but also for the realities of working in the field. This will give new graduates the confidence they need to transition smoothly into bedside care, knowing they are equipped both intellectually and emotionally.

How Do We Bridge This Gap?

How do we bridge this gap? We address this in two different settings—first, how we can bridge the gap in the classroom, and then how to do so on the clinical side.

In the Classroom

Starting with the classroom setting, it is essential to ensure that the curriculum is continuously adapted to meet the evolving demands of the field. This includes integrating new equipment and therapies and incorporating practical, real-world scenarios. In my experience, one of the most frequent requests from students is the inclusion of more patient scenarios. They want the opportunity to think through real-life cases in the safety of the classroom setting so they feel more prepared when they transition to clinical rotations or their first jobs as new graduates.

Incorporating personal experiences is another critical element of making the classroom more relevant to clinical practice. One of the requirements for being an instructor is to have several years of RT experience, and sharing those personal stories helps students understand the depth and importance of the material. When we discuss different therapies or ventilator modes, it is often just theoretical information to them—until we can relate it to real experiences. For example, explaining, "In this situation, I used this ventilator mode, and these were the results I observed," makes the lesson much more tangible. Students tend to engage more actively when we bring these real-world examples into the classroom, and they can better grasp how the knowledge will apply to their future work.

What is interesting is that many students who have worked in hospitals often raise their hands to share their own experiences. They will recount scenarios they encountered but did not fully understand at the time. As they progress through their classes and gain more knowledge, they often have those "lightbulb moments" where everything clicks, and they finally understand the therapies or procedures they observed in action. I encourage this sharing, not only from my end but also from the students. These personal experiences, whether from a clinical setting or elsewhere, enrich the learning environment and help connect theory to practice.

This leads us to the importance of active student engagement. One effective way to foster this is through the use of case studies. We can start by providing printed case studies and allowing students to work through them individually, followed by small group discussions. These discussions give students the opportunity to think critically about different scenarios, share their perspectives, and work together to apply the knowledge they have learned. This kind of active engagement, whether through group work, class participation, or personal storytelling, helps bridge the gap between classroom learning and real-world application.

Of course, we need to incorporate lab activities to further solidify their learning. For example, in a therapeutic lab, students could practice setting up nebulizers, administering medications, or performing other respiratory therapies. In a mechanical ventilation lab, they can get hands-on experience using ventilators and even practice intubating patients. These lab activities provide crucial opportunities for students to apply their knowledge in a controlled environment, allowing them to build confidence and competence before moving into the clinical setting.

One of my favorite approaches to fostering engagement and confidence is making the students the teachers. I have seen this method used in several schools, which is incredibly effective. It forces students to take ownership of the material and gain the confidence they will need when they are the ones explaining treatments to patients, nurses, or family members.

There are a couple of ways I incorporate this into my classes. I assign students to explain complex concepts—either in small groups or as a written exercise. For example, they might need to explain mechanical ventilator modes, specific respiratory therapies, or medications. One of the key elements of this exercise is having them tailor their explanations for different audiences. I ask them to think about how they would explain a medication or therapy to a healthcare professional who already has some understanding, versus a patient or family member who may not be familiar with medical terms.

This exercise is not only a great study technique but also a way to gauge their level of understanding. A technique I was taught when I was in school was, “If you can teach it, you know it well. If you cannot teach it, you need to study it more.” It is a simple but effective way to see what students truly understand and where they might need to focus their study efforts. Teaching forces them to think critically and organize their knowledge in a way that is clear and coherent, which is exactly what they’ll need to do when they are in the field, explaining treatments to patients or collaborating with other healthcare professionals.

Making it clear how language needs to change depending on the audience strengthens students’ abilities at the bedside. Being able to explain complex respiratory concepts in two different ways—one for healthcare professionals and one for patients or family members—makes them more effective communicators and helps them build trust and rapport with their audience. This adaptability is crucial in real-world settings, where clear, concise communication is key.

Another way to turn students into teachers is through skills fairs. These events give students the opportunity to demonstrate therapies or procedures—sometimes to their classmates and sometimes to the community. Skills fairs can be organized as school-wide events, with other programs involved, such as nursing or medical assisting. Inviting other healthcare programs to participate offers a great opportunity for interdisciplinary learning, and it is a fun and interactive way for students to showcase what they’ve learned.

What is especially meaningful about these events is the involvement of family and friends. Inviting them to observe allows students to show off everything they have learned up to that point while also providing a much-needed boost of support from their loved ones. This is particularly important as students juggle the demands of school, work, and personal obligations. Seeing that their hard work is recognized and supported by their family and friends can be a huge motivator and confidence builder as they prepare for the transition to clinical practice.

In the Classroom: Simulations

An exciting way we bridge the gap in the classroom is by using computerized mannequins to create realistic simulations. These mannequins allow us to replicate a true hospital environment right in the lab, offering students hands-on experience in a controlled setting. The three photos here show the mannequins I currently use in my teaching, which provide a wide range of patient assessment skills and scenarios.

Simulations with these mannequins create a safe space for students to practice patient care without the fear of harming anyone. They understand that this is a time to make mistakes and learn from them, which is invaluable in helping them build confidence and skills. The controlled nature of the simulation allows for real-time feedback and the opportunity to repeat procedures until they feel more comfortable.

One of the key areas these mannequins help with is patient assessment. They can simulate breath sounds, vital signs, EKG changes, and more. Some mannequins even allow students to practice drawing arterial blood gases (ABGs), performing CPR, or conducting intubations. For an added level of realism, some mannequins can also "talk," responding to students’ questions based on inputs from a tablet that controls the simulation. This interactive feature gives students the chance to practice communicating with patients, further preparing them for real-world bedside care.

The use of these computerized mannequins has been a game-changer for bridging the gap between the classroom and clinical settings, allowing students to experience a wide range of patient scenarios in a safe and controlled environment.

In the Classroom: Exploring Ethical and Cultural Considerations

• Facilitating thoughtful discussions
  • Encouraging open-ended class discussions in small or large groups
• Addressing complex scenarios
  • Approaches to family interactions during comfort care extubation
  • Effective communication with patients expressing fear of intubation

A key part of bridging the gap in the classroom is addressing ethical and cultural considerations, which can be challenging for some students. These discussions often bring up the more difficult and emotional aspects of our careers—what I like to call the “uncomfortable truths” of the job we have chosen. However, facilitating these conversations is essential for preparing students for the realities they will face in the field.

I usually start these discussions in smaller groups. Students often feel more comfortable talking about sensitive topics with a small group of friends, allowing them to explore these issues in a safer, more supportive environment. Afterward, if anyone feels comfortable sharing their thoughts or experiences with the entire class, I encourage them to do so. This helps foster a deeper understanding of these complex topics while keeping the discussion respectful and empathetic.

One important topic we discuss is family interactions during comfort care extubation. This is something I am personally very grateful for, as my own preceptor handled it with professionalism and empathy when I was a student. Before we entered the room, my preceptor calmly coached me on how to approach the situation, how to show compassion, and how to give the family the appropriate space they needed during such an emotionally charged time. Learning how to navigate these moments with empathy and professionalism is vital, and discussing these situations in class helps prepare students for the emotional realities they may encounter.

We explore other difficult patient scenarios—such as patients who are scared, about to be intubated, struggling with severe shortness of breath, or facing surgery. Understanding how to communicate effectively in these situations is crucial. Students need to learn how to provide reassurance and comfort while navigating the complexity of patient emotions. Additionally, it is important for students to know the resources available to them—whether that is reaching out to a supervisor, a chaplain, or other healthcare professionals for support in these tough moments.

I also like to give a disclaimer before we begin these conversations. If any students have recently experienced loss or trauma, I provide them with the space to step out of the classroom if they feel uncomfortable. Creating a respectful and compassionate environment for these discussions is critical to helping students process the more challenging aspects of our profession.

At the Bedside

• Comprehensive orientation program 
• Gradual introduction to clinical duties
• Providing ongoing education and training opportunities
• Supportive mentorship initiatives

Now, looking at the bedside perspective, one of the most effective ways to bridge the gap for new graduates is through a strong orientation program. A comprehensive orientation helps new grads transition from the classroom to clinical practice with greater confidence and competence. One critical area of focus during orientation should be time management and triage strategies—two essential skills that can be particularly challenging for new graduates to master.

Time management is often something new grads learn as they go, but giving them dedicated time to understand the hospital's preferred methods for triaging treatments, administering medications, or managing patient loads can make a huge difference. Offering guidance on how to prioritize tasks and manage their time efficiently—whether through learning hospital-specific shortcuts or best practices—can prevent them from feeling overwhelmed in those early weeks on the job.

In addition to practical skills, helping new graduates understand the hospital’s organizational structure is key. Knowing who to go to for support, understanding the chain of command, and familiarizing oneself with the roles of other departments all contribute to a smoother transition into clinical practice. These are often overlooked elements of bedside care, but they can have a significant impact on how well new graduates adjust to the demands of the job.

A strong orientation program not only provides new graduates with the tools they need to succeed but also builds their confidence as they integrate into the healthcare team. When they feel supported, they are more likely to thrive in the fast-paced and often stressful environment of bedside care.

An effective orientation program also helps new graduates understand who to report to if they have questions or concerns. It clarifies essential details like who to call if they are running late, sick, or encountering any issues. This takes away some of the added stress that comes with being new—not just to the career but to the hospital and its specific protocols. Clarifying these expectations early on helps new graduates feel more confident and supported as they navigate their new roles.

Although I cannot provide all the specifics of each hospital’s expectations in the classroom, I often have students ask me for clarification before they start their clinical rotations. I always remind them to ask their instructors or preceptors because every hospital operates differently. This is why having these details as part of the orientation is so important—it eases their minds and gives them a clearer understanding of what is expected from the start.

One thing I often told new graduates when I was precepting was, “I understand you are new, and I do not expect you to know everything yet. Nobody knows everything—that’s why continuing education exists.” Reassuring them in this way helps take some of the burden off, allowing them to focus on learning and growing in their new role. It is crucial for them to understand that their responsibilities will gradually increase as they become more familiar with the hospital, its protocols, and their role within the team. By easing their transition through strong orientation programs and clear communication, we set new graduates up for success, helping them gain confidence and competence at the bedside.

On that note, a gradual introduction to clinical duties can be highly beneficial for new graduates. Instead of overwhelming them by throwing them into every responsibility at once, it is helpful to start with a smaller workload, perhaps focusing on just one area of the hospital. This allows them to get acclimated to their new environment, develop their patient assessment skills, and adjust to the reality of working independently. Gradually increasing their responsibilities helps combat imposter syndrome, which is common when they first transition from working under a preceptor to being on their own. By easing them in at a slower pace, you can significantly boost their mental well-being, job satisfaction, career satisfaction, and overall confidence.

A great strategy, similar to what we do in the classroom, is incorporating simulation training into the clinical setting. Simulation-based training is becoming increasingly common in healthcare and is particularly useful for preparing staff for high-stakes scenarios, such as code or rapid response situations. These simulations allow healthcare professionals to practice protocols in a safe environment, identifying areas where they may have missed a step or could improve their decision-making, all without affecting real patients. This hands-on training helps employees refine their skills and build confidence before facing such situations in real life.

Holding regular in-services is another effective way to provide ongoing training, especially when new equipment is introduced to the hospital. Instead of simply integrating new equipment and expecting employees to adapt, having dedicated in-services where experts walk through the ins and outs of the equipment is much more effective. This not only ensures that staff are comfortable with the new tools but also improves patient safety and care quality by minimizing confusion or errors.

By gradually introducing clinical duties, offering simulation training, and providing regular in-services, hospitals can create a more supportive environment for new graduates and seasoned professionals alike, fostering a culture of continuous learning and skill refinement.

In-services also serve an important role in ensuring that employees understand why certain equipment is being introduced or why other equipment is being phased out. Change can be intimidating, and providing clear communication about the reasoning behind these decisions helps reduce uncertainty and fosters more openness to new protocols or tools. In-services create a valuable opportunity for dialogue between leadership, management, and employees, which not only enhances understanding but also encourages feedback from staff who will be using the equipment on the front lines.

An effective initiative is holding skills fairs, which many hospitals and departments already incorporate. Skills fairs can serve multiple purposes. Experienced staff members offer an opportunity to gain teaching experience by demonstrating skills that can help develop their instructional abilities. For new graduates, attending these fairs allows them to observe and learn skills they may not yet have mastered but will need to perform as their training progresses. This exposure can help new RTs better understand the future scope of their role and the additional duties they may take on as their careers develop.

In some cases, these skills fairs can also be extended to the broader community, inviting people outside the healthcare field to learn more about what respiratory therapists and other healthcare professionals do. This not only provides a great learning opportunity but also allows healthcare professionals to engage with the community in a meaningful way, helping raise awareness about the role of RTs in patient care.

By fostering open communication through in-services and providing learning opportunities via skills fairs, hospitals can promote an environment of continuous growth and collaboration, helping both new and experienced RTs feel more connected to their roles and the evolving needs of patient care.

Then, consider a mentorship program, which plays a crucial role in guiding professional growth for both new graduates and seasoned professionals. Mentorship provides a structured system of support where mentees have someone they can turn to for guidance, advice, and encouragement throughout their time at the hospital. These mentors can help new employees navigate career ladders, offering insights into potential career advancements and how to achieve their goals.

One of the key benefits of mentorship is the sense of security it provides. New graduates know they have someone they can go to without fear of judgment, someone who is dedicated to supporting their development. The mentor is there to listen, answer questions, and share personal experiences to help the mentee think through challenging situations more effectively. This kind of supportive relationship can be incredibly valuable in helping new graduates gain confidence and competence in their roles.

Research has shown that mentorship programs have wide-ranging benefits. Not only do they help improve job satisfaction and competence in new graduates, but they also contribute to better employee retention. For seasoned professionals, having a mentor can help reinvigorate their passion for the job, while for new RTs, it can significantly reduce feelings of isolation or imposter syndrome. Additionally, these programs have been shown to enhance compassionate patient care, as having a role model to demonstrate empathy and professionalism encourages mentees to adopt these same qualities.

Ultimately, a strong mentor serves as a role model, showing new graduates what it means to be a skilled and compassionate respiratory therapist. A good mentor's ongoing impact extends far beyond the first few months on the job—it can positively influence the mentee’s entire career, shaping how they approach patient care and professional development for years to come.

Enhancing Well-being

• Provide access to mental health resources
• Enhancing resilience and work-life balance

A critical way to support employees, especially new graduates, is by providing access to mental health resources. This is particularly important for those who may not yet be fully equipped to handle the high-stress and emotionally taxing environments they encounter. Mental health resources can help them manage the pressures of the job and develop healthy coping mechanisms for these challenges.

These resources might include counseling services, stress management workshops, or mindfulness exercises that incorporate breathing techniques and low-impact, low-intensity activities. Peer support groups can also be valuable, as they foster a culture of openness and support. These groups help reduce the stigma surrounding mental health by reinforcing the message that it is okay not to feel 100% all the time. it is human to have tough days in healthcare, and creating a safe space to acknowledge those feelings can go a long way toward promoting emotional well-being.

A significant part of this support is fostering resilience—the ability to bounce back from challenges. Not every day in healthcare will be easy, and being able to recover from the emotional toll of the work is critical for long-term job satisfaction and mental health. New graduates, in particular, look to more experienced staff to see how they handle the emotional demands of the job. They often wonder, "How do they still do this? How do they prevent burnout?"

Encouraging employees to prioritize self-care and use their paid time off (PTO) is a key aspect of building resilience. Adequate PTO allows staff to step away, relax, recharge, and spend time with family. When they return to work, they are rested, refreshed, and better prepared to face the challenges of patient care. Taking these breaks not only prevents burnout but also reinforces emotional resilience, helping employees maintain a healthier work-life balance.

By promoting the use of mental health resources and encouraging breaks, hospitals and healthcare facilities can help their staff build the emotional resilience necessary to thrive in the long term. This will ultimately lead to better patient care and greater overall job satisfaction.

Impact of Bridging the Gap

• Enhanced therapist confidence and competence
  • Benefit for the educational system: positive perception of student experience can lead to a positive reputation in the community, higher placement rates, and higher enrollment rates
  • Benefit to the healthcare institution: enhanced patient care and employee well-being

Bridging the gap between education and clinical settings has a significant and multifaceted impact, benefiting both the educational system and healthcare institutions.

Impact on the Educational System:
For educational institutions, creating a seamless connection between classroom learning and clinical practice can profoundly impact students' perceptions of their experiences. When students feel well-prepared, confident, and supported during their education, they foster a positive view of their program. This positive perception is often shared through word of mouth, leading to a strong reputation within the community.

A good reputation can drive higher enrollment rates, as prospective students are more likely to choose programs that are well-respected and trusted. Additionally, when students graduate feeling competent and ready to enter the field, it boosts the institution’s placement rates, further enhancing its reputation. As these graduates enter the workforce and interact with others—whether it be phlebotomists, CNAs, transporters, or other healthcare professionals—they often share their experiences. If they speak positively about their education and how prepared they feel, this can inspire others to consider a career in RT, helping to address the current shortage of RTs and meet the increasing demand for respiratory care professionals.

Impact on Healthcare Institutions:
The benefits are just as significant for healthcare institutions. When new graduates enter the workforce feeling confident in their skills and knowledge, patient care is enhanced. Competent, well-prepared RTs are better equipped to provide high-quality care, make informed decisions, and collaborate effectively with other healthcare professionals. This directly contributes to improved patient outcomes and overall patient satisfaction.

When employees feel well-supported—through strong orientation programs, mental health resources, mentorship, and opportunities for professional growth—it positively impacts their well-being and job satisfaction. This can reduce turnover rates, improve employee retention, and foster a healthier work environment where staff feel valued and engaged. Ultimately, this contributes to a more stable and efficient healthcare workforce, which benefits both patients and the institution as a whole.

By bridging the gap between education and clinical practice, both sides stand to gain. The educational system builds a strong, trusted reputation, while healthcare institutions benefit from competent, satisfied employees who deliver better patient care.

Summary

Enhanced patient care leads to better outcomes and a more positive patient experience, which is particularly important when patients are at such a vulnerable and often frightening point in their lives. When RTs are well-prepared and confident, they can help patients feel safe, comfortable, and supported during their stay, contributing to their overall health and recovery. This compassionate, competent care not only benefits the patients directly but also enhances the healthcare facility’s reputation.

A healthcare institution known for providing high-quality care and positive patient experiences gains a competitive advantage in the community. Through word of mouth, a reputation of excellence spreads, making the facility more trusted and respected. In turn, this reputation attracts more patients and strengthens the facility’s standing among other healthcare providers.

Furthermore, this improved quality of care and supportive work environment boosts job satisfaction among RTs. When employees feel competent, valued, and part of a supportive team, it leads to higher employee retention. This means more experienced staff are available to participate in mentorship programs, helping to train the next generation of RTs, which in turn reduces burnout and creates a more resilient workforce.

Fostering continuous learning and professional development becomes easier when RTs are confident and passionate about their work. These student-turned-employees are more likely to seek out opportunities to learn and grow, to take on new challenges, and to contribute more actively to their profession. This enthusiasm for growth is exactly what the field of respiratory therapy needs, especially in times of high demand and workforce shortages.

In summary, bridging the gap between education and clinical practice not only leads to enhanced patient care and better outcomes but also strengthens the healthcare institution’s reputation, improves employee satisfaction and retention, and fosters an environment of continuous learning and professional growth. it is a win-win for everyone involved—patients, healthcare providers, and the field of respiratory therapy itself.

Questions and Answers

What are your ideas for how we can better prepare our tests to reflect real-world scenarios?

While everyone is thinking about that, I personally believe that simply being aware of the gap between classroom knowledge and real-world practice is a crucial first step toward bridging it. Acknowledging this gap helps us take intentional steps to create stronger respiratory therapists in the future. By focusing on real-world applications in testing, we can help the RT profession grow, gain more responsibilities, and become an integral part of the healthcare community. This will contribute to the continued development of advanced practice and master’s programs, which are already starting to take hold.

How can we keep instructors up to date with the latest practices?

I really like this idea that someone brought up—having students help bridge the knowledge gap. I have actually seen this happen in my own experience. For example, a student recently pointed out a new method for sending sputum samples that I hadn’t encountered before. It was eye-opening. We looked into it and discovered it was a newer method designed to prevent contamination. I have also had students update me on the transition to new equipment, like the V60 BiPAP. Keeping an open dialogue with students not only helps them feel empowered but also keeps instructors informed about current practices in the field.

How does reflecting on our own experiences as students help us connect with new graduates?

Someone mentioned how important it is to remember how we felt as students, and I couldn’t agree more. Reflecting on those early experiences really gives us perspective. I remember, as someone with no prior healthcare experience, feeling completely intimidated. The scariest part for me was not necessarily the knowledge—it was talking to patients. Even though I felt confident in the material, applying that knowledge in real interactions was daunting. It is important for us to keep these memories fresh because they remind us of the challenges that new graduates face as they transition from student to practitioner.

Can simulations be used for debriefing sessions or for practice talking to families?

That is a great question! Personally, I haven’t used simulations in that specific way yet. However, I’m scheduled to attend training soon to learn how to use mannequins in a more comprehensive way, beyond just patient care. we have done some role-play scenarios where students practice explaining things to us, and I act as the patient. For example, I pretend I have no medical knowledge and ask questions like, “What does inhalation mean?” This forces students to break down complex concepts into simpler terms. I would love to take this a step further and use mannequins for this kind of communication training as well.

What about incorporating equipment troubleshooting or dealing with technology failures into simulation scenarios? Would that better prepare students for real-world challenges?

Absolutely! That is something I have been considering a lot. Equipment troubleshooting, particularly with mechanical ventilation, can be tricky. Students do not always enjoy learning how to troubleshoot waveforms at first, but it is a vital skill. I use mannequins that simulate changes in compliance and resistance, which have been incredibly helpful in demonstrating these challenges. Additionally, there are online tools that simulate ABG (arterial blood gas) changes in response to different ventilation settings, and those have been a big help as well. It is definitely an area where simulation and technology can significantly enhance student preparedness.

How do you see AI being incorporated into learning and the academic side of respiratory therapy?

That has been a huge conversation lately. When I first started teaching, it was relatively easy to assess students through traditional papers. But with the rise of AI tools like ChatGPT, it is become more complex. Instead of fighting against it, we have adapted and started incorporating AI into our assignments. For example, students can give AI a personality, tell it who they are (e.g., “I’m the respiratory therapist treating you today”), and then interact with the AI as if it were a patient in a clinical scenario. The AI responds as a programmed patient, and it has completely changed how we approach assignments. It is a game-changer for practicing patient interactions.

How is AI being incorporated into hospital systems?

I’m curious about that, too! For those in the audience, it would be interesting to hear how AI has been integrated into the hospital systems where you work. AI is evolving so quickly, and its role in healthcare is only going to grow. it is becoming clear that AI will play a significant part in both clinical practice and education moving forward.

You talked about mentorship, which I think is key. How early do you think mentorship should be started—during education or upon entering the workforce?

That is a great question, and I think the timing depends on what both the student and potential mentors are willing to do. I always encourage students to keep in touch with their clinical instructors, provided the instructor is open to it. Clinical instructors can become excellent mentors even after the formal teaching period is over. However, with instructors and preceptors often working with many students, it can be difficult for them to maintain ongoing mentorship for everyone.

In my experience, formal mentorship typically starts once students are hired at a hospital. That is usually when they are assigned an official mentor to help them transition into the workforce. However, having an unofficial mentor—someone you feel comfortable reaching out to during school or clinical rotations—is never a bad thing. I personally leaned on informal mentors a lot when I was a student, and it made a huge difference.

There are different requirements for graduates when it comes to officially working for us, but we have had past students come back and offer mentorship to current students. Some even leave their contact information on a board so that students can reach out if they need help. We also invite former students to come and talk to our newer students, as well as those about to graduate. They give tips on the interviewing process, what to expect when entering the field, and how to feel more confident about the transition. It is really valuable for students to hear from someone who’s just been through it themselves.

Experience is key throughout your presentation, especially in terms of interdisciplinary education. In the real world, we interact with a variety of professionals—medical students, doctors, nurses, phlebotomists, and others. What are your thoughts on incorporating interdisciplinary experiences into the academic setting to better prepare students for these real-world interactions?

I think it is incredibly important. Interdisciplinary education is essential because, in the real world, we are constantly collaborating with professionals from all areas of healthcare. Whether in a hospital setting or post-acute care, you will encounter medical students, doctors, nurses, phlebotomists, and many others. It is vital to prepare students for these interactions early on, whether through simulation or by providing more education in this area.

Personally, it is one of the reasons I love skills fairs so much—they allow students to present their knowledge to other professions. At the school where I work, we have several other medical career degrees and certificates on campus, and we try to team up as much as possible. My department collaborates with other programs, such as occupational therapy assistant and physical therapy assistant programs, to bring our students together. We aim to simulate real-world scenarios where students from different disciplines can work together, just as they would in a hospital or clinical setting. This kind of collaboration helps them understand how to communicate and share knowledge across professions, which is critical for providing comprehensive patient care.

References

American Association for Respiratory Care. (2023, December 18). Why be an RT? www.aarc.org

Hookmani, A. A., Lalani, N., Sultan, N., Zubairi, A., Hussain, A., Hasan, B. S., & Rasheed, M.A. (2021). Development of an on-job mentorship programme to improve nursing experience for enhanced patient experience of compassionate care. BMC Nursing, 20(1), 175.

National Academies of Sciences, Engineering, and Medicine. (2018). Bridging the education-to-practice gap. In Improving health professional education and practice through technology: Proceedings of a workshop. National Academies Press. https://www.ncbi.nlm.nih.gov/books/NBK532784/National Healthcareer Association. (2023). Bridging the classroom-to-practice gap: How to prepare students for the reality of healthcare. 

Opoku, E. N., Jacobs-Nzuzi Khuabi, L.-A., & Van Niekerk, L. (2021). Exploring the factors that affect the transition from student to health professional: An integrative review. BMC Medical Education, 21(1), 535. 

Shoghi, M., Sajadi, M., Oskuie, F., Dehnad, A., & Borimnejad, L. (2019). Strategies for bridging the theory-practice gap from the perspective of nursing experts. Heliyon, 5(9), e02503.

Sreedharan, J. K., Gopalakrishnan, G. K., Jose, A. M., Albalawi, I. A., Alkhathami, M. G., Satheesan, K. N., Alqahtani, A. S., Alonaiziy, M. M., Alsukhayri, A. A., Alqahtani, S. A., & Alqahtani, A. S. (2024). Simulation-based teaching and learning in respiratory care education: A narrative review. Advances in Medical Education and Practice, 15, 473–486.

Editor’s note: This text-based course is an edited transcript of the webinar, SMA in Pediatrics (Spinal Muscular Atrophy), presented by Nadia Boussalham, BS, RRT.

It is recommended that you download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Recognize Spinal Muscular Atrophy (SMA) and review its implications in pediatric patients
• Discuss the different types of Spinal Muscular Atrophy (SMA) and identify the available medications for treatment
• Describe respiratory treatments and management strategies for pediatric patients diagnosed with Spinal Muscular Atrophy (SMA)

What Happens With SMA?

To begin with, Spinal Muscular Atrophy (SMA) is a genetic disorder that causes muscle weakness, particularly in the skeletal muscles. As a result, it can severely affect a child's ability to crawl, walk, or even control head movements. In more severe cases, SMA can impair the muscles involved in breathing and swallowing, posing serious health risks.

The root of the problem lies in the motor neurons, which control muscle strength and movement. These neurons are located in the spinal cord and the lower part of the brain. In individuals with SMA, these motor neurons start to break down, preventing the brain’s signals from reaching the muscles. As a result, the muscles weaken and eventually deteriorate, a process known as atrophy, similar to what occurs in other genetic disorders.

SMA is an autosomal recessive disorder, meaning a person must inherit two mutated genes—one from each parent—to develop the condition. Most forms of SMA are linked to a mutation in the SMN1 gene, which fails to produce sufficient protein to support the motor neurons. Without enough of this protein, the neurons degenerate and lose their ability to send signals to the muscles, leading to progressive muscle weakening and damage.

Genetic Disease

A child with spinal muscular atrophy (SMA) inherits one copy of the mutated gene from each parent. For a child to develop SMA, they must inherit two non-functioning SMN1 genes—one from each parent. This pattern of inheritance is known as autosomal recessive, meaning both copies of the gene must be defective for the disease to manifest.

If both parents are carriers of the same SMN1 gene mutation, there is a 25% (or one in four) chance that the child will inherit the mutated gene from both parents, resulting in the child developing SMA. This is because each parent has one functioning and one non-functioning gene copy, and the likelihood of both non-functioning genes being passed down simultaneously is 25%. This scenario can happen with no prior symptoms in the family, as carriers of the mutation are asymptomatic.

In addition to the 25% chance of having a child with SMA, there is a 50% chance that the child will inherit only one copy of the mutated gene, making them a carrier, like their parents. Carriers of the SMA gene do not exhibit symptoms of the disease but can pass the mutated gene to their children. This means that while carriers themselves are unaffected, they still have a 50% chance of passing the defective gene to the next generation, increasing the likelihood of SMA in future descendants if both parents are carriers.

Lastly, there is a 25% chance that the child will inherit two fully functioning SMN1 genes, one from each parent, meaning the child will neither have the disease nor be a carrier of the mutated gene. In this case, the child is entirely free from the SMA gene mutation and its associated risks.

It is crucial to understand the value of carrier testing, which can identify individuals who carry the SMN1 gene mutation. Carrier testing is particularly important for families with a history of SMA or for couples planning to have children. Early knowledge of carrier status allows for genetic counseling, where healthcare professionals can help prospective parents understand the risks and implications of SMA, guide them in making informed reproductive decisions, and discuss potential options like in vitro fertilization (IVF) with pre-implantation genetic diagnosis (PGD) to select embryos without the mutation.

Additionally, prenatal testing can be conducted during pregnancy to determine if the fetus has inherited the mutated genes. This can provide critical information for managing pregnancy and preparing for potential outcomes if the child is diagnosed with SMA.

Overall, understanding the inheritance pattern of SMA and the options available for carrier testing and genetic counseling can help families make proactive choices and manage risks associated with this genetic disorder.

Severe Neuromuscular Disease

SMA is a severe and progressive neuromuscular disease that primarily affects motor neurons, leading to muscle weakness and atrophy. According to the Centers for Disease Control and Prevention (CDC), as of 2021, approximately one in every 10,000 births result in a baby being born with SMA, making it one of the most common causes of genetic infant mortality. Furthermore, an estimated one in 51 people worldwide is a carrier of the SMA gene mutation, underscoring its prevalence as one of the most common rare diseases.

This frequency places SMA alongside other well-known genetic conditions such as cystic fibrosis, Duchenne muscular dystrophy, and amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig's disease. Like these conditions, SMA can have a profound impact on motor function, with the severity of symptoms varying based on the specific type of SMA and the number of copies of the SMN2 gene a person carries.

SMA affects individuals across all genders, races, and ethnicities, with no disparities in its prevalence. Both males and females are equally likely to inherit the disease, as SMA is passed down through an autosomal recessive inheritance pattern. This means that for a child to develop SMA, they must inherit two copies of the defective SMN1 gene—one from each parent. If both parents are carriers of the mutation, there is a 25% chance that their child will inherit both faulty genes and develop SMA, a 50% chance that the child will be a carrier like the parents and a 25% chance that the child will inherit two normal copies of the SMN1 gene.

The diagnosis of SMA is confirmed through molecular genetic testing, a highly reliable method that identifies mutations in the SMN1 gene responsible for the disorder. Genetic testing typically involves a blood sample, and in some cases, prenatal genetic testing may be offered if there is a family history of SMA or if both parents are known carriers. In recent years, many states have also included SMA in their newborn screening programs, allowing for early detection before symptoms appear. Early diagnosis is critical because it enables early intervention with treatments that can significantly improve outcomes, particularly with the advent of gene therapy and splice-modifying therapies.

Diagnosis of SMA

Testing for mutations in the SMN1 and SMN2 genes is highly reliable and considered the gold standard for diagnosing spinal muscular atrophy (SMA) when typical symptoms are present. Because of the accuracy of genetic testing, there is usually no need for a muscle biopsy. Genetic testing involves a quantitative analysis of both SMN1 and SMN2 genes using a technique known as multiplex ligation-dependent probe amplification (MLPA). This method allows for the detection of copy number variations in both genes.

Another commonly used method is PCR followed by restriction digest, which can identify homozygous deletions in the SMN1 gene. While PCR is faster and less expensive than MLPA, it does not provide a quantitative analysis of SMN1 or SMN2 copy numbers. However, it is often readily available in many labs and remains a reliable diagnostic option.

Understanding the number of SMN1 copies is crucial for identifying heterozygous deletions, while the number of SMN2 copies plays a key role in predicting disease severity and guiding therapeutic approaches. In diagnosing SMA, it is important to note that some of its symptoms can resemble those of other neuromuscular disorders, such as muscular dystrophy. To determine the cause of these symptoms, healthcare providers will typically conduct a physical exam and obtain a comprehensive medical history. Physicians may also order additional tests, including genetic testing, to confirm the diagnosis of SMA.

Some of the tests used to diagnose SMA include blood tests, such as enzyme and protein tests, which check for elevated levels of creatine kinase. This enzyme is released into the bloodstream when muscles deteriorate, serving as a potential indicator of muscle damage. A genetic test is another critical diagnostic tool specifically designed to identify mutations in the SMN1 gene. Genetic testing is highly effective, with a 95% success rate in detecting altered SMN1 genes.

In some states, SMA is included in routine newborn screening, which may also involve nerve conduction tests, such as an electromyogram (EMG). An EMG measures the electrical activity of nerves and muscles, helping to assess neuromuscular function.

In rare cases, a muscle biopsy may be performed. This procedure involves removing a small sample of muscle tissue and sending it to a lab for analysis. The biopsy can reveal muscle atrophy, which, as previously mentioned, is the progressive loss of muscle tissue.

But why does this happen? As we have discussed, spinal muscular atrophy is a genetic disorder. Most forms of SMA are caused by mutations in the survival motor neuron (SMN) gene, which leads to the degeneration of motor neurons and the resulting muscle weakness and atrophy.

Why Does It Happen?

The SMN1 gene, located on the fifth chromosome, is crucial for producing the survival motor neuron (SMN) protein, which plays an essential role in the health and function of motor neurons. These motor neurons are responsible for transmitting signals from the brain to the muscles, allowing for voluntary muscle movements. When the SMN1 gene is functioning normally, it produces sufficient levels of the SMN protein to maintain normal motor neuron function, enabling muscles to receive the necessary signals to move.

However, when the SMN1 gene is mutated or deleted, there is an insufficient production of SMN protein, leading to the degeneration of motor neurons. This deterioration disrupts the brain's ability to communicate with the muscles, ultimately causing the characteristic muscle weakness and wasting (atrophy) seen in SMA. The progressive loss of motor neurons results in the muscles' inability to contract and move, affecting a person's mobility and, in severe cases, their ability to breathe and swallow.

The severity of SMA is heavily influenced by the number of copies of the SMN2 gene, a gene that is similar to SMN1 but produces less functional SMN protein. The SMN2 gene is considered a "backup" gene because, while it cannot fully replace SMN1, it can still produce a small amount of functional SMN protein. The number of SMN2 copies a person has varies from individual to individual, and this variation significantly impacts the severity and progression of the disease.

Individuals with fewer copies of SMN2 (typically one or two copies) tend to experience the most severe forms of SMA, such as Type 1 SMA, which manifests in infancy. These individuals produce very little functional SMN protein, leading to the early onset of symptoms, including severe muscle weakness, difficulty breathing, and problems with swallowing.

Individuals with more copies of SMN2 (three or more copies) generally have a later onset and a milder disease course, as seen in Type 2 or Type 3 SMA. These individuals produce more SMN protein, which provides some level of compensation for the loss of SMN1 function. This results in less severe symptoms, such as delayed motor milestones (e.g., sitting, standing, walking), but they still experience progressive muscle weakness over time.

In Type 4 SMA, which typically occurs in adulthood, individuals may have up to six or eight copies of SMN2, allowing for a relatively mild progression of the disease with less impairment in daily activities compared to earlier-onset forms.

While the SMN2 gene provides some compensation for the lack of SMN1, most of the SMN protein it produces is truncated and non-functional due to a splicing error that removes exon 7. Only a small fraction of the protein produced by SMN2 is full-length and functional. Therefore, the more copies of SMN2 an individual has, the more functional SMN protein is produced, which helps mitigate the severity of the disease but does not fully prevent the symptoms of SMA.

What Is A Gene?

Figure 1. Illustration of a gene (Continued, Getty).

A gene is the basic physical and functional unit of heredity, made up of DNA (Figure 1). Some genes provide instructions for making molecules called proteins, which are essential for the body’s structure and function. In humans, genes vary widely in size, ranging from a few hundred DNA bases to over 2 million bases.

Humans have approximately 20,000 to 25,000 genes—that is a lot of genetic material! To keep track of them, scientists give each gene a unique name. Since gene names can be long, they are often assigned symbols, which are short combinations of letters and sometimes numbers that serve as an abbreviated version of the full gene name. For example, a gene on chromosome seven associated with cystic fibrosis is called the cystic fibrosis transmembrane conductance regulator, but its symbol is CFTR.

Gene Defect in SMA

• Patients with SMA lack a functioning SMN1 gene
• The SMN1 gene tells the body how to make survival motor neuron (SMN) protein 

Patients with SMA lack a functioning SMN1 gene. The SMN1 gene provides instructions for the body to produce SMN protein, which is essential for maintaining the health and function of motor neurons.

To give an example, most people are familiar with cystic fibrosis, a genetic condition linked to a specific gene mutation. Similarly, the most common form of SMA is caused by a mutated or missing SMN1 gene. This gene is located on chromosome five and produces the SMN protein, which is critical for motor neuron survival. When a mutation occurs in both copies of the SMN1 gene (one on each chromosome five), there is a deficiency in SMN protein production. Normally, most proteins produced by SMN1 are full-length and functional, but in SMA, little to no full-length, functional SMN protein is made.

However, this loss can be partially compensated by the presence of neighboring SMN2 genes, which are 99% similar to SMN1. The number of SMN2 gene copies varies between individuals. Although most proteins produced by SMN2 are short and non-functional, some are full-length and functional. The more copies of SMN2 a person has, the more functional SMN protein is produced, which can moderate the severity of the disease.

SMA is a neuromuscular disorder characterized by this deficiency in SMN protein, leading to the degeneration of motor neurons and progressive muscle weakness. Understanding the role of both SMN1 and SMN2 is essential for grasping the genetic basis and variability of the disease.

SMN Protein

Figure 2. Structure of a motor neuron (Continued, Getty).

Figure 2 illustrates the structure of a motor neuron. The motor neuron dysfunction in SMA leads to progressive muscle weakness and atrophy, with the severity typically greater in the proximal muscles—those closer to the center of the body, such as the muscles in the trunk, chest, upper legs, and arms. In contrast, the distal muscles, such as those in the hands and feet, are generally less affected. This pattern of muscle weakness makes tasks like standing, walking, or lifting objects more difficult, especially as the disease progresses.

The SMN protein, which is deficient in SMA, plays a critical role in processing molecules called messenger RNA (mRNA). mRNA is essential in the process of protein synthesis, where genetic information from DNA is translated into functional proteins. The SMN protein is specifically involved in the assembly of small nuclear ribonucleoproteins (snRNPs), which are necessary for the accurate splicing of pre-mRNA. Proper splicing ensures that mRNA is correctly formed, allowing the production of functional proteins. Additionally, the SMN protein supports the development and maintenance of dendrites and axons, which are extensions of nerve cells (neurons) that facilitate the transmission of signals between the brain, spinal cord, and muscles.

For example, the phrenic nerve, which originates in the neck and extends to the diaphragm, sends involuntary signals to the diaphragm to control breathing. In severe forms of SMA, the degeneration of motor neurons that control the phrenic nerve can compromise respiratory function, making it difficult for affected individuals to breathe independently. This is why many patients with severe SMA, particularly Type 1, often require respiratory support, such as non-invasive ventilation or mechanical ventilation, to assist with breathing.

The SMN2 gene is considered the disease-modifying gene in SMA because it is almost identical to SMN1, except for a single nucleotide difference in exon 7. This small difference has significant consequences for the processing of SMN2 mRNA. In most cases, the exclusion of exon 7 during the splicing process results in the production of truncated, non-functional versions of the SMN protein. However, SMN2 can still produce some functional SMN protein, as one of the versions, known as isoform D, includes exon 7 and is full-length and functional.

Isoform D accounts for approximately 10% of the total functional SMN protein produced by SMN2. While this small amount of protein can help mitigate the severity of SMA, it is insufficient to fully compensate for the loss of SMN1. The more copies of SMN2 a person has, the greater the amount of isoform D that can be produced, which helps increase the overall levels of functional SMN protein in the body. This is why individuals with more copies of SMN2 tend to have a milder form of SMA with a later onset of symptoms, as their bodies can produce more functional SMN protein.

In severe cases of SMA, such as Type 1, patients may have only one or two copies of SMN2, leading to very low levels of functional SMN protein. This results in early-onset symptoms, such as profound muscle weakness, difficulty swallowing, and respiratory complications. On the other hand, patients with Type 3 or Type 4 SMA often have three or more copies of SMN2, allowing for a higher production of isoform D and thus a milder disease course with later onset symptoms and slower progression of muscle weakness.

SMN2 Gene

The SMN2 gene produces several different versions of the SMN protein, most of which are shorter and quickly degraded due to the exclusion of exon 7 during the splicing process. These truncated proteins are non-functional and cannot adequately support motor neuron survival. Only a small fraction of the protein produced by SMN2 is full-length and functional, which contributes to the overall amount of functional SMN protein in the body.

The number of SMN2 gene copies a person has can vary between individuals, ranging from two to eight copies, and this number plays a crucial role in determining the severity and type of SMA a person develops. The more copies of SMN2 a person has, the more functional SMN protein they can produce, which helps mitigate the severity of the disease.

• Type 1 SMA (the most severe form of the disease) is typically associated with two copies of the SMN2 gene. Patients with Type 1 SMA usually show symptoms early in infancy, such as severe muscle weakness, respiratory issues, and difficulty swallowing. These patients often require respiratory support and have a limited ability to achieve motor milestones, such as sitting or standing without assistance.
• Type 2 SMA patients usually have three copies of SMN2. This form of the disease presents in early childhood, with symptoms appearing between six months and two years of age. While Type 2 patients may be able to sit independently, they generally cannot walk unaided and will experience progressive muscle weakness over time.
• Type 3 SMA, which can manifest later in childhood or adolescence, is also associated with three copies of SMN2 but tends to be less severe than Type 2. Within Type 3, there is a subcategory known as Type 3b SMA, which is linked to four copies of SMN2. Individuals with Type 3b typically experience a later onset of symptoms and may retain the ability to walk longer than those with fewer SMN2 copies, though they will still experience progressive muscle weakness.
• Type 4 SMA, the mildest form of the disease, usually appears in adulthood and is linked to four to six copies of SMN2. Patients with Type 4 SMA may retain most of their motor function for a significant portion of their lives and tend to experience slower progression of muscle weakness compared to those with earlier-onset forms of the disease.

The relationship between SMN2 copy number and the severity of SMA is a key factor in understanding the variability of the disease. In patients with more SMN2 copies, the increased production of full-length SMN protein provides greater support for motor neuron function, leading to a milder disease course. However, despite the presence of additional SMN2 copies, none of the forms of SMA can be completely prevented, as SMN2 cannot fully replace the function of the SMN1 gene.

As we continue, we will delve deeper into the different types of SMA and discuss their clinical characteristics, treatment strategies, and management approaches to help better understand the variability and progression of this complex neuromuscular disorder.

Figure 3. Illustration of normal muscle and atrophied muscle (Continued, Getty).

In SMA, the deterioration of motor neurons—the nerves responsible for controlling muscle strength and movement—leads to progressive muscle weakness (Figure 3). These motor neurons are located in the spinal cord and the lower part of the brain. As they break down, they lose the ability to transmit signals from the brain to the muscles. Without these signals, muscles are unable to contract, leading to a gradual loss of muscle mass, a process known as atrophy.

Muscle weakness in SMA is usually symmetrical, meaning it affects both sides of the body equally. The weakness tends to be more severe in the proximal muscles, which are the muscles closest to the body’s core, such as those in the shoulders, hips, thighs, and upper arms. In contrast, the distal muscles, such as those in the hands and feet, are often less affected. This pattern of weakness makes it difficult for individuals with SMA to perform tasks like lifting objects, walking, or even holding up their heads in severe cases.

As the muscles atrophy, they become visibly smaller and thinner. In advanced stages of SMA, this muscle wasting can lead to significant physical impairments, including difficulty with basic motor functions, such as sitting up or moving the limbs. Over time, the lack of muscle activity can also result in complications such as joint contractures (stiffening of joints due to shortened muscles) and scoliosis (curvature of the spine), which can further limit mobility.

In addition to muscle weakness, the breakdown of motor neurons in severe cases of SMA can also affect respiratory muscles, particularly the diaphragm, making it difficult for patients to breathe independently. This is why many patients with more severe forms of SMA may require respiratory support, such as non-invasive ventilation or mechanical ventilation, to assist with breathing. As muscle atrophy in SMA is a gradual process, early intervention through physical therapy, assistive devices, and modern treatments can help slow the progression and improve the patient’s quality of life.

Staying Ahead of the Progression of SMA Today

SMA is often discovered through newborn screening, which has become a routine part of early diagnostics in many countries. If a child tests positive for SMA during this screening, doctors will typically order genetic tests to confirm the diagnosis and determine the number of copies of the SMN2 backup gene that the child has. These tests may also detect specific genetic mutations that indicate whether the SMN1 gene is malfunctioning or missing entirely. The number of SMN2 copies is crucial because it plays a significant role in predicting the severity of SMA—the more copies a person has, the milder the progression of the disease is likely to be. Identifying the number of SMN2 copies before a baby shows any symptoms is vital for initiating early treatment, which can significantly alter the course of the disease.

For example, if left untreated, a baby with only two copies of SMN2 is likely to show symptoms much earlier than a baby with four copies. In the past, before newborn screening was widely implemented, most children weren’t diagnosed with SMA until they began showing symptoms. At that point, the child was assigned a "type" of SMA based on when symptoms first appeared and which motor milestones they had or had not reached. Since newborn screening wasn’t always routine, this classification was largely based on observation and, in many cases, a degree of guesswork. The earlier the onset of symptoms, the more severe the type of SMA was assumed to be. There are currently four main types of SMA, with an additional fifth type that can be classified as Type 0 or congenital SMA.

By screening newborns and identifying SMA before symptoms appear, doctors can now take a more proactive approach. Early diagnosis through newborn screening and genetic testing has revolutionized how SMA is managed. It allows families and healthcare providers to stay ahead of the disease, implement treatments before irreversible damage occurs, and give children with SMA a better chance at a more typical developmental trajectory.

Different Types of SMA

There are four main types of SMA, each varying in severity, onset, and progression. Understanding these types is crucial for identifying the disease and providing appropriate treatment. Additionally, there is a Type 0, or congenital SMA, which is extremely rare and severe.

• Type 1 SMA (Werdnig-Hoffmann disease):
  • This is the most common and severe form of SMA. Without treatment, it can be fatal, sometimes even before birth or within the first two years of life. Children with Type 1 SMA often show symptoms very early, usually by the age of 6 months. These symptoms include severe muscle weakness, difficulty breathing, and trouble swallowing. Thanks to routine newborn screenings, most children are diagnosed before they are assigned a specific type, allowing for early intervention with therapies that can dramatically improve their prognosis. Treatments such as Spinraza and Zolgensma can slow the progression of the disease and help maintain motor function.
• Type 2 SMA:
  • Type 2 SMA typically presents in infancy, but it is less severe than Type 1. Children with Type 2 usually develop symptoms between 6 and 18 months of age. While they may be able to sit independently, they generally cannot walk unaided. Muscle weakness progresses over time, and respiratory issues may develop later. With advancements in treatment, many children with Type 2 SMA can live longer and maintain more motor function than previously possible.
• Type 3 SMA (Kugelberg-Welander disease):
  • Type 3 SMA has a later onset, usually during childhood or adolescence. Individuals with Type 3 can often walk independently for some time but may gradually lose the ability to walk as they age. Symptoms such as muscle weakness and fatigue become more pronounced over time, especially in the legs and hips. While less severe than Types 1 and 2, Type 3 can still significantly impact daily life, and ongoing treatment and physical therapy are essential to maintain mobility for as long as possible.
• Type 4 SMA:
  • Type 4 SMA is the mildest form, usually manifesting in adulthood. Symptoms such as muscle weakness and difficulty with movement develop slowly and may not become apparent until later in life. Individuals with Type 4 may not realize they have SMA for years, as the progression is very gradual. While this form of SMA is the least debilitating, it still requires medical management to slow the progression and address muscle fatigue and weakness.
• Type 0 (congenital SMA):
  • Although rare, Type 0 SMA is the most severe form, often presenting at birth. Babies born with Type 0 typically show signs of severe muscle weakness and respiratory difficulties right away. Without immediate treatment, Type 0 SMA is often fatal within the first few months of life. Early diagnosis and intervention, even in these severe cases, can offer some improvement in survival and quality of life.

The different types of SMA vary not only in severity but also in the age of onset and rate of progression. Type 1 is the most severe, with rapid progression and early onset, while Type 4 is the slowest-developing form, often not diagnosed until adulthood. Some individuals with Type 3 or 4 SMA may not realize they have the condition until years after symptoms begin due to the gradual progression of muscle weakness. Early diagnosis, genetic testing, and advancements in treatment have significantly improved outcomes across all types of SMA, allowing many individuals to live longer, healthier lives with better motor function.

Type 1 (Infantile Onset)

Now, let's discuss Type 1 SMA, also known as infantile-onset SMA or Werdnig-Hoffmann disease. This is the most common and severe form of spinal muscular atrophy, typically affecting infants within the first six months of life. Muscle weakness associated with Type 1 SMA is often noticeable by around three months of age, but symptoms can begin as early as birth and appear anytime up to six months. 

Children with Type 1 SMA often display a sunken chest appearance. Type 1 can be further classified into Type 1a, Type 1b, and Type 1c, with each subtype showing very similar symptoms but differing in the timing of onset and the severity of motor function impairment.

• Type 1b SMA: Symptoms typically emerge between zero to three months of age. Infants with Type 1b exhibit profound muscle weakness, much like their Type 1a counterparts. Early respiratory failure and severe hypotonia are common, as are sucking and swallowing difficulties, which complicate feeding and lead to malnutrition.
• Type 1c SMA: Onset occurs between zero to six months, and these patients may display mild to moderate head control—a slight improvement over Type 1a and 1b. Unlike Type 1a, these infants may be able to roll over, but they will never sit unsupported. Without respiratory support, the lifespan for infants with Type 1c is generally less than two years.

Across all subtypes of Type 1 SMA, affected infants often present with a characteristic frog-leg posture, where their legs are positioned outward, resembling a frog. This posture results from the profound weakness in their proximal muscles, particularly in the hips and thighs. Additionally, they display hyporeflexia, a diminished or absent reflex response, which is typical in children with motor neuron dysfunction.

Feeding issues are common, as these infants have significant sucking and swallowing difficulties—symptoms that typically start to become apparent in children around six months of age when they begin eating solid foods. Weakness in the muscles responsible for these actions increases the risk of aspiration and malnutrition, further complicating their care.

Children with Type 1 SMA experience profound muscle weakness and hypotonia, which significantly impairs their ability to achieve basic motor milestones. For example, these children are typically unable to sit independently, roll over, or hold their heads up, which are movements usually expected at this developmental stage. In addition to motor deficits, children with Type 1 often lack control over their head movement, which is one of the early signs of this severe muscle weakness.

One of the most critical complications of Type 1 SMA is early respiratory failure. The muscles responsible for breathing, including the diaphragm and intercostal muscles (between the ribs), are weakened, making it difficult for these infants to breathe effectively. This often leads to life-threatening respiratory problems early in life. Many children with Type 1 require respiratory support, such as non-invasive ventilation or even tracheostomy with mechanical ventilation, to assist with breathing and maintain oxygen levels.

In addition to respiratory issues, infants with Type 1 SMA often have trouble with feeding and swallowing, as the muscles involved in these functions are also weakened. This can lead to poor weight gain, malnutrition, and an increased risk of aspiration pneumonia—a serious condition where food or liquids are inhaled into the lungs due to weak swallowing muscles.

While Type 1 SMA presents with a range of severe challenges, early diagnosis through newborn screening and the availability of advanced treatments have significantly improved the prognosis for many of these children. However, even with treatment, children with Type 1 SMA often require ongoing medical support to manage symptoms and maintain quality of life.

Type 2 (Dubowitz Disease)

Now, moving on to Type 2 SMA, also known as Dubowitz disease, which is considered a mild to severe form of SMA. Children with Type 2 SMA typically have three or more copies of the SMN2 gene, which results in a milder disease course compared to Type 1. Symptoms of Type 2 SMA usually begin to manifest between six and 18 months of age, often when motor milestones such as sitting, crawling, and walking are expected to develop. 

Importantly, the lifespan of children with Type 2 SMA is generally longer than that of Type 1 patients, often exceeding two years. With the right combination of respiratory support and therapeutic interventions, many children with Type 2 SMA can live well into adolescence and adulthood, with improved quality of life through medical management and physical therapy.

Unlike Type 1 SMA, where the lifespan is typically less than two years without respiratory support, children with Type 2 SMA can achieve important motor milestones, such as being able to sit unassisted. However, they are generally unable to walk independently, which distinguishes Type 2 as an intermediate form of spinal muscular atrophy. While these milestones are often delayed compared to typically developing children, they still represent significant progress for individuals with Type 2 SMA.

In addition to delayed motor development, Type 2 SMA often causes postural hand tremors and progressive weakness, particularly in the proximal leg muscles. This weakness affects the muscles closest to the body's core, making it difficult for children to stand or walk without assistance. Over time, the weakness in the legs becomes more pronounced, leading to increased reliance on mobility aids such as wheelchairs.

One common complication in children with Type 2 SMA is the development of scoliosis, a curvature of the spine that occurs as a result of weakened muscles that can no longer support proper posture. Scoliosis can progress over time and may require orthopedic intervention or surgical correction to improve the child’s quality of life and prevent further complications with breathing or sitting.

The severity of symptoms in Type 2 SMA can vary widely. Some children may experience respiratory difficulties, requiring non-invasive ventilation to assist with breathing, while others may maintain stable respiratory function for longer periods. Over time, muscle weakness tends to progress, and affected individuals may lose some of the motor abilities they initially developed.

Type 3 (Kugelberg-Welander Disease)

Type 3 SMA, also known as Kugelberg-Welander disease, children experience less severe symptoms compared to Types 1 and 2. The onset of symptoms typically occurs later, usually between 18 months and three years of age. Unlike children with Type 1 and Type 2 SMA, those with Type 3 can often walk independently for a period of time. However, this ability may gradually decline as they age due to progressive muscle weakness.

As we see across the spectrum of SMA types, the age of symptom onset becomes progressively later with each type. In Type 1, symptoms manifest very early, often within the first few months of life. For Type 2, symptoms typically appear between 6 and 18 months. By the time we reach Type 3, symptoms do not usually present until toddlerhood or early childhood. This later onset is associated with a milder disease progression, though muscle weakness, particularly in the legs, continues to worsen over time.

Children with Type 3 SMA generally retain the ability to walk unassisted at some point in their lives, distinguishing them from those with Type 1 and Type 2. However, they often present with progressive proximal weakness, especially in the legs, more so than in the arms. Over time, this leg weakness may necessitate the use of a wheelchair, especially as the child grows older and walking becomes more difficult.

In many ways, Type 3 SMA resembles muscular dystrophy, given the gradual loss of motor function and progressive muscle weakness. While the disease progression is slower than in Type 1 and Type 2, the ongoing weakening of the leg muscles can still significantly impact mobility and quality of life.

Type 4 (Adult SMA)

Lastly, Type 4 SMA is the adult form of spinal muscular atrophy. This form typically begins in adulthood, often after the age of 35, and is characterized by a slow progression of symptoms. Because the disease develops so gradually, many adults do not even realize they have SMA until years after the initial symptoms appear. Unlike the earlier-onset types of SMA, Type 4 is generally milder, though it still involves muscle weakness that worsens over time.

One notable difference in Type 4 SMA is the absence of severe breathing difficulties that are more commonly seen in infants with Type 1 SMA. However, breathing issues can still develop in adults, albeit to a lesser extent. Problems may include weak or underdeveloped lungs, shortness of breath, and shallow breathing, particularly while sleeping. Some adults may also experience stomach breathing, a term used to describe the reliance on abdominal muscles rather than the diaphragm for breathing. While no one actually breathes "on their stomach," this phrase is often used in reference to SMA, indicating a change in breathing mechanics due to weakened respiratory muscles.

Though Type 4 SMA is the least severe form of the disease, its slow progression can still impact daily activities, especially as muscle weakness in the legs and arms becomes more noticeable with age. Early diagnosis and medical intervention can help manage symptoms and maintain mobility for as long as possible.

Congenital SMA

Congenital SMA, also referred to as Type 0 SMA, is the most severe and rare form of SMA. This type can be identified in utero and is characterized by profound muscle weakness and hypotonia (low muscle tone) at birth. In many cases, there may be a history of decreased fetal movement during pregnancy, which can signal early signs of muscle degeneration before birth. Due to this lack of movement in the womb, infants with congenital SMA are often born with joint contractures (stiffness in joints due to restricted movement) or even broken bones as a result of the fragility of their muscles and skeletal structure.

In addition to the musculoskeletal issues, infants with congenital SMA frequently experience severe respiratory compromise from birth. The muscles responsible for breathing are significantly weakened, leading to life-threatening breathing difficulties. Congenital SMA also carries a higher incidence of heart defects, which can be detected either in utero via prenatal screenings or shortly after birth. These heart issues further complicate the infant’s health and contribute to the overall poor prognosis for survival.

Sadly, infants diagnosed with congenital SMA typically have a very limited lifespan, rarely surviving beyond six months of age without intensive medical intervention. The combination of respiratory failure, feeding difficulties, and other complications makes this type of SMA particularly challenging to manage.

Studies have also shown that seizures are frequently seen in infants with Type 0 SMA. These seizures are often linked to hypoxic-ischemic encephalopathy (HIE), a condition caused by oxygen deprivation to the brain during or shortly after birth. This birth asphyxia exacerbates the neurological damage, further complicating the infant's overall condition and contributing to poor survival outcomes.

While congenital SMA remains rare, it underscores the importance of early detection and the critical need for advanced medical interventions in severe cases. Unfortunately, even with early diagnosis, the severity of Type 0 SMA limits the options for treatment, and the focus is often on providing palliative care to manage symptoms and improve comfort.

Breathing Difficulties

As we have learned, SMA primarily affects the muscles, including those between the ribs, which are essential for normal breathing. In children with SMA, the intercostal muscles (the muscles between the ribs) often don’t function properly due to weakness, but the diaphragm typically remains unaffected. As a result, the chest wall does not expand as it normally should during breathing. Instead, the diaphragm pulls the ribcage down, causing the stomach area to expand rather than the chest. This gives the appearance that the child is "breathing from their stomach," a phenomenon often referred to as stomach breathing in SMA.

While this type of breathing may look unusual, it is the body’s way of compensating for the weakened chest muscles. The term "terminal stomach breathing" is sometimes used to describe this characteristic, reflecting how the diaphragm takes over the work of breathing when the chest wall muscles are compromised.

Feeding Difficulties

Another common symptom of SMA is feeding difficulties, which arise from the muscle weakness that extends to the muscles involved in sucking and swallowing. This weakness makes it challenging for children to eat or drink properly, leading to potential complications such as poor weight gain, malnutrition, and an increased risk of aspiration—where food or liquid accidentally enters the lungs instead of the stomach. Aspiration can further complicate the child's condition by increasing the risk of respiratory infections, including aspiration pneumonia.

Due to the difficulty with swallowing, specialized interventions may be required to ensure children with SMA receive the nutrition and calories they need for healthy growth. For younger children or those with more severe muscle weakness, feeding tubes may be necessary to bypass the challenges of oral feeding. In some cases, modified diets, such as thicker liquids or pureed foods, can help reduce the risk of choking or aspiration during meals.

For older children who can manage some oral intake, cutting food into smaller pieces or offering softer textures can make it easier for them to chew and swallow, reducing the risk of choking. Swallowing specialists and physical therapists can also work with children to develop techniques for safer eating and drinking. These professionals may use exercises to strengthen the swallowing muscles and help children learn adaptive strategies for safer meals.

However, if these modifications are not effective and the child continues to struggle with eating and drinking safely, a feeding tube may be necessary to ensure proper nutrition and prevent further complications related to poor intake. This step can be crucial for maintaining the child's overall health and preventing malnutrition.

Muscle Weakness

In SMA, muscle weakness typically begins in the shoulder and leg muscles, which are among the most affected areas when the condition is diagnosed in infancy, around age one. In many cases, the muscles in the lower limbs are impacted first, leading to difficulty with basic motor functions such as sitting or walking. This can significantly delay a child’s motor development milestones—one of the early signs that parents may notice. When a baby with SMA isn't meeting important milestones, such as being able to sit up or crawl, parents often become concerned and seek medical evaluation.

In addition to lower limb weakness, infants with SMA may show signs of poor neck and head control, which further impairs their ability to achieve motor milestones. The inability to control the head or maintain posture is a common observation, especially in children with Type 1 or Type 2 SMA.

Unfortunately, muscle weakness in SMA tends to worsen over time. As the disease progresses, the muscles become increasingly weaker, leading to a gradual decline in motor function. Due to the progressive nature of the condition, some children who are able to walk during childhood may lose this ability as they get older. This deterioration of muscle strength can eventually lead to the need for mobility aids, such as wheelchairs, as walking becomes more difficult or impossible.

The loss of motor function can be emotionally and physically challenging for both the child and their family. As the disease advances, maintaining mobility and independence becomes more difficult, emphasizing the need for early intervention and therapies that can slow the progression of the disease and support muscle function for as long as possible.

Scoliosis

Scoliosis, or the irregular curvature of the spine, is a common complication in children with SMA. This condition develops because the muscles that support the spine are too weak to maintain proper alignment, causing the spine to curve abnormally over time. Without sufficient muscle strength to keep the spine in place, the curvature can become progressively worse, especially as the child grows.

Scoliosis not only affects a child's posture, but it can also lead to severe pain, discomfort, and even numbness in some cases. As the curvature worsens, it can place pressure on the surrounding muscles, nerves, and internal organs, potentially affecting breathing and mobility. In severe cases, scoliosis may require orthopedic intervention, such as bracing or surgical correction, to prevent further complications and improve the child's quality of life. Early detection and management of scoliosis in children with SMA are critical to minimizing its impact on the child's mobility and overall well-being.

Unique Features of SMA Patients

In addition, severe cases of scoliosis can lead to breathing difficulties, as the curvature of the spine may compress the lungs and restrict their expansion. Children with scoliosis often display physical signs such as uneven shoulders, a curved spine, and uneven hips. As mentioned earlier in the presentation, the bell-shaped chest is a unique feature seen in many patients with SMA, and it can be clearly observed in the photo of the baby. This characteristic chest shape occurs because these children rely almost exclusively on their diaphragm for breathing, as the weakened chest muscles are unable to expand properly.

When the diaphragm is overused for breathing, the chest muscles remain underdeveloped, which prevents the chest from expanding in a normal, rounded fashion. This leads to the bell-shaped chest, where the chest is wider at the bottom and narrower at the top, giving the appearance of an inverted bell. In a healthy individual, the rib cage expands evenly during breathing, but in children with SMA, the chest appears sunken as the rib cage pulls inward, and the sternum (the bone in the middle of the chest) may become depressed or pushed inward. This abnormal development further contributes to the respiratory challenges these children face.

Another physical characteristic seen in SMA patients, particularly those who rely on non-invasive ventilation (NIV), is a flattened face. Prolonged use of ventilation masks can gradually alter the shape of the face, as the constant pressure from the mask flattens the bones and soft tissues, especially around the cheeks and nose. This facial flattening is more pronounced in SMA patients due to their long-term reliance on NIV, often beginning from a very young age.

Many children with SMA begin using non-invasive ventilation early in life and continue to rely on it as they grow. During illness, they may need to use NIV continuously throughout the day, with only short breaks to relieve pressure on their face. These breaks help prevent the worsening of the facial flattening while still supporting their respiratory needs.

Another notable feature of SMA patients is their muffled voice quality. Due to decreased lung volumes and weakened respiratory muscles, it becomes difficult for them to phonate or produce clear sounds. Adequate airflow past the vocal cords is essential for strong, clear speech, but the weakened muscles in SMA patients limit this airflow, resulting in a muffled voice. The reduced lung capacity makes it challenging for them to generate the necessary force to project their voice, further contributing to the muffled sound.

One helpful tool we have utilized at our hospital is a Speak X, a sticker microphone that attaches to the noninvasive ventilation mask. This device has been particularly beneficial for our SMA patients who struggle with a muffled voice. The positive pressure from the ventilation mask, combined with their already reduced vocal volume, makes it difficult to understand them clearly. The Speak X microphone allows them to phonate more effectively by amplifying their voice through the mask.

The microphone picks up their voice and transmits it to a receiver outside the mask, where we, as caregivers, can hear them more clearly through a connected external speaker or microphone. While their voice is still somewhat muffled, the Speak X significantly improves our ability to understand what they are saying, whether they are trying to express a need or communicate with family and medical staff.

Unfortunately, to my knowledge, these Speak X microphones are not yet available for home use, but they have been a valuable tool in the hospital setting, enhancing communication between SMA patients and their caregivers.

Respiratory Infections

Frequent respiratory infections are a common symptom of SMA, and respiratory complications are the leading cause of morbidity and mortality in patients with this condition. The respiratory muscle weakness associated with SMA leads to an impaired ability to cough, making it difficult to clear mucus and debris from the airways. This increases the risk of recurrent respiratory tract infections, including pneumonia, which can eventually progress to respiratory failure if left untreated.

The weakened respiratory muscles, combined with breathing difficulties inherent to SMA, make patients—particularly infants and young children with early-onset forms—highly susceptible to infections. The inability to effectively clear the lungs through coughing means that bacteria and viruses can more easily take hold, leading to severe respiratory infections.

For infants diagnosed with early-onset SMA, these infections are particularly dangerous and are often the reason why many do not survive beyond a few months or years. Their already compromised ability to breathe makes it exceedingly difficult for them to cope with the added strain of a respiratory infection. When a severe respiratory infection develops, the additional burden on their already weak respiratory system can be overwhelming, often leading to respiratory failure or other life-threatening complications.

The impact of these infections highlights the critical need for proactive respiratory management in SMA patients, including the use of non-invasive ventilation, airway clearance techniques, and regular monitoring to prevent infections and manage them quickly if they do occur.

Common Respiratory Symptoms in Children With SMA

Common respiratory symptoms in children with SMA include chest wall underdevelopment and lung underdevelopment, which contribute to an impaired cough. This impaired cough makes it difficult for the child to clear secretions from the lower airways, resulting in poor secretion clearance. As a result, the respiratory therapist plays a key role in pulmonary toileting, utilizing techniques and equipment to help these children manage their airway secretions more effectively.

Children with SMA are also prone to recurrent respiratory infections, which further exacerbate muscle weakness and compromise the integrity of the lung parenchyma (the functional tissue of the lungs). Viral respiratory infections—such as those caused by COVID-19, rhinovirus, enterovirus, or parainfluenza—can be especially severe in SMA patients, as their already weakened respiratory muscles struggle to fight off the infection.

Aspiration problems are another common complication in SMA. Swallowing difficulties often lead to food or liquids entering the airways, which can result in aspiration pneumonia. This poses an additional risk to the respiratory health of these children, who are already vulnerable to infections.

Hypoventilation, or shallow breathing, is also common in SMA patients due to their inability to take deep breaths. This can lead to sleep problems, as their breathing may become even more shallow while asleep, contributing to sleep-disordered breathing. In such cases, families may consider having a sleep study performed to assess the child's breathing patterns during sleep. This is often requested by the family or recommended by the pulmonary care team to gain further insights into how best to manage the child's respiratory challenges.

Treatment Options for SMA

Now, let's discuss how we can potentially treat SMA. While there is currently no cure for SMA, three FDA-approved drugs have been developed to treat the condition: Spinraza, Zolgensma, and Evrysdi. These treatments have been groundbreaking, but as you can see, they come at a high cost, and the prices can be staggering.

The first drug to be approved was Spinraza, which received FDA approval in December 2016 for the treatment of all forms of SMA. Spinraza is priced around $625,000 to $750,000 for the first year of treatment. After that, the cost is reduced to approximately $375,000 annually, which is still a significant financial burden, considering that most patients will require lifelong treatment.

Despite its cost, Spinraza has proven to be effective, with around 40% of patients treated with the drug achieving improvements in motor skills milestones. In contrast, none of the control group patients in clinical trials showed significant improvement. Spinraza works by being injected into the cerebrospinal fluid surrounding the spinal cord, where it helps increase the production of functional SMN protein, which is critical for motor neuron survival.

As a long-term treatment, Spinraza has dramatically changed the natural history of SMA, especially in Type 1 and later-onset SMA (Types 2 and 3). In key randomized controlled trials, Spinraza has shown significant improvements in motor function and survival rates in patients with early-onset SMA (Type 1) and later-onset forms (Types 2 and 3). These results offer hope for many families facing the challenges of SMA, as patients can now experience improved motor function and extended survival through early and consistent treatment with Spinraza.

Spinraza has shown greater benefits when treatment is started early in life, with significant improvements in motor function and survival rates for infants and young children. However, even older children—up to 15 years of age—have experienced clinically meaningful improvements in motor function, although the benefits are typically more pronounced in those who begin treatment earlier.

How does Spinraza work? It is administered intrathecally, meaning it is injected directly into the cerebrospinal fluid surrounding the spinal cord, which allows the medication to reach the motor neurons more effectively. The treatment protocol begins with an initiation phase involving four loading doses in the first year. This initiation phase is the most expensive, as the first three doses are administered 14 days apart, with the fourth dose given 30 days after the third. After these four initial doses, a maintenance dose is required every four months to continue treatment.

Spinraza works by binding to a specific sequence downstream of exon 7 on the SMN2 gene—which, as we discussed earlier in the presentation, is crucial for increasing the production of functional SMN protein. In patients with SMA, only about 10% of the SMN2 gene produces properly spliced SMN protein. By targeting exon 7, Spinraza helps the body produce more full-length, functional SMN protein, which is essential for motor neuron survival and improved motor function. This increase in SMN protein helps slow the progression of muscle weakness and supports better outcomes for individuals with SMA.

Spinraza binds to SMN2, allowing the gene to increase the production of functional SMN protein, which is critical for improving motor neuron survival and function in patients with SMA. While Spinraza has significant benefits, it is important to note that, though rare, there are some potential risks associated with its administration.

One potential risk is an increased risk of bleeding. Complications involving bleeding have been observed in patients receiving intrathecal medications like Spinraza. Because of this risk, blood tests are routinely performed before starting treatment and prior to each subsequent dose to monitor for any abnormalities in clotting or blood health. These tests help ensure that the patient is not at elevated risk for bleeding complications during treatment.

Similarly, there is also an increased risk of kidney damage, which has been reported with the administration of medications similar to Spinraza. To mitigate this risk, kidney function tests are also performed regularly before treatment and prior to each dose. These tests are crucial for monitoring kidney health and preventing any potential complications related to kidney function during the course of treatment.

By closely monitoring both blood health and kidney function, healthcare providers can help ensure the safety of patients receiving Spinraza while maximizing the treatment's benefits. Before each dose of Spinraza, a urine test should be obtained to monitor kidney function and detect any signs of potential damage. In addition to the risks of bleeding and kidney complications, there are several common side effects associated with Spinraza. These include lower respiratory infections, fevers, constipation, headaches, vomiting, back pain, and post-lumbar puncture syndrome. As healthcare providers, it is crucial to monitor these side effects and remain vigilant about the potential risks of bleeding and kidney damage.

Zolgensma is a gene replacement therapy specifically designed for individuals with SMA. In SMA patients, the SMN2 gene serves as the primary source of SMN protein production, but it only generates around 10% of the functional SMN protein needed. Zolgensma works by delivering a new, working SMN1 gene directly to the body’s cells, effectively replacing the function of the missing or defective SMN1 gene. This is a major breakthrough because it allows the cells—particularly the motor neuron cells—to begin producing the SMN protein needed to maintain motor function and prevent muscle weakness.

Approved by the FDA in 2019, Zolgensma represents a significant advancement in the treatment of SMA. As a one-time gene replacement therapy, it has the potential to dramatically change the course of the disease by addressing the root cause of SMA at the genetic level, allowing for improved motor function and a better quality of life for those with SMA.

Zolgensma costs approximately $2.1 million for a single-use treatment, making it one of the most expensive drugs in the world. The high cost of this gene therapy is due to the expensive research and development processes involved, as well as the complexity and cost of manufacturing gene therapies. Developing gene therapy is significantly more expensive than traditional drugs due to the specialized technology required to create these treatments, including the use of viral vectors and genetic engineering.

Unlike Spinraza, which requires lifelong administration, Zolgensma is a one-time dose delivered through intravenous (IV) infusion. The drug works by using a viral vector to deliver a functional human SMN1 gene directly to the motor neurons, effectively replacing the defective or missing SMN1 gene that causes SMA.

Zolgensma is FDA-approved for children under the age of two years with SMA Type 1, the most severe form of the disease. However, it comes with some serious potential side effects. One of the primary risks is an increase in liver enzyme levels, which can lead to acute liver injury or, in severe cases, acute liver failure, a condition that could be fatal. Due to this risk, patients receiving Zolgensma are given an oral corticosteroid before and after the infusion to help protect the liver and manage inflammation. In addition, patients will undergo regular blood tests to monitor their liver function and ensure any potential liver issues are detected early.

Another potential complication is decreased platelet counts, which can increase the risk of bleeding and bruising. Parents and caregivers are advised to seek immediate medical attention if the patient experiences any unexpected bleeding or bruising following the infusion. Lastly, like many other medications, including Spinraza, vomiting is a common side effect of Zolgensma.

Lastly, Evrysdi (risdiplam) was FDA-approved in 2020, making it the first oral drug treatment for SMA. The cost of Evrysdi is approximately $27,884 per year, making it more affordable compared to other SMA treatments like Spinraza and Zolgensma. Evrysdi is a small molecule SMN2 splicing modifier designed to treat the underlying cause of SMA by increasing the production of full-length SMN protein, which is essential for maintaining motor neuron function. It is approved for SMA patients who are two months of age and older, offering a broader age range for treatment compared to other therapies.

Like all medications, Evrysdi has its side effects, and these differ slightly based on the type of SMA being treated:

• In later-onset SMA, common side effects include fever, diarrhea, and rash.
• In infantile-onset SMA, the side effects also include fever, diarrhea, and rash, but additional symptoms such as runny nose, sneezing, sore throat (signs of upper respiratory infections), lung infections (lower respiratory infections), constipation, vomiting, and cough are more frequently observed.

The introduction of Evrysdi as an oral medication has provided a more convenient treatment option for many SMA patients, especially those who may find regular intrathecal injections or IV infusions challenging.

The Role of a Respiratory Therapist With SMA Patients

• Assess patient
• Discuss with parents/caregivers baseline treatments when the patient is well
• Suggested therapies:
  • Bronchodilators and hypertonic saline
  • Cough assist 
  • CPT/Vest therapy and postural drainage
  • Some therapy schedules may be every 2 hours to prevent plugging and intubation

Previously, patients with SMA had limited treatment options, and their care was often restricted to managing symptoms rather than addressing the underlying cause of the disease. However, with recent medical advances, patients now have access to a variety of treatments that can significantly improve their quality of life and help manage the comorbidities associated with SMA, such as respiratory issues. This is where the role of the respiratory therapist becomes essential.

As medical treatments like Spinraza, Zolgensma, and Evrysdi have become available, respiratory therapists play a critical role in supporting patients' respiratory health and helping manage complications such as impaired cough, recurrent infections, and respiratory muscle weakness. Their expertise in pulmonary toileting, ventilatory support, and airway clearance techniques can make a substantial difference in the long-term health and survival of SMA patients.

As learning and research in the field of SMA continue to evolve, the role of respiratory therapists (RTs) has become increasingly important in providing early and aggressive respiratory therapies for these patients. Implementing these therapies as soon as possible is critical for managing respiratory distress and preventing complications.

The first step for an RT when an SMA patient is admitted with any type of respiratory distress is to assess the patient immediately. A key part of this assessment involves communicating with the parents or caregivers to understand the patient’s baseline respiratory status when they are well. This provides valuable information for establishing a plan of care and allows the healthcare team to better understand the degree of deterioration when the patient is sick.

Some of the respiratory therapies commonly administered by RTs for SMA patients include:

• Bronchodilators: Medications like albuterol or levalbuterol (Xopenex) are used to help open the airways, making breathing easier for the patient.
• Hypertonic saline nebulizers: These are often given to help thin mucus, making it easier for the patient to clear secretions from their airways.
• Pulmozyme (dornase alfa): This is another medication frequently used in SMA patients to break down thick mucus in the lungs, improving airway clearance and reducing the risk of respiratory infections.

By employing these therapies, RTs can help manage respiratory complications and improve the overall pulmonary health of patients with SMA. Maintaining open communication with caregivers about the patient’s home care regimen is vital for ensuring that treatments are tailored to the individual needs of each patient.

Cough Assist Device

One of the key respiratory treatments for SMA patients is the use of a cough assist device, also known as an insufflator-exsufflator machine. This non-invasive device helps clear the lungs by mimicking the action of a natural cough. The machine works by blowing air into the lungs and then quickly sucking it out, helping to expel mucus that the patient would otherwise struggle to clear on their own. The goal of the cough assist is to increase the amount of mucus expelled, reducing the risk of respiratory infections and other complications.

Chest Physiotherapy (CPT)

Next, we have chest physiotherapy, commonly referred to as CPT therapy. This therapy involves gently clapping on the chest wall to help loosen mucus. Alternatively, a pneumatic percussor, a vibrating device, can be used to help loosen mucus by using vibration and gravity to encourage the movement of secretions from the lower airways to the upper airways, which can then trigger a cough. For some SMA patients, this therapy may be required daily, while for others, it may only be necessary during illness, depending on their baseline respiratory status.

Vest Therapy

Another effective tool is vest therapy, which involves the use of a wearable device that vibrates to help loosen and move mucus. The vest connects to an air pulse generator that inflates and deflates the vest around the patient’s chest. This vibration helps dislodge mucus so it can be coughed out more easily. Vest therapy sessions typically last anywhere from 10 to 30 minutes and can be customized with different pressures and frequencies (measured in hertz). The therapy is most effective when done in the reverse Trendelenburg position, which uses gravity to help move mucus from the lower airways to the upper airways, where it can be suctioned or expelled with the help of the cough assist device. For many SMA patients, these therapies can be scheduled as frequently as every 2 hours to prevent airway plugging and reduce the risk of requiring intubation.

Invasive Ventilation in SMA Patients

While invasive ventilation is an option for SMA patients, it is typically considered a last resort. Invasive ventilation involves inserting a breathing tube into the airway and attaching it to a mechanical ventilator, which assists or fully controls breathing. Long-term invasive ventilation usually requires a tracheostomy, where a doctor makes a small incision in the neck and inserts a tube directly into the trachea. This procedure is more common as SMA patients age and their disease progresses, particularly when non-invasive ventilation is no longer sufficient.

Many individuals with SMA, especially those with Type 1 (non-sitters), may require more breathing support as they grow older and their respiratory muscles weaken. However, many SMA patients can successfully manage their respiratory needs with non-invasive ventilation, using breathing support primarily during sleep or when they are sick. The decision to move from non-invasive to invasive ventilation should be carefully discussed with healthcare providers, as it is a significant step in the care of an SMA patient. These decisions are based on the individual’s needs and the progression of the disease, and it's crucial for parents and caregivers to have open discussions with their medical team as early as possible after diagnosis.

NIV and the SMA Patient

• BIPAP
• Pushes air in and opens lungs through positive pressure ventilation
• SMA type 2 or 3 may only need support while sleeping or when ill
• Cure SMA: if the child who already uses Bipap is sick, they will need to use Bipap during all sleep, including naps, and sometimes while awake
• OSA 
• Hypoventilation

Non-invasive ventilation (NIV) is very common for patients with SMA, and one of the most widely used forms is BiPAP (Bilevel Positive Airway Pressure). At our hospital, BiPAP is the primary non-invasive ventilation option for SMA patients. This type of ventilation is particularly beneficial for individuals with SMA because the intercostal muscles—the muscles located between the ribs that help the chest expand and allow the lungs to fill with air—are often significantly weakened by the disease.

Due to the weakness of these intercostal muscles, SMA patients struggle to maintain a normal breathing pattern. A BiPAP machine helps facilitate breathing by using positive pressure to push air into the lungs, supporting their weakened respiratory muscles. The machine provides two different levels of pressure:

• Higher pressure during inhalation, which allows the patient to take in a larger volume of air.
• Lower pressure during exhalation, which helps ease the breathing process by reducing the resistance as the patient breathes out.

BiPAP machines are designed to sense the normal breathing cycle and synchronize with the patient's natural rhythm. This is especially important for SMA patients, as they often experience dysynchrony between their breathing efforts and the need for support when they are sick or in respiratory distress. The synchronization capability of the BiPAP helps ensure the machine works in tandem with the patient’s own breathing efforts, making breathing more comfortable and effective.

Additionally, a BiPAP machine plays a vital role in ensuring patients receive adequate air during deep sleep. SMA patients may not breathe as effectively while sleeping due to their weakened respiratory muscles, so the BiPAP helps maintain proper ventilation and oxygen levels throughout the night.

Because SMA patients are typically shallow breathers, many patients with Type 2 or Type 3 SMA can manage with BiPAP and only require this support while sleeping or during illness. Even something as minor as the common cold can significantly weaken breathing in children with SMA. According to Cure SMA, if a child who already uses BiPAP contracts a cold, they will need to use the machine during all sleep periods—including daytime naps, nighttime sleep, and anytime they doze off. This ensures that their lungs stay open and prevents derecruitment (collapse of the small airways). In some cases, BiPAP may even be needed while the child is awake, depending on the severity of their symptoms.

For Type 3 SMA patients, both children and adults, frequent checkups are essential to monitor for any breathing difficulties that may not be immediately noticeable. These can include conditions such as obstructive sleep apnea and hypoventilation (shallow breathing). In these cases, a sleep study may be recommended to ensure that the patient is receiving the appropriate level of BiPAP support while sleeping, especially when at home. Proper BiPAP use during all types of sleep can greatly benefit SMA patients, helping them maintain adequate ventilation and oxygenation.

However, NIV does have some potential side effects. One of the most common issues is facial indentation or skin breakdown from the mask, which occurs due to the tightness required to create a proper seal on the face. To protect against skin damage, we can use products like Mepilex or LiquiCell—skin protection materials that are applied to the patient’s face to prevent irritation and breakdown from prolonged mask use. In some cases, a different mask size or type may be needed to improve comfort and fit.

We have a plethora of options for comfort, including various mask sizes and fittings to ensure a proper and comfortable fit for each patient, from children to adults. Ensuring the right fit is essential for effective BiPAP therapy.

It is also important to note that patients should never eat or drink while using the BiPAP machine. Doing so increases the risk of aspiration, where food or beverages can be inhaled into the lungs, which could lead to aspiration pneumonia—a serious complication we want to avoid.

In addition to this, there are other potential risks and side effects associated with BiPAP use, including:

• Dry mouth: This can occur due to the constant flow of air.
• Eye irritation: Air leaks around the mask may cause discomfort or dryness in the eyes.
• Mask leaks: Leaks from the mask can reduce the air pressure being delivered, compromising the machine’s ability to keep the lungs open. It is essential to ensure that the leak is appropriate and that the mask is properly fitted to maintain effective therapy.
• Sinus pain or congestion: The positive air pressure can sometimes cause discomfort in the sinuses.
• Mild stomach bloating: This can happen if air is inadvertently swallowed, causing it to accumulate in the stomach.

By addressing these issues, we can help ensure the BiPAP machine works effectively and comfortably for each patient, preventing complications while providing the necessary respiratory support.

Respiratory Care Options for Desaturations

When managing desaturations in SMA patients, it's crucial to remember that oxygen supplementation should not be provided without the concurrent use of BiPAP or another form of non-invasive ventilation. As RTs, our focus should always be on lung expansion. If the patient is desaturating, it is important to assess the situation thoroughly and choose the most effective course of action. This often includes performing a cough assist treatment, followed by suctioning to clear the airways. Additionally, evaluating whether the patient requires airway pressure release ventilation (APRV) or other forms of respiratory support is key to maintaining adequate oxygenation.

Our goal is to choose the most effective interventions while providing the patient with the best breathing support possible. By taking a proactive approach, we can help prevent further desaturations and ensure the patient’s lungs stay as open and clear as possible.

SMA is one of the most common rare diseases, and although there is no cure, there are currently three FDA-approved drugs available to help manage its symptoms. The treatment of SMA requires multidisciplinary management, addressing not only the neurological aspects but also the respiratory complications that arise. The role of the respiratory therapist is critical in providing ongoing care, including pulmonary toileting, airway clearance, and ventilatory support, all of which are vital for the survival and quality of life of SMA patients.

Questions and Answers

For a respiratory therapist, what are the key considerations when transitioning an SMA patient from the hospital to home care in terms of equipment needs, caregiver training, and setting them up for success?

It is crucial to ensure that the BiPAP mask fits properly and there’s minimal leakage to maintain lung expansion. Many SMA patients rely on BiPAP for breathing support. Proper caregiver training on respiratory toileting, including the use of bronchodilators, cough assist, and suctioning, is essential. We also emphasize how to handle emergency situations, such as a mucus plug or respiratory distress, and when to use a bag mask.

Most families are well-versed in the condition, often participating in support groups for emotional and practical support. For some, even small things like customizing vest therapy devices can brighten their day, as these patients spend a significant amount of time on pulmonary care.

Can you tell us more about the Speak X device you mentioned earlier?

The Speak X is a small microphone sticker that attaches to the patient’s non-invasive mask. It helps amplify their voice, making it easier for caregivers to hear, despite the muffled effect caused by the mask. While it doesn’t eliminate the muffling completely, it allows patients to communicate without removing the mask, which helps avoid derecruiting their lungs. The device is especially helpful for teens who want to communicate more freely.

How important is communication for SMA patients, especially teens?

Communication is vital, especially for teens who want to express themselves socially. Devices like the Speak X help them talk more easily without compromising their respiratory support, reducing frustration and improving their ability to express needs or interests.

References

https://www.cdc.gov/

Mercuri, E., Finkel, R. S., Muntoni, F., Wirth, B., Montes, J., Main, M., Mazzone, E. S., Vitale, M., Snyder, B., Quijano-Roy, S., Bertini, E., Davis, R. H., Meyer, O. H., Simonds, A. K., Schroth, M. K., Graham, R. J., Kirschner, J., Iannaccone, S. T., Crawford, T. O., Woods, S., … SMA Care Group (2018). Diagnosis and management of spinal muscular atrophy: Part 1: Recommendations for diagnosis, rehabilitation, orthopedic and nutritional care. Neuromuscular disorders: NMD, 28(2), 103–115. 

Nemours Children’s Hospital. (2023). Spinal Muscular Atrophy (SMA.https://kidshealth.org/en/parents/sma.html

Office of the Commissioner. (2020, August 7). FDA approves oral treatment for spinal muscular atrophy. U.S. Food And Drug Administration. https://www.fda.gov/news-events/press-announcements/fda-approves-oral-treatment-spinal-muscular-atrophy

Respiratory therapy for SMA (2024). mySMAteam. https://www.mysmateam.com

Roland, J. (2022, February 28). What are the signs of spinal muscular atrophy? Healthline. https://www.healthline.com/health/signs-of-spinal-muscular-atrophy#symptoms

Editor’s note: This text-based course is an edited transcript of the webinar, Bronchopulmonary dysplasia (BPD) Historical and Scientific Update, presented by Katlyn Burr, MSM-HCA, RRT, RRT-NPS, AE-C.

It is recommended to download the course handout to supplement this text format.

Learning Outcomes

After this course, participants will be able to:

• Define BPD
• Discuss the historical background and advancement of the definition and disease
• Review best practices to drive the best patient outcomes in BPD patients

The Birth of BPD

The origins of Bronchopulmonary Dysplasia (BPD) can be traced back to the era of President Kennedy. The story begins with the challenges that President Kennedy and his wife, First Lady Jackie Kennedy, faced in starting a family. Before his presidency, the couple endured heartache. Their first pregnancy ended in a miscarriage, and their second, tragically, resulted in the stillbirth of a daughter, Arabella. Despite these losses, they were eventually blessed with two healthy children, Caroline and John. However, one year into Kennedy’s presidency, Jackie became pregnant again. This time, she gave birth prematurely to a son, Patrick, at 34 weeks. Unfortunately, Patrick only survived for 39 hours, succumbing to respiratory distress syndrome and hyaline membrane disease.

That same year, a Canadian doctor made significant strides in neonatology by pioneering the controversial use of a ventilator. His groundbreaking work saved a similarly ill 34-week-old baby, marking a pivotal moment in the history of neonatal care and the development of treatments for conditions like BPD. Unfortunately, American doctors at the time were unable to replicate the success seen elsewhere. When Patrick was born at Otis Air Force Base, it became immediately clear that he was showing signs of respiratory distress and would require urgent intervention. At that time, the available treatments for babies with respiratory distress and hyaline membrane disease were limited. The medical team focused on stabilizing his blood gases, adjusting his blood chemistry as best they could, and administering hyperbaric oxygen. Despite their efforts, these measures were not enough to save Patrick.

When President Kennedy learned about the Canadian doctor who successfully used a ventilator to save a very sick 34-week-old baby, he felt a deep sense of embarrassment. Patrick's death had already sharpened the national focus on neonatal lung disease, a condition responsible for about 20% of all neonatal deaths in the late 1960s and early 1970s. In response, President Kennedy signed into law a significant grant authorizing $265 million over five years for newborn research. This initiative was sponsored by the National Institute of Child Health and Human Development, an organization that Kennedy had established with his sister, Eunice Shriver,  a year earlier.

While $265 million was a significant sum at the time, in today’s terms, it equates to about $2.1 billion—a truly remarkable investment in advancing neonatal research, particularly in lung development, to help newborns survive. Sadly, President Kennedy was assassinated three months after Patrick’s birth and death, and he never witnessed the breakthroughs in research and treatments that have since saved countless lives.

Patrick's birth and death did indeed intensify the focus on neonatal lung disease, but other critical developments were also underway. One of the most significant was the discovery of surfactants, which played a pivotal role in the evolution of BPD. In 1957, John Clements became the first researcher to identify a mucoprotein, later known as surfactant, which was crucial for maintaining alveolar stability in animal models.

Avery and Mead, two pioneering researchers, observed that the surface tension of lung extracts from premature infants with hyaline membrane disease was significantly higher than that of similarly sized infants who were dying of non-respiratory causes. This critical finding led them to hypothesize that the increased surface tension and subsequent lung collapse were due to the absence of surfactant in infants weighing less than 1,100 grams. The term Bronchopulmonary Dysplasia (BPD) was later coined to describe this emerging pattern of lung disease in premature infants who were surviving longer, thanks to advances in ventilator care. Today, BPD is recognized as the most common cause of chronic lung disease in infancy. The clinical, radiological, and pathological features of BPD were first detailed over three decades ago.

Before the 1960s and the introduction of the controversial mechanical ventilator, premature infants who developed respiratory distress syndrome often faced two outcomes: they either passed away within their first week of life, as Patrick did, or they survived without significant pulmonary complications. However, with advancements in medical technology and the use of mechanical ventilation, infants who once would have perished are now being supported and given a chance to live. While mechanical ventilation greatly improved the survival rates of these infants, it also led to a new form of lung injury.

Old BPD

In 1967, William Northway first described this new chronic lung disease, known as Bronchopulmonary Dysplasia (BPD). He observed it in a group of premature infants with respiratory distress syndrome who had undergone prolonged ventilation with high oxygen concentrations and high peak inspiratory pressures.

The infants studied had a mean gestational age of 34 weeks and an average weight of 2.4 kilograms. All of them required oxygen 28 days after birth and showed progressive changes on chest radiographs, which were graded according to severity. Pathologic examination of their lung tissues revealed necrotizing bronchiolitis, vascular changes indicative of pulmonary hypertension, infiltration of inflammatory cells, and alternating areas of atelectasis and pulmonary fibrosis. The term "bronchopulmonary dysplasia" was coined to emphasize that both the airways and the lung parenchyma were affected. These abnormalities were attributed to injuries caused by mechanical ventilation and prolonged oxygen exposure. Since Northway’s initial definition in 1967, advancements in medical technology have led to an evolving understanding and redefinition of BPD.

In 1979, Bancalari and colleagues introduced the first revision to Northway's original definition of BPD. Their updated criteria included the need for oxygen at 28 days, chronic changes on a chest X-ray, and the presence of tachypnea with crackles or retractions, though they removed the grading system for chest X-rays. As time passed, it became evident that fewer babies required as much oxygen at 28 days post-birth, prompting another update in 1988. This revision shifted the focus to assessing supplemental oxygen needs at 36 weeks postmenstrual age. However, as medical technology continued to advance, the 1988 definition became less predictive and less useful. With the increased survival rates of extremely low birth weight infants and the broader spectrum of disease severity, new treatment options for respiratory distress have further refined our understanding and management of BPD.

New BPD

The failure to account for gestational age at birth and disease severity led to concerns that the existing definition of BPD was inadequate. In 2000, a review of the definition of BPD and chronic lung disease of infancy in preterm infants was conducted at a workshop hosted by the National Institute of Child Health and Human Development and the National Heart, Lung, and Blood Institute. The consensus from this workshop addressed two key groups of infants: those born at less than 32 weeks estimated gestational age. For infants requiring oxygen at 28 days, they were reassessed at 36 weeks postmenstrual age. Based on this reassessment, infants breathing room air at 36 weeks were classified as having mild BPD, those requiring less than 30% FiO2 were classified as having moderate BPD, and those needing more than 30% FiO2 or positive pressure ventilation were classified as having severe BPD.

Old versus New BPD

It is not until about 32 weeks of gestation that alveoli begin to form, which is a key reason why the definitions of BPD have evolved. The "old" BPD primarily affected older preterm infants who suffered from structural injuries to their lungs. In contrast, "new" BPD involves caring for infants who may not have significant structural damage but instead experience developmental arrest or delays in lung tissue maturation due to their extremely early birth. Despite the evolution of the BPD definition over time, a consensus remains: chronic lung disease develops in preterm infants exposed to oxygen and positive pressure ventilation. BPD cannot occur in term infants; it is a condition exclusive to those born preterm and who require oxygen and positive pressure ventilation.

BPD Definitions

The evolution of BPD definitions reflects our growing understanding of the condition and the advancements in neonatal care over the decades.

• 1967 (Northway): The initial definition of BPD was based on progressive clinical symptoms, radiographic findings, and histological changes. This definition highlighted the physical changes in the lungs that could be observed over time.
• 1988 (Shennan): The definition was refined to focus on the need for supplemental oxygen at 36 weeks postmenstrual age (PMA) as a key criterion, marking a shift toward recognizing the ongoing oxygen dependency as a critical aspect of BPD.
• 2004 (Walsh): A more physiological approach was introduced, defining BPD in infants ≤32 weeks gestational age (GA) at 36 weeks PMA by the requirement for invasive mechanical ventilation (IMV) or continuous positive airway pressure (CPAP). Additional criteria included a PaO₂/FiO₂ ratio ≥0.3 or failure to maintain oxygen saturation ≥90% for 30 minutes following an oxygen reduction test.
• 1979 (Tooley): This definition focused on radiographic abnormalities, identifying abnormal lung findings on a radiograph at 30 days of life as a key indicator. Critical PaO₂ was defined as less than 60 mmHg in room air, and PaCO₂ as less than 45 mmHg, with oxygen dependency at 30 days being a significant marker.
• 2001 (NIH): BPD was categorized based on FiO₂ requirements for 28 or more days. The severity was graded according to the level of oxygen support required: mild BPD was associated with breathing in room air, moderate BPD with FiO₂ less than 0.3, and severe BPD with FiO₂ ≥ 0.3 and/or the need for CPAP or IMV.
• 2018 (NIH): The definition was further refined to apply to infants ≤32 weeks GA with persistent radiographic lung disease who required respiratory support at 36 weeks PMA for three or more days to maintain arterial oxygen saturation between 90-95%. The grading system became more detailed, with specific criteria based on the type and level of respiratory support needed, including considerations for the risk of death.
• 2019 (Jensen): This definition focused on grading BPD in infants less than 32 weeks GA based on the level of respiratory support required at 36 weeks PMA or discharge. The grades ranged from mild, involving nasal cannula flow ≤2 LPM, to severe, requiring invasive mechanical ventilation.

This progression in BPD definitions shows a trend towards more precise and individualized criteria, reflecting the complexities of the condition as we better understand its varied presentations and underlying mechanisms. As neonatal care continues to evolve, the hope is that more preventive and less invasive treatments will be developed, reducing the need for intensive interventions. However, as we push the boundaries of survival for younger and more fragile infants, the necessity for advanced medical technologies, including potentially more invasive options like external wound management or liquid ventilation, may also increase. This duality underscores the ongoing challenge of balancing advancements in care with the needs of an increasingly vulnerable patient population.

BPD Evolvement

The evolution of BPD definitions continued with significant updates in 2018 and 2019. In 2018, the NIH introduced a new grading system, replacing the traditional terms of mild, moderate, and severe BPD with a more nuanced classification of grades I, II, III, and IIIa. This change aimed to provide a more precise characterization of the disease based on the level of respiratory support required by the infant.

In 2019, the grading system was further refined. The NIH removed grade IIIa and focused on grades I, II, and III, specifically for infants born at less than 32 weeks gestational age. This updated system categorizes BPD based on the level of respiratory support required at 36 weeks postmenstrual age or at discharge, whichever occurs first.

• Grade I BPD is assigned to infants who are on nasal cannula flow rates of less than or equal to two liters per minute.
• Grade II BPD applies to those with nasal cannula flow rates greater than two liters per minute, or those who require CPAP or other non-invasive respiratory support.
• Grade III BPD is used for infants who require invasive mechanical ventilation at 36 weeks postmenstrual age or at discharge.

This refined classification system allows for a more detailed understanding of the severity of BPD, which can better guide treatment decisions and provide clearer prognostic information. By categorizing BPD based on specific respiratory needs, clinicians can more accurately assess the level of care required and anticipate potential challenges as these infants continue to develop.

Review of BPD

• Chronic Lung Disease
• Developed in preterm infants who are exposed to:
  • Oxygen
  • Positive Pressure Ventilation
• Difficult to manage because conventional treatment of symptoms results in the disease
• The premature development of the lung allows for recovery if we provide appropriate intervention
   

If you recall your anatomy and physiology classes as a respiratory therapy student, you likely had a lecture on fetal lung development. During that course, you might remember learning about the stages of lung development. Around 16 weeks of gestation, the fetus enters the canalicular stage, and by approximately 23 weeks, the development progresses to the saccular stage.

All of these factors must converge for BPD to develop. The disease has always been challenging to manage because the very treatments used to address it can also cause or exacerbate the condition. Additionally, the premature development of the lungs presents its own set of challenges. However, due to the immaturity of these lungs, there is a narrow window in which appropriate interventions can aid recovery without further damaging lung tissue.

BPD occurs when lung development arrests during the late canalicular to saccular stages. The pathology of BPD is characterized by decreased septation and alveolar hypoplasia, leading to the formation of large, simplified alveoli. This abnormality significantly reduces the surface area available for gas exchange, further complicating the condition.

These infants also exhibit dysregulated vasculature, characterized by smooth muscle hyperplasia in their pulmonary vessels and abnormal alveolar capillaries. Additionally, there is increased interstitial fibroproliferation and impaired alveolar septation. The advantage of being born early is that their lung development is still ongoing. Although these infants may not have fully formed alveolar sacs at birth, their lung tissue continues to develop after they are born.

Review of BPD- Lung Development

Remarkably, babies grow approximately 3.3 alveoli per second from birth until they reach the age of one. This means that every moment spent caring for a baby at the bedside during their first year of life, they were developing around three new alveoli every second. These alveoli are the tiny air sacs in the lungs where gas exchange occurs, and their development is crucial for establishing healthy lung function.

This rapid growth does not stop after the first year; it continues at a rate of about one alveolus per second until the age of two. This incredible pace of alveolar development is vital for building the lung’s capacity to exchange oxygen and carbon dioxide efficiently, which is especially critical in premature infants. Premature infants often have underdeveloped lungs, making them more susceptible to conditions like bronchopulmonary dysplasia (BPD).

For these vulnerable infants, receiving protective ventilation strategies, such as gentle ventilation and permissive hypercapnia, can make a significant difference. By minimizing lung injury and promoting a favorable environment for lung development, these interventions help ensure that the new alveoli they rapidly form are healthy. This not only has the potential to reduce the severity of lung disease but also supports better long-term outcomes, including improved lung function and a reduced risk of respiratory complications as they grow.

Understanding the critical period of alveolar development underscores the importance of providing optimal care during the early stages of life, particularly for those born prematurely. It also highlights the potential for targeted interventions to make a lasting impact on the health and well-being of these infants.

Alveolar Multiplication

The theory of alveolar multiplication, which involves the subdivision of terminal units, the formation of primary pulmonary saccules and secondary alveolar crests, and the alveolarization of non-alveolated and partly alveolated airways, is not new. Although the precise mechanisms of alveolar development and the relative importance of these processes are still not fully understood, it is clear that alveolar growth is most rapid in the first years of life and appears to slow down as we age.

Some research suggests that alveolar growth stops by around age eight, while other evidence indicates it may continue until somatic growth ceases. For example, a 2011 study published in the American Journal of Respiratory and Critical Care Medicine examined 100 patients aged 7 to 21 years. The researchers used hyperpolarized helium, which the patients inhaled before undergoing MRI scans. The hyperpolarized gas, acting like a magnet, is aligned in one direction, as you can see in the image on the screen. By analyzing how the gas decayed in the lungs, the researchers could estimate the size of the alveoli. They found that while the size of the alveoli showed very little difference, total lung volume increased significantly, ranging from about one to four liters.

Researchers concluded that if the size of the alveoli remains largely unchanged, the increase in lung size must be due to the growth of new alveoli. This suggests that until we stop growing in height, we likely continue developing alveoli. This is particularly fascinating for those who care for pediatric patients, who are constantly growing.

BPD- CXR Findings

• Coarse, irregular, rope-like, linear densities
• Could represent atelectasis or fibrosis
• Lucent cyst-like foci
• Areas of air-trapping
• Shifting atelectasis
• May be combined with pneumonia

In children with BPD, chest X-rays typically reveal irregular rope-like densities that can resemble atelectasis or fibrosis. These images often show lucent cyst foci and multiple areas of air trapping. When comparing serial X-rays taken on different days, one might observe shifting atelectatic areas within the lungs of these patients. All of these factors, including conditions like pneumonia, can occur simultaneously in a child with BPD. 

BPD Prevalence

• 45-68% of VLBW infants diagnosed with BPD
• 80% of infants born 22-24 weeks of gestation are diagnosed with BPD, whereas only 20% of infants at 28 weeks develop BPD
• ~40% of preterm infants born prior to 29 weeks GA
• 11-50% in different countries around the world
• 10,000 births annually in the US with BPD
• 12-39% for preterm babies born before 32 weeks GA
• <1000g babies is 30-50%
• Overall, younger, smaller, less mature babies are at higher risk (Mandell et al., 2019; Clin Perinatol Zhang et al., 2022)

The prevalence of BPD varies widely depending on the definitions used, as you have seen with the different criteria that have evolved over time. The reported prevalence is influenced by factors such as whether the definition of very low birth weight versus extremely low birth weight infants is used and whether all babies are included or only a subset. In 2010, the National Institute of Child Health and Human Development Neonatal Research Network used severity-based and physiologic definitions of BPD and estimated that as many as 68% of very low birth weight infants could be diagnosed with BPD.

In the United States, approximately 10,000 babies born each year will either have or develop Bronchopulmonary Dysplasia (BPD). The risk of developing BPD is directly related to the baby's age, size, and maturity—the younger, smaller, and less mature the infant, the higher the risk of developing BPD. This risk is also closely linked to the severity of the disease.

BPD remains the most expensive morbidity in neonatal intensive care units (NICUs), with an estimated annual economic burden of $1.7 billion in the United States. Caring for these patients in NICUs costs the healthcare system $1.7 billion each year, making the reduction of BPD risk a critical clinical and economic priority in the care of very low birth weight infants.

BPD Impact

These patients face a significant challenge, with mortality rates reaching up to 40%. Additionally, about 25% of infants with moderate to severe BPD develop BPD-associated pulmonary hypertension, a condition linked to even higher rates of mortality and morbidity. The most common causes of death in these patients include recurrent respiratory tract infections, pulmonary heart disease, and pulmonary hypertension.

For those who survive, the challenges do not end there. About 50% of these patients are readmitted within the first year, often due to lower respiratory tract infections. Survivors also face a heightened risk of various complications, including gross motor delays, reactive airway disease, asthma, emphysema, RSV, bronchiolitis, growth delays, language delays, and ongoing cardiopulmonary issues.

Given these severe outcomes, it is crucial to do everything possible to reduce the risk of developing BPD or mitigate its severity in the patients we care for. Early intervention, careful management, and ongoing monitoring are essential to improve long-term outcomes and quality of life for these vulnerable infants.

Predisposing Factors

The development of BPD is influenced by several predisposing factors, especially in infants born prematurely. These infants have underdeveloped lungs and often experience stressors that not only contribute to their premature birth but also play a role in the onset of BPD. These stressors can directly impede lung development or trigger an immune response that worsens the condition.

When the immune response is activated, it leads to an increase in free radicals and inflammatory markers. This reaction causes the body to enter a defensive mode, halting normal developmental processes. The resulting inflammation, swelling, and injury further contribute to the development of BPD.

From a postnatal perspective, premature birth alone is a significant risk factor for BPD. The combination of underdeveloped lungs and the immune responses triggered by various stressors creates a challenging environment for healthy lung development, highlighting the importance of prevention and careful management in reducing the impact of BPD.

Lung immaturity at birth increases the likelihood of developing BPD. Other risk factors include poor nutrition, the need for mechanical ventilation and oxygen, and the development of infection or sepsis shortly after birth. Certain demographic groups are also at higher risk, including male infants, those with low birth weight, white infants, and those with impaired growth for gestational age. A family history of asthma further increases the likelihood of developing BPD.

In addition to underdeveloped lungs, premature babies are often affected by conditions such as chorioamnionitis, sepsis, and pneumonia. These conditions contribute to inflammation and oxidative stress, which increase microvascular permeability and lead to pulmonary edema. Treatment for these symptoms typically involves the use of oxygen, positive pressure ventilation, and sometimes nitric oxide. Unfortunately, while necessary, these interventions can lead to aberrant tissue repair and a slowed rate of alveolarization. For instance, instead of the normal rate of developing 3.3 alveoli per second, this process might slow to one or none, leading to impaired alveolar and vascular development—key factors in the progression of BPD.

The complexity of BPD underscores the need for individualized care and ongoing research to better understand and mitigate the risks associated with this condition.

Maternal Factors

From a maternal standpoint, several factors can significantly contribute to a baby's risk of developing BPD. If the mother smoked during pregnancy, had intrauterine growth restriction, or was diagnosed with preeclampsia, her baby is at an elevated risk for BPD. Additionally, preterm babies, who are often born with low birth weight and underdeveloped organs, are already at a greater risk for developing bronchopulmonary dysplasia due to their premature status. These maternal and neonatal factors combined can increase the vulnerability of these infants to BPD and related complications.

Pre-Term Delivery

The same increased risk applies to babies with lower gestational ages. Unfortunately, in our efforts to support these extremely low and very low birth weight infants, as well as those born at reduced gestational ages, we often rely on mechanical ventilation and supplemental oxygen. While these interventions are crucial for sustaining life, they can inadvertently contribute to the development of BPD, further compounding the problem. The very treatments that are necessary for survival can also increase the risk of lung injury, highlighting the delicate balance required in the care of these vulnerable infants.

Chorioamnionitis

Chorioamnionitis, an inflammation of the fetal membranes typically caused by an ascending infection, has been investigated as a potential cause of BPD. The research findings in this area have been mixed. Some studies have indicated an increased risk of BPD in the presence of maternal chorioamnionitis, while others have shown no difference or even a decreased risk.

In 2009, a significant 13-year multicenter study conducted by Lahra and colleagues examined this relationship and concluded that histologic chorioamnionitis was actually protective against BPD. This surprising finding led other researchers, such as Wright and Kirpani, to explore whether the fetal response to chorioamnionitis might play a role in the development of BPD. This area of research continues to be explored as we seek to better understand the complex factors contributing to BPD. Wright and Kirpani delved into the role of a transcription factor, nuclear kB, and its involvement in inflammation in the pathogenesis of BPD. This area is still under investigation, and much more research is needed to fully understand these mechanisms.

Ureaplasma Colonization in the Infant Lung and Bacteria Sepsis

In 2005, Schelonka and colleagues conducted a meta-analysis of 23 studies, which revealed a significant association between ureaplasma colonization and the development of BPD at 36 weeks gestational age. The meta-analysis included 23 studies that measured BPD at 28 days postnatally and eight studies that measured BPD at 36 weeks postmenstrual age. The analysis found a significant association between ureaplasma colonization and BPD at both measurement points, although the association was more pronounced in smaller studies with fewer participants.

Additionally, bacterial sepsis has consistently been linked to higher rates of BPD, further emphasizing the complex interplay between infections and the development of this condition. Understanding these connections is crucial for improving prevention and treatment strategies for BPD. In one cohort study, researchers reviewed recent literature ranging from bench studies to clinical trials and discovered that BPD rates increased from 35% to 62% following early onset sepsis. This and other studies demonstrate a strong association between sepsis and chronic lung disease, particularly highlighting the role of gram-negative bacteria in the development of bronchopulmonary dysplasia (BPD).

Patent Ductus Arteriosus (PDA)

Patent ductus arteriosus (PDA) is another condition that can contribute to hemodynamic instability, and it has been linked to an increased risk of BPD. The left-to-right shunting through a PDA can cause lung endothelial damage, which, combined with the increased need for mechanical ventilation due to pulmonary edema and lung dysfunction, may elevate the risk of BPD in patients with PDA. These findings underscore the complex interplay between various conditions and the development of BPD, making it clear that managing these risk factors is crucial in reducing the incidence and severity of the disease.

However, some studies have shown that despite reducing the size of PDA, indomethacin prophylaxis does not decrease the rates of BPD. Interestingly, PDA ligation has been associated with an increased risk of BPD rather than reducing it. This suggests that the relationship between PDA and BPD may not be direct or causal. Instead, it appears that factors such as high fluid intake in the first days after birth may predispose infants to both PDA and BPD, leading to an observed association.

Moreover, lower serum cortisol levels in very low birthweight infants have been correlated with both PDA and BPD. This correlation suggests that early adrenal insufficiency in these infants could be a contributing factor that explains the link between the two conditions.

Genetic Factors

Genetic factors are also being explored as potential predispositions for BPD. Significant research is currently underway to identify specific genes, nucleotides, alleles, and mRNA that may contribute to a genetic predisposition to BPD. This ongoing work could provide valuable insights into the underlying causes of BPD and help identify at-risk infants earlier, allowing for more targeted interventions.

Yu and colleagues, along with Parad and Torgerson in the TOLSURF study, are currently investigating various genetic factors related to BPD. These researchers are exceptionally knowledgeable, and while we do not have enough time today to delve into all their findings, it is important to note that the evidence so far is mixed. Some studies suggest that BPD can run in families—if one baby has BPD, there is a higher likelihood that a subsequent baby might also develop it. However, twin studies have not consistently shown strong heritability, indicating that more research is needed to understand which genetic factors might predispose infants to BPD.

What we do know is that premature babies are at a significantly higher risk for developing BPD due to their underdeveloped lungs. These immature lungs often lead to signs of respiratory distress, which we commonly treat with positive pressure and oxygen therapy. While these treatments are necessary, they can also contribute to the development of BPD, underscoring the complexity of managing and preventing this condition. More research is needed to clarify the genetic components and improve our strategies for treating at-risk infants.

Given this complex cycle, the critical question becomes: How can we prevent it from occurring? The literature discusses a variety of prevention strategies, each with potential roles in the treatment and management of BPD. We'll explore these strategies, examining how they are supported by current research and their practical application in clinical settings.

Prevention Strategies

Reducing PPV

When we discuss prevention strategies for BPD, one key principle is to minimize the amount of oxygen and positive pressure ventilation these babies receive. Both barotrauma and volutrauma can cause significant lung damage, and this is especially true in the fragile lungs of premature infants. Any ventilation with increased volumes or pressures can lead to immediate lung injury. For instance, even a small number of large-volume breaths delivered with a bag valve mask during resuscitation can cause harm, particularly in surfactant-deficient lungs that do not inflate uniformly.

The risk of injury is especially high during initial resuscitation attempts. During this critical period, the goal is to create functional residual capacity while carefully managing ventilator volumes to stay below the total lung capacity. Striking this balance is challenging but crucial to avoid lung damage.

Reducing oxygen %

Oxygen toxicity is another major factor in the development of BPD. Exposure to high levels of oxygen (hyperoxia) can halt lung development, generate reactive oxygen species, and trigger the inflammatory process. This cascade of events can lead to the type of lung injury that contributes to BPD. Therefore, the careful management of oxygen levels is essential in preventing the development of this condition.

In 2009, a significant study published in Pediatrics by Vento explored the impact of oxygen levels during resuscitation on infants born between 24 and 28 weeks of gestational age. This randomized controlled trial assigned babies to two different FiO₂ groups for resuscitation—one group received 30% FiO₂, while the other received 90% FiO₂. The results were striking: in the group that received 30% FiO₂, the incidence of BPD was reduced by half, from 32% to 15%.

Moreover, the study found that biomarkers of oxidative stress increased exponentially in the group exposed to 90% FiO₂, and these increases correlated strongly with the development of BPD. This research underscores the importance of minimizing oxygen exposure in these vulnerable infants. Providing less oxygen not only reduces oxidative stress but also supports the creation of new alveoli, which is crucial for healthy lung development. These findings highlight the need for careful oxygen management in the care of premature infants, particularly those at risk for or diagnosed with BPD.

When managing infants at risk for BPD, even small adjustments in oxygen delivery can make a significant difference. For instance, when administering a nebulizer treatment, it is beneficial to use 21% oxygen (room air) rather than 100%. Similarly, employing a high-flow device can be advantageous because it allows for the use of higher flow rates with lower FiO₂, with the settings for flow and FiO₂ being adjustable independently rather than being tied together. This approach helps reduce the risk of oxygen toxicity while still providing the necessary respiratory support.

Antenatal corticosteroids

Antenatal corticosteroids have become a standard of care for women between 24 and 34 weeks of gestation who are experiencing preterm labor. These steroids are administered to help accelerate fetal lung development. However, their effect on the incidence of BPD remains a topic of debate. While the mechanism of action for corticosteroids in promoting lung maturation is well understood and listed on the current slide, some animal studies have raised concerns. These studies suggest that corticosteroids might arrest alveolarization and microvascular development, potentially contributing to the development of BPD. Therefore, while antenatal corticosteroids are widely used, their role in BPD prevention continues to be carefully evaluated.

Postnatal corticosteroids

The use of postnatal corticosteroids in managing BPD should be carefully considered on a case-by-case basis. Early studies indicated that administering corticosteroids within the first two weeks of birth could reduce the risk of developing BPD and shorten the time to extubation. However, when corticosteroids are administered later, more than three weeks after birth, they may not reduce the risk of BPD but can still help facilitate earlier extubation.

The side effects of corticosteroids in this population are consistent with those observed in others, including hyperglycemia, hypertension, gastrointestinal bleeding, hypertrophic cardiomyopathy, and an increased risk of infection. Importantly, long-term studies have highlighted a clear association between postnatal corticosteroid use and poor neurodevelopmental outcomes, including an increased risk of cerebral palsy.

A recent study published in JAMA in 2021 suggested that early initiation of medium cumulative doses of systemic dexamethasone might be the most effective regimen for reducing mortality associated with BPD by 36 weeks postmenstrual age. This finding underscores the importance of carefully weighing the benefits and risks of corticosteroid use in premature infants to optimize outcomes.

Azithromycin

Azithromycin and other macrolides, known for their antibiotic and anti-inflammatory properties, have been investigated as potential therapies for preventing BPD in preterm infants, particularly due to their activity against ureaplasma infections. In one randomized controlled trial, a six-week course of azithromycin was administered to very low birth weight infants, but the results showed no statistically significant difference in BPD incidence compared to a placebo. However, among infants colonized with ureaplasma, azithromycin did reduce the incidence of BPD, indicating a potential benefit in this specific subgroup.

Vitamin A

Vitamin A, or retinol, plays a crucial role in the regulation of lung development and injury repair. Low levels of vitamin A have been associated with an increased risk of developing BPD. Consequently, prophylactic administration of vitamin A has been shown to significantly reduce the risk of BPD in extremely low birth weight infants. Importantly, this intervention did not result in any difference in neurodevelopmental impairment at 18- and 22-month follow-up visits for this patient population, making it a promising strategy for BPD prevention without long-term adverse effects.

Vitamin E and Selenium

Currently, there is no evidence to support the use of vitamin E or selenium for reducing or preventing the development of BPD in preterm infants. However, other prevention strategies have shown promise.

Caffeine

One such strategy is the use of caffeine, as demonstrated in the Caffeine for Apnea of Prematurity Trial. This trial compared caffeine to a placebo administered within the first 10 days after birth. Although the primary focus was on preventing apnea of prematurity, the study unexpectedly found a significant reduction in the incidence of BPD at 36 weeks postmenstrual age in the group that received caffeine compared to the placebo group. The exact mechanism by which caffeine reduces the risk of BPD is still unclear.

Pentoxifylline

Another potential intervention is pentoxifylline, a non-specific phosphodiesterase inhibitor known for its ability to decrease pulmonary inflammation. In a study comparing nebulized pentoxifylline to intravenous dexamethasone, nebulized pentoxifylline was found to reduce the risk of BPD by 27%. This suggests that pentoxifylline might offer a beneficial approach to reducing BPD risk, though further research is needed to confirm these findings and better understand the underlying mechanisms.

Cromolyn

Cromolyn, a mast cell stabilizer commonly used in the treatment of asthma, has not been effective in preventing BPD in preterm infants. Despite its benefits in other respiratory conditions, it does not appear to offer protection against BPD.

Nitric Oxide

Nitric oxide, on the other hand, has shown promise in reducing oxidative stress and supporting lung development. However, studies in humans have produced mixed results. Because of this inconsistency, the National Institutes of Health (NIH) consensus statement does not recommend the routine use of nitric oxide in the care of preterm infants. Nonetheless, the NIH acknowledges that basic research, particularly animal studies, has provided valuable insights into the potential benefits of nitric oxide for lung development and function in infants at high risk for BPD. The consensus calls for more research in this area to better understand its role and potential applications.

Surfactant

Surfactant therapy, delivered either through the INSURE (Intubation-SURfactant-Extubation) approach or the LISA (Less Invasive Surfactant Administration) technique, offers a way to administer surfactant to premature infants without the need for intubation. This approach has been effective in reducing the risk of respiratory distress syndrome (RDS) in these babies. However, despite its benefits in managing RDS, surfactant therapy has not been shown to significantly reduce the incidence of BPD by 36 weeks gestational age.

Ventilatory Strategies

In terms of ventilatory strategies, goals for managing infants with BPD have included practices like permissive hypercapnia and gentle ventilation. Although clinical trials have not demonstrated a significant reduction in BPD rates with permissive hypercapnia, some trends suggest a potential reduction in BPD without an increase in adverse events.

Studies comparing ventilation strategies, specifically high-frequency ventilation versus conventional ventilation, have shown that both methods result in nearly comparable rates of BPD in this population. This indicates that while the choice of ventilation strategy is crucial for managing premature infants, neither approach has proven to be markedly superior in reducing the incidence of BPD.

Acetylcysteine

Acetylcysteine, a mucolytic agent, has been explored for its potential to prevent BPD development. However, current evidence does not support its effectiveness in reducing the risk of BPD.

Nutrition

One of the most discussed topics in the literature concerning BPD patients is fluid management, which is crucial from the day these infants are born through all of their outpatient care. Babies at risk for BPD are often fluid-restricted because excessive fluid intake during the first 10 days after birth has been linked to an increased risk of BPD. To compensate for the reduced fluid intake, feedings are fortified to ensure these infants receive adequate calories. Infants who develop BPD may require up to 40% more kilocalories than their age-matched peers to meet their energy needs and support their growth and development.

Infants with BPD continue to have an increased caloric expenditure, approximately 35% above their typical needs. Unfortunately, 30 to 65% of these infants experience growth failure soon after their initial hospital discharge. To mitigate this risk, it is crucial to ensure that they are set up for success with the appropriate formula and caloric intake before they leave the hospital. However, even with optimal in-hospital care, strong outpatient follow-up is essential. This follow-up ensures that these babies continue to meet their elevated caloric needs and support their growth and development.

When it comes to prevention strategies for BPD, there is a wide array of options and interventions to consider. Each has its own set of benefits, limitations, and areas where further research is needed to optimize care for these vulnerable infants. The various prevention strategies we've discussed are categorized based on their proven benefits, according to the available literature. it is important to remember that no two patients with BPD are exactly alike, and their care must be tailored to their individual needs and circumstances.

Treatment of Established BPD

Each patient with BPD has a unique journey, making it crucial to tailor treatment and care to the individual needs of the child and their family. Once a child begins to show signs of BPD or is diagnosed with the condition, the focus naturally shifts from prevention to treatment. Several strategies can be employed to manage BPD effectively. Among these, inhaled steroids, diuretics, and bronchodilators are the most commonly referenced treatments in the literature. These therapies are central to managing the symptoms and complications associated with BPD, helping to improve outcomes for these vulnerable patients.

Inhaled Steroids

Inhaled corticosteroids have been increasingly employed in the treatment of both developing and established BPD. The growing body of evidence supports their use, particularly in terms of their positive impact on patient outcomes. This underscores the importance of continuously refining and personalizing treatment strategies to meet the specific needs of each child with BPD.

A Cochrane Systematic Review of randomized controlled trials provided significant insights into this treatment approach. The review found that early administration of inhaled steroids to very low birth weight infants effectively reduces the incidence of death or chronic lung disease at 36 weeks postmenstrual age, whether considering all randomized infants or the survivors.

However, it is crucial to identify the optimal risk-benefit ratio for these patients. This involves exploring different delivery techniques and dosing schedules to maximize both short- and long-term benefits while minimizing adverse effects. Of particular concern are the neurodevelopmental outcomes associated with the use of inhaled steroids, making it essential to carefully weigh the potential benefits against any potential risks. Further research in this area will be key to optimizing care for infants with BPD.

Diuretics

Diuretics are commonly used in patients with known BPD to reduce pulmonary alveolar and interstitial edema and improve lung function. However, the effectiveness of diuretics, particularly systemic loop diuretics like furosemide, has been subject to extensive research with mixed results.

A systematic review of clinical trials investigating the use of intravenous (IV) or enteral furosemide in infants with developing or established BPD found no consistent benefit for infants less than three weeks old. For infants older than three weeks, a single dose of 1 mg per kg of IV furosemide only provided transient improvement in lung mechanics. Based on this evidence, the literature suggests that systemic loop diuretics should not be routinely used for infants with BPD.

In contrast, a Cochrane Review focusing on thiazides and spironolactone for patients with moderate BPD found that these medications improved lung mechanics. Moreover, when administered for four weeks, they were associated with a reduction in mortality among these patients.

Aerosolized diuretics have also been studied, but they have not shown long-term benefits and are not routinely recommended. For patients with BPD who are on diuretics in an outpatient setting, the best approach is to allow for growth rather than increasing the diuretic dose. A gradual weaning of diuretics as the child grows is often the preferred strategy in managing these patients.

Bronchodilators

Studies have shown that inhaled bronchodilators, particularly beta-agonists, can provide short-term improvement in lung function for infants with BPD, especially during acute exacerbations. These medications are not necessary on a regular basis but can be beneficial during respiratory infections or when reversible bronchospasm occurs.

Growth and Nutrition

In terms of growth and nutrition, it is crucial to select the appropriate caloric intake for these infants, typically ranging from 22 to 30 calories per ounce. The balance between fat and carbohydrates is also important, as these babies need nutrients like zinc to support tissue repair, carbohydrate tolerance, and immune healing. Additional vitamin A is often recommended, and it is important to avoid lipid restriction and excessive glucose infusion in this patient population.

European Respiratory Society Guideline

The European Respiratory Society's consensus group (Duijts et al., 2020) conducted a thorough review of several key areas related to the care of BPD patients after discharge, but they concluded that the evidence supporting many interventions is generally low. For instance, they do not recommend routine lung imaging for BPD patients unless the patient has severe BPD or significant respiratory symptoms. Similarly, they advise against using lung function tests to monitor children with BPD, citing the low certainty of the evidence.

When it comes to deciding whether to send a child with BPD to daycare, the task force suggests that this decision should be based on a combination of factors, including local experience, the child's age, the season, and the family's preferences and circumstances. They support the use of inhaled bronchodilators only during acute exacerbations, as we discussed earlier. Additionally, they recommend against treating BPD children with inhaled or systemic corticosteroids and advocate for the weight growth weaning strategy for diuretics.

This comprehensive approach underscores the importance of individualized care for BPD patients. It emphasizes the need to base treatment decisions on evidence-based practices while also considering the unique needs and circumstances of each child and their family. The European Respiratory Society's consensus group also recommended that for children with BPD, supplemental oxygen should be maintained with a minimum saturation target level of 90% until further studies provide more definitive guidance.

Van Hus et al., in a study published in Acta Paediatrica in 2016, examined neurologic outcomes in NICU babies through a multicenter randomized controlled trial. This study involved 176 infants who were either born at less than 32 weeks of gestational age or weighed less than 1,500 grams at birth. The infants were divided into two groups: an intervention group and a control group. Neurological assessments were conducted at 12 and 24 months to evaluate the impact of the intervention on their cognitive and motor development.

The intervention group received seven to nine physical therapy visits in their home, while the control group received standard care. Importantly, if infants in the control group met the criteria for home physical therapy, they still received those visits as part of their standard care. The researchers were able to follow these infants for an impressive 5 1/2 years, which is a substantial duration when studying BPD patients. After this period, they had a good follow-up rate, with 69 and 67 patients remaining in the intervention and control groups, respectively.

The study found that children with BPD who received home physical therapy showed significant benefits in both cognitive and motor domains compared to those who received standard care. The differences observed between the intervention and control groups were quite pronounced, as illustrated in the slides.

This research highlights the importance of recommending outpatient support, such as physical therapy, for children with BPD. Such interventions can have a profound impact on their neurodevelopmental, learning, and cognitive outcomes in the long term, underscoring the need for a comprehensive approach to their care beyond the NICU.

Surfactant Study

The next study, conducted by Hascoet et al. and published in JAMA Pediatrics in 2016, focused on the effects of late surfactant administration in infants with prolonged respiratory distress who remained on ventilators at 36 weeks postmenstrual age and at one year postmenstrual age. This was a double-blind, randomized, controlled trial conducted across 13 centers involving 113 patients. The infants were randomized to receive either 200 mg per kg of surfactant or a syringe filled with air. To maintain blinding, the syringes were weighted the same and covered in light-protective tubing, so those administering the treatment were unaware of whether they were delivering surfactant or air. This careful design aimed to ensure the objectivity of the trial’s outcomes.

The study by Hascoet et al. showed no significant difference in outcomes at 36 weeks postmenstrual age between the two groups. However, the intervention group that received late surfactant administration was associated with reduced respiratory morbidity at one year of age, indicating a potential long-term benefit.

The next study, conducted by Yeh et al. and published in the American Journal of Respiratory and Critical Care Medicine in 2015, was a clinical trial conducted at two neonatal centers in the US and Taiwan. This trial included infants with severe respiratory distress who required mechanical ventilation and had oxygen requirements exceeding 50%. The intervention group received a combination of surfactant and budesonide, while the control group received only surfactant until the infants required 30% or less FiO2 or were extubated.

In this study, Survanta, a specific type of surfactant, was administered every eight hours for up to six doses, following the manufacturer's instructions. The results were significant: the incidence of BPD or death in the intervention group was reduced from 66% in the control group to 42%. This finding suggests that the combination of surfactant and budesonide could be effective in reducing the incidence of BPD or death in infants with severe respiratory distress. The study demonstrated a significant reduction in the incidence of BPD or death when multiple doses of surfactant and budesonide were administered to infants with severe respiratory distress. This treatment was continued until the patients were either extubated or required less than 30% FiO2. The intervention group saw a reduction in the incidence of BPD or death from 66% in the control group to 42%, highlighting the potential effectiveness of this combined therapy in improving outcomes for these high-risk infants.

SUPPORT Trial 2017

The SUPPORT trial, conducted in 2017, was a significant randomized controlled trial that used a multicenter approach to examine the effects of different oxygen saturation (SpO2) targets on preterm infants. The study specifically focused on infants born between 24 and 27 weeks of gestational age and included a large cohort of 1,316 infants. These infants were randomized into two groups with different SpO2 targets: 85-89% and 91-95%.

The trial aimed to determine the association of PaCO2 levels with severe intraventricular hemorrhage (IVH), BPD, and neurodevelopmental outcomes at 18 and 22 months of age. The analysis of blood gases revealed that a higher PaCO2 was an independent predictor of several adverse outcomes, including severe IVH and death, BPD and death, and neurodevelopmental impact and death.

These findings underscore the importance of closely monitoring and managing PaCO2 levels in preterm infants to minimize the risk of these severe complications. The SUPPORT trial provided critical insights into how different oxygenation strategies and PaCO2 levels can influence the long-term outcomes of very preterm infants.

Montelukast Treatment in Severe BPD

The study by Ruprecht et al., published in Respiration in 2014, explored the use of montelukast as a treatment for severe BPD in preterm infants. This unblinded prospective trial included infants between 23 and 27 weeks of gestational age, all of whom were diagnosed with severe BPD. The treatment regimen involved administering montelukast at a dose of 1 mg per kg once daily for the first week, increasing to 1.5 mg per kg in the second week and 2 mg per kg in the third week. Treatment continued until the clinical signs of BPD cleared or the infant was discharged.

The results were quite compelling. The survival rate in the treatment group was 91%, compared to 36% in the non-treatment group, demonstrating a significant survival advantage for those receiving montelukast. Additionally, the treatment group experienced a dramatic reduction in the number of days on mechanical ventilation, from an average of 103 days down to 41 days. This reduction in ventilation days by more than half further highlights the potential effectiveness of montelukast in managing severe BPD and improving outcomes in this vulnerable population.

Hydrocortisone

Renault et al. published a significant study in 2016 that investigated the effects of hydrocortisone on infants born at less than 27 weeks gestational age. The study was conducted between 2005 and 2008 across two centers, with one center administering hydrocortisone to these infants while the other did not. The results were notable: the use of hydrocortisone was associated with a reduction in the incidence of bronchopulmonary dysplasia (BPD). Moreover, at the two-year follow-up, there was no observed neurodevelopmental impairment in the infants who received hydrocortisone, suggesting that this treatment could be both effective and safe in preventing BPD without long-term neurodevelopmental risks.

The following two studies you mentioned are more recent and represent some of the cutting-edge research currently being explored. These studies are part of the ongoing efforts to expand our understanding of BPD prevention and treatment and could shape future approaches to neonatal care.

Mesenchymal Stem Cells

If you haven't heard about mesenchymal stem cells, or MSCs for short, they play a crucial role in lung development. Stem cell dysfunction can hinder the self-repair mechanisms of immature lung tissue, contributing to the development of BPD. Research has shown that the depletion or dysfunction of endogenous or progenitor stem cells can increase the risk of BPD. In animal studies, exogenous stem cells have been found to protect and repair lung injury, partly due to their ability to preserve the pools of endogenous stem cells.

Bone marrow-derived MSCs have shown considerable promise in improving BPD by preventing lung inflammation. What's particularly interesting is that the beneficial effects of MSCs are believed to be primarily hormone-related rather than due to the cells' ability to engraft into lung tissue. The discovery of MSCs in human umbilical cord tissue and cord blood marked a significant advancement, as it provided a clinically relevant and feasible source of these potent cells for the treatment of neonatal diseases, including BPD. This breakthrough opens new avenues for treating BPD and potentially improving outcomes for affected infants. This development opens up new possibilities for treating BPD by harnessing the regenerative potential of MSCs, offering hope for better outcomes in affected infants.

For example, Chang et al., in The Journal of Pediatrics, reported on a phase I trial of human cord blood-derived MSCs successfully conducted in South Korea involving nine extremely preterm neonates. The two-year outcomes from this trial did not reveal any safety concerns, which is encouraging for the continued exploration of this treatment. In the United States, another phase I clinical trial of human umbilical cord blood-derived MSCs has been completed, with a phase II trial currently underway. In this trial, the babies received three doses of MSCs, and it was found that the severity of BPD was lower in those who received the transplant.

Beyond MSCs, other sources of cells are also under investigation. An Australian group has been studying stem-like cells derived from placental membranes, specifically human amnion epithelial cells (HAECs), which have shown therapeutic promise in preclinical models of BPD. This group conducted the first-in-human clinical trial of HAECs in neonates with BPD to assess the safety of these cells. With the exception of one patient who developed respiratory distress attributed to an embolic event, the investigators reported no other adverse events related to the administration of these cells. This suggests that HAECs could be another promising avenue for treating BPD.

Additionally, there is growing interest in the potential role of insulin-like growth factor (IGF-1) in treating BPD. IGF-1, part of the insulin family, is crucial for promoting mitosis, stimulating cell proliferation, and driving DNA synthesis, which are key processes in pulmonary development during both the fetal and postnatal periods. IGF-1 is an important regulator of fetal growth, lung angiogenesis, and overall lung development, making it a potential therapeutic target for improving outcomes in infants at risk of or suffering from BPD. These emerging therapies, including MSCs, HAECs, and IGF-1, represent exciting developments in the quest to better understand and treat BPD, offering new hope for improving the lives of affected infants.

Insulin-like Growth Factor-1

IGF-1 levels increase significantly during the last two trimesters of pregnancy, with a sharp rise that you would clearly see on a graph. After birth, these levels decrease rapidly. In extremely preterm neonates, lower serum IGF-1 levels have been independently associated with an increased risk of BPD and other complications such as retinopathy of prematurity.

In neonatal rodent models, administering IGF-1 appears to reduce lung injury caused by hypoxia, even when the animals are exposed to oxygen. This suggests that IGF-1 could help mitigate some of the damage associated with oxygen therapy, which is often necessary for preterm infants. Several studies have reported that IGF-1 influences BPD development and progression by regulating biological processes related to the disease. Additionally, the exogenous administration of IGF-1 has been shown to alleviate lung inflammation, reduce cell apoptosis, and correct alveolar development disorders in children with BPD.

These findings suggest that IGF-1 could be a promising new target for treating BPD. For instance, recombinant human IGF-1, when combined with its binding protein (known as RH1 GF-1), has been shown to reduce the number of extremely preterm neonates developing severe BPD and shift the disease severity towards a milder form of BPD. This means that even if these infants are born prematurely and require oxygen and positive pressure ventilation, increasing their IGF-1 levels could potentially reduce their risk of developing BPD or at least lead to a milder form of the disease.

The potential of IGF-1 as a therapeutic target is indeed exciting, as it offers a new avenue for improving outcomes in preterm infants who are at high risk of BPD

Limitations

When discussing BPD research, it is important to acknowledge several limitations, particularly the ongoing controversy over meaningful endpoints. One of the biggest questions in the field is determining the appropriate duration for studying patients with BPD. Should research focus only on the period when they are in the NICU, or should it extend to when they leave the PICU, their first outpatient primary care visit, or even further? Some argue that studies should continue until these individuals reach significant life milestones, such as entering kindergarten, graduating from high school, starting their first job, or even until they have children or pass away. The challenge lies in deciding at what point the data collected provides the most meaningful and relevant insights.

Additionally, there are significant gaps in our understanding of long-term clinical outcomes for BPD patients. Specifically, there is limited information on what certain treatments or diagnoses mean for these individuals as they progress into adulthood and geriatrics. For example, how does BPD impact their long-term lung function, overall health, and quality of life? What are the potential late-onset complications? These are critical questions that remain largely unanswered due to the difficulty of conducting long-term studies and the variability in individual outcomes.

The controversy over meaningful endpoints and the scarcity of long-term data make it challenging to develop a comprehensive understanding of BPD and its implications across the lifespan. This highlights the need for continued research that not only addresses immediate outcomes but also tracks patients well into adulthood to provide a fuller picture of how BPD affects long-term health and well-being.

These are critical questions that highlight the complexities and uncertainties in BPD research, particularly regarding the long-term consequences of current treatments. For instance, if patients receive multiple doses of surfactant during infancy, we do not yet know if this could lead to stiffer lungs later in life, potentially contributing to conditions like COPD or emphysema as they age. The long-term pulmonary outcomes for BPD survivors are not well understood, especially as these individuals reach older adulthood, and this remains an area needing further study.

Another area of active discussion in the literature is the role of placental dysfunction as a primary factor in the development of BPD. The relationship between antenatal exposures—such as maternal smoking—and early postnatal events—like neonatal sepsis—has not been fully explored in terms of which has the most significant impact on BPD risk and severity.

There are still many unknowns regarding how these factors interact. For example, if a mother smokes during pregnancy and the infant later develops neonatal sepsis, does the combination of these factors exacerbate the risk of BPD, or does one dominate? Additionally, we need to understand better whether prevention strategies can mitigate these risks or if certain predisposing factors might offset the benefits of interventions aimed at reducing BPD incidence.

These gaps in our knowledge underscore the need for more comprehensive studies that examine the interplay between antenatal exposures, postnatal events, and various treatment strategies. Understanding these relationships could inform better prevention and treatment approaches, potentially leading to improved long-term outcomes for individuals with BPD.

There is still much to learn about the complex and multifactorial nature of BPD. Currently, there is limited research that connects the dots between various factors, such as antenatal exposures, postnatal events, and the development of BPD. Some researchers are now exploring the idea that BPD may actually begin during early fetal life. If this proves to be true, it could revolutionize our understanding of BPD and how we predict its occurrence. For instance, it might be possible in the future to identify babies at risk for BPD through amniotic fluid samples or choriocentesis long before they are exposed to oxygen or positive pressure ventilation. This would represent a significant shift from our current understanding and the traditional definition of BPD, which primarily focuses on postnatal factors.

The fact that we do not fully understand the pathophysiologic mechanisms leading to BPD highlights how complex this condition is. We are gradually learning more, but the pathogenesis of BPD remains highly multifactorial. It involves a wide range of pre and post-natal exposures that influence lung development in ways we do not yet fully comprehend. The interplay between these factors—ranging from genetic predispositions to environmental influences like maternal smoking or neonatal sepsis—makes it challenging to pinpoint a single cause or to develop a one-size-fits-all prevention or treatment strategy.

As research continues to evolve, gaining a deeper understanding of these mechanisms and their interactions will be crucial. It could open the door to new diagnostic tools, early interventions, and personalized treatment approaches that could significantly improve outcomes for infants at risk of or diagnosed with BPD.

The explanation captures the complexity of BPD and how various exposures and factors interact to influence its development. BPD likely involves multiple different pathophysiologies, depending on the timing and combinations of exposures. Some exposures may protect against BPD and promote lung repair, while others may injure the preterm lung and contribute to BPD pathogenesis. This dynamic interaction leads to the clinical manifestations observed, where BPD-typical lungs develop or, alternatively, where lung health is preserved. For those seeking a deeper understanding of BPD, it is essential to address any questions related to the evidence and historical context. 

Questions and Answers

Could you share your thoughts on how the decision to administer antenatal corticosteroids is made, particularly given that it is made before birth?

Certainly. The decision to administer antenatal corticosteroids can vary greatly depending on where you are—whether in different regions of the United States or around the world. The recommendations can differ based on the provider's experience and the specific circumstances of the pregnancy. From what I've seen in the literature, the key takeaway is to administer these steroids early if they are deemed beneficial. However, it is important not to continue administering them after the baby has been in the NICU for three weeks and has been on a ventilator. At that point, the evidence indicates a significant risk of poor neurodevelopmental outcomes, which suggests that it wouldn't be appropriate to continue treatment at that stage.

We discussed how nutrition is crucial for these children. After they leave the hospital or ICU, how long should we continue to monitor their nutritional status? Additionally, how significant is the impact of nutrition on their growth? It seems like these factors are interrelated—almost like a "chicken or the egg" situation. Could you elaborate on that?

Absolutely, that makes perfect sense. I think it is really important to communicate to the families of BPD patients that they are facing significant challenges. A large proportion of these babies—around 65%—are diagnosed with growth failure after they leave the hospital. While we can do a lot to support them nutritionally in the hospital, the resources available at home are often more limited. it is crucial to emphasize to parents that inadequate nutrition could lead to their child needing to be readmitted. We should provide them with resources and guidance to ensure they feel in control. Something as seemingly small as not finishing a full bottle can have a much bigger impact on a child with BPD than on a healthy newborn. If a healthy newborn only takes three ounces instead of six, it might not be a big deal. However, for a child with BPD, that difference can be significant. That is why it is so important to share information and educate families about the challenges they may face. By helping them understand what they are up against, we can better partner with them to ensure their child’s success.

Given all the research you have reviewed, do you believe we’re on the right path toward effectively bridging the gap between the evidence-based recommendations you presented and what we are currently implementing? Considering that change can often be gradual, how do you see this progress unfolding?

I agree that having multiple definitions is something we need to address by working towards a consensus definition that everyone can agree on. However, I understand that it is challenging because we cannot predict the medical advancements that will occur in five or ten years when we set the definition today. Considering the history of how these definitions have evolved and the new treatments we're implementing, it makes sense, but it also complicates determining the best treatment plans. The constant changes and shifting targets make it difficult. That said, it is wonderful to see these babies surviving and thriving—becoming functional toddlers, attending school, and eventually creating families of their own. However, it is crucial that we continue to follow up and support these patients into adulthood and even into their geriatric years. I believe we’re on the right track, but it would be beneficial to see more global collaboration and consensus.

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