Assessing respiratory muscle effort during noninvasive respiratory support in acute hypoxemic respiratory failure: A State-of-the Art Review from physiology to bedside
3
Issued Date
2026-12-01
Resource Type
ISSN
09643397
eISSN
15324036
Scopus ID
2-s2.0-105043757076
Journal Title
Intensive and Critical Care Nursing
Volume
97
Rights Holder(s)
SCOPUS
Bibliographic Citation
Intensive and Critical Care Nursing Vol.97 (2026)
Suggested Citation
Fazzini B., Tonelli R., Gosselink R., Lucchini A., Galazzi A., Swingwood E., Marti D., Rezoagli E., Paulus F., Schultz M.J., Rocco P.R.M., Battaglini D. Assessing respiratory muscle effort during noninvasive respiratory support in acute hypoxemic respiratory failure: A State-of-the Art Review from physiology to bedside. Intensive and Critical Care Nursing Vol.97 (2026). doi:10.1016/j.iccn.2026.104490 Retrieved from: https://repository.li.mahidol.ac.th/handle/123456789/117895
Title
Assessing respiratory muscle effort during noninvasive respiratory support in acute hypoxemic respiratory failure: A State-of-the Art Review from physiology to bedside
Author's Affiliation
Universiteit van Amsterdam
Universidade Federal do Rio de Janeiro
Università degli Studi di Genova
Medizinische Universität Wien
Stellenbosch University
Università degli Studi di Milano-Bicocca
Hospital Clínic de Barcelona
KU Leuven– University Hospital Leuven
Barts and The London School of Medicine and Dentistry
IRCCS Azienda Ospedaliera Metropolitana
University of the West of England
Nuffield Department of Medicine
The Royal London Hospital
Fondazione IRCCS San Gerardo dei Tintori
Azienda Ospedaliero - Universitaria di Modena
Kantonsspital St.Gallen
University Hospitals Bristol and Weston NHS Foundation Trust
Mahidol Oxford Tropical Medicine Research Unit
Hogeschool van Amsterdam, University of Applied Sciences
Departement Revalidatiewetenschappen
Università LUM
Universidade Federal do Rio de Janeiro
Università degli Studi di Genova
Medizinische Universität Wien
Stellenbosch University
Università degli Studi di Milano-Bicocca
Hospital Clínic de Barcelona
KU Leuven– University Hospital Leuven
Barts and The London School of Medicine and Dentistry
IRCCS Azienda Ospedaliera Metropolitana
University of the West of England
Nuffield Department of Medicine
The Royal London Hospital
Fondazione IRCCS San Gerardo dei Tintori
Azienda Ospedaliero - Universitaria di Modena
Kantonsspital St.Gallen
University Hospitals Bristol and Weston NHS Foundation Trust
Mahidol Oxford Tropical Medicine Research Unit
Hogeschool van Amsterdam, University of Applied Sciences
Departement Revalidatiewetenschappen
Università LUM
Corresponding Author(s)
Other Contributor(s)
Abstract
Objectives: Respiratory muscle effort is an important determinant of pathophysiology and clinical outcomes in patients with acute hypoxemic respiratory failure receiving noninvasive respiratory support (NIRS). Excessive effort reflects an imbalance between ventilatory load and muscle capacity and has been associated with patient self-inflicted lung injury, treatment failure, and worse outcomes, particularly when escalation to invasive ventilation is delayed. This review provides a clinically focused synthesis of the physiological determinants, bedside assessment, and practical implications of respiratory muscle effort during NIRS. Methods: We included physiological, translational and clinical studies evaluating the assessment and clinical implications of respiratory muscle effort in patients with AHRF receiving NIRS. Evidence was selected to emphasize clinical applicability and bedside relevance. Results: Clinical signs and simple indices remain essential for early detection of increased respiratory effort but lack specificity. They are widely available, scalable, and low-cost, although they require clinical experience for accurate interpretation. Advanced monitoring—including oesophageal pressure measurement, respiratory muscle ultrasound, and electrical impedance tomography—provides physiological insight but is variably available, more resource-intensive, and requires expertise.A tiered approach to monitoring, integrating scalable bedside assessment with selective use of advanced tools, may represent a pragmatic framework for clinical implementation. NIRS modalities—including high-flow nasal oxygen, continuous positive airway pressure, and bilevel ventilation—affect respiratory effort through distinct mechanisms and may fail to adequately unload respiratory muscles if not carefully titrated. Persistently elevated effort may occur despite acceptable oxygenation and is associated with clinical deterioration. Conclusions: Respiratory muscle effort should be considered a key component of patient assessment during NIRS. Structured and repeated evaluation using a combination of clinical signs and, when available, advanced monitoring, may help identify harmful breathing patterns and support timely escalation of care.Future research should prioritise pragmatic monitoring strategies, actionable thresholds, and integration into routine practice across diverse healthcare settings. Implications for clinical practice: Routine assessment of respiratory effort, integrating clinical observation with available monitoring tools, may improve titration of respiratory support, reduce the risk of delayed intubation, and support more individualized care in patients with AHRF. Embedding a tiered, feasibility-informed approach to respiratory effort monitoring may enhance translation from physiological insight to routine bedside care.