NLS 5854 Training Using Respiratory Function Monitoring: TF Systematic Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy.

The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none.

The following Task Force members and other authors declared an intellectual conflict of interest, and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees:

• Author Schmölzer has conducted and published articles related to respiratory function monitoring (RFM) during simulation. {Binder 2014 R120, Dvorsky 2023 e2022059839, Law 2024 217, Schmölzer 2011 F254, Schmölzer 2010 F393, Schmölzer 2019 151177, Wagner 2019 e20182441}

• Author Thio has conducted and published studies evaluating RFM in simulation. {Dalley 2024 100535, O'Currain 2019 F582}

These authors were excluded from participation in decisions about inclusion of studies and risk of bias adjudication for the articles that they have authored.

CoSTR Citation

Ramaswamy VV*, Fabres J*, Schmölzer GM, Fuerch JH, Thio M, Szyld E, Sawyer T, Abiramalatha T, Rabi Y, Wyckoff MH, Weiner GM, Liley HG. on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Neonatal Resuscitation Training Using Respiratory Function Monitoring. [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Neonatal Life Support Task Force, [date].  Available from: http://ilcor.org

*Lead co-authors

ILCOR has identified the need for high-quality trials of training interventions that could improve the effectiveness of resuscitation skills of health care professionals (HCPs). Positive pressure ventilation (PPV) through a face mask is a critical skill for resuscitating newly born infants, that must be performed effectively, to avoid harm from underventilation or overventilation. Mask PPV ventilation skills are often poor despite simulation-based training, indicating need for improvement. {Kaufman 2013 , O'Donnell 2005 } Respiratory function monitoring (RFM) may enable trainees to improve their mask PPV skills, {Wood 2008 F380} and could assist their knowledge of importance of face mask leak, airway obstruction and other impediments to effective PPV. When used with manikins in which there are no internal leaks, RFM can measure and display various face mask PPV variables such as leak around the face mask, tidal volume (VT), ventilation rate, peak inflation pressure (PIP) and positive end expiratory pressure (PEEP) in real time and thereby help trainees to improve their knowledge and skills. {Binder 2014 R120, O'Currain 2019 F582, Rød 2022 886775}

There is evidence for use of feedback devices as teaching tools. They have potential to improve motor skills through active experimentation and deliberate practice. As an example of this, a review conducted by the ILCOR Education, Implementation and Training Task Force suggested benefits from use of feedback devices to improve chest compression rate, depth, release, and hand position during cardiopulmonary resuscitation training. {Greif 2020 S222}

The continuous evidence evaluation process for the formulation of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review for which a protocol was registered in PROSPERO (CRD42024514139). {Fabres 2024 } The systematic review team comprised Neonatal Life Support Task Force and content expert group members. The review is complementary to NLS#806 – Respiratory Function Monitoring for Neonatal Resuscitation, which examined the impact of RFMs during infant resuscitations on clinical outcomes. {Fuerch 2022 2666}

Systematic Review

PICOST

Population:  Trainees or health care professionals who receive neonatal resuscitation training.

Intervention: Use of a RFM device during simulation training.

Comparators: No use of a RFM device during simulation training.

Outcomes: 

Training performance (measured in simulation setting):

• Knowledge at training conclusion, up to 1 year and beyond 1 year (important)

• Skill performance at training conclusion, up to 1 year and beyond 1 year (important). Outcomes related to skill performance included mask leak, VT, PIP, ventilation rate, PEEP, time to effective ventilation, duration of sustained effective ventilation, and time to identify and correct any problems with PPV. These outcomes were evaluated at various time points, including during and immediately after the training session, and at various follow-up intervals up to a maximum of three months after the initial training.

Transfer to clinical performance (measured in delivery room (DR) setting):

• Quality of performance in actual resuscitations. (critical)

Clinical outcomes (effectiveness of training in improving clinical outcomes):

• Patient survival (critical)

• Respiratory clinical outcomes during PPV in the DR (important)

• Time to heart rate ≥ 100 beats per minute. (important)

Financial outcomes:

• Cost-effectiveness of using RFM in neonatal resuscitation training (important)

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-RCTs, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion. Unpublished studies (e.g., conference abstracts, trial protocols) were excluded. All relevant publications in any language were eligible for inclusion as long as there was an English abstract.

Timeframe:  From inception of the electronic databases and trial registries searched until 9th May 2025.

PROSPERO Registration CRD42024514139.

EtD Table: NLS NLS 5854 Etd RFM for training for posting on ILCOR Co STR website

Consensus on Science

MEDLINE (via PubMed). Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials (CENTRAL) and trial registries were searched from inception until 9th May 2025. (Appendix) Covidence web-based software was used for screening of studies. After the removal of duplicates, 796 titles and abstracts were screened. Of these, 27 full texts were evaluated for possible inclusion. A total of 16 studies, 3 RCTs {Data 2023 e2022060599, Dvorsky 2023 e2022059839, O'Currain 2019 F582}; 5 cross-over RCTs {Binder 2014 R120, Gurung 2019 , Ikuta 2025 249, Law 2024 217, Ní Chathasaigh 2025 100937}, and 8 non-RCTs, comprising two observational studies with crossover design{Tracy 2024 F535, Wood 2008 F380} and 6 other studies {Dalley 2024 100535, Kelm 2012 583, Loganathan 2025 66, Mazza 2017 e0186731, Ni Chathasaigh 2024 F505, Rød 2022 886775} were included in the systematic review. Most studies used term infant manikins but varied in whether they used a self-inflating bag or T-piece resuscitator.

The risk of bias (RoB) in parallel-design RCTs was assessed using RoB tool version 2.0 and RoB tool 2.0 for cross-over RCTs. {Sterne 2019 } RoB in non-RCTs was evaluated using the Risk Of Bias In Non-Randomized Studies – of Interventions (ROBINS-I) version 1.0. {Sterne 2016 i4919}

Many studies reported medians and interquartile ranges (IQR), as appropriate for data that were not normally distributed, where metanalysis was undertaken, the method of Wan et al. was used to estimate means and standard deviations for comparison purposes. {Wan 2014 135}

Certainty of evidence for all the outcomes was assessed according to Core Grading of Recommendations Assessment, Development and Evaluation (GRADE). {Guyatt 2025 e081903} Random effects meta-analyses were performed using the R-software (Version 2024.12.0+467). Data from cross-over RCTs and studies with before-after designs were combined for meta-analysis after consideration of the domains related to confounding and selection bias. Studies that could not be included in the meta-analyses are presented in a narrative.

The following sub-group analyses were planned a priori:

• Level of participants’ prior experience in neonatal resuscitation

• Level of participants’ prior experience in using RFM

• Type of manikin

• Type of RFM

Use of the modified Credibility of Effect Modification Analyses (ICEMAN) tool was planned for subgroup analyses. {Schandelmaier 2020 }

Despite the apparent simplicity of the intervention and comparator, summarizing the evidence from included studies was challenging due to variations in study design, how the RFM was used in training and outcome measurements. Hence three types of comparisons were evaluated:

Comparison 1: RFM screen was visible to the participants in the intervention group and concealed in the control group during both training and outcome assessment phase. This was addressed in 7 RCTs or crossover trials, {Data 2023 e2022060599, Dvorsky 2023 e2022059839, Ikuta 2025 249, Law 2024 217, Loganathan 2025 66, Ní Chathasaigh 2025 100937, Tracy 2024 F535} of which five could be meta-analysed.

This comparison most directly addressed the PICO question. Although PPV variables were measured using RFM in baseline and study intervention phases, for the purposes of addressing the PICO question, the meta-analysis only combined results from each study from (a final) outcome assessment phase. Among studies included in this comparison, some arms of an included 4-arm study also addressed comparison 3. {Dvorsky 2023 e2022059839}

Comparison 2: RFM screen was concealed during a baseline phase, visible to the participants during a training phase, and concealed again in the outcome measurement phase. The outcome phase was compared to the baseline phase. {Kelm 2012 583, Mazza 2017 e0186731, Ni Chathasaigh 2024 F505, Wood 2008 F380} These single arm studies provided information about transfer of skills from performance in simulation with RFM with screen visible, to performance with RFM with screen concealed, and one study also measured retention of skills a month after training. {Kelm 2012 583}

An additional study evaluated the bundled use of RFM together with instructor feedback. This study assessed whether skills acquired during training with the use of RFM with the screen visible and instructor feedback were transferred to a simulation scenario at follow-up two months later. Trainee performance during a baseline session (prior to the initial training, during which the RFM display was concealed) were compared with those from a follow-up session, in which the RFM display was also concealed. {Rød 2022 886775} Because the interventions were bundled, not evaluated separately, this study is included under Comparison 2 rather than Comparison 3 (Inclusion of instructor feedback).

Comparison 3: Inclusion of instructor feedback: Participants in the intervention group received verbal feedback from an instructor {Dvorsky 2023 e2022059839} or simulated team leader {Binder 2014 R120} to whom an RFM screen was visible, whereas the control group received no verbal feedback. These studies assess a different kind of training intervention, where the RFM was used to augment feedback from a simulated team leader {Binder 2014 R120} or to enhance instructor feedback. {Dvorsky 2023 e2022059839}

The two studies in comparison 3 were very different. One included medical students who were novices in neonatal resuscitation and simulation {Dvorsky 2023 e2022059839} and the other included experienced practitioners. {Binder 2014 R120} Simulation task complexity also varied, with one study examining intubation in preparation for neonatal surgery and combining use of a video-laryngoscope and an RFM {Dvorsky 2023 e2022059839}, while the other studied a scenario in which all manikins were receiving chest compressions. {Binder 2014 R120}

For all comparisons, evidence from both RCTs and non-RCTs was considered. The source with highest certainty of evidence was prioritized. {Guyatt 2025 e081903} None of the included studies evaluating the different comparisons reported any of the pre-specified critical or clinical outcomes in the protocol.

Most studies involved clustering of RFM results for inflations by participant, and in some cases the size and nature of clusters (number of inflations per event recording) may have differed between phases or arms of a study. In some cases, there are other forms of clustering such as repeated measures using the same participants. Because statistical adjustment for clustering was unaddressed or was not reported in individual studies (or the meta-analyses), this may have artificially increased apparent precision. {Roberts 2005 152} This is acknowledged as a limitation of the evidence. 

A single Evidence to Decision framework was formulated for all three comparisons to arrive at recommendations.

Comparison 1: RFM screen visible to the participants in the intervention group and concealed in the control group during both training and outcome assessment phase.

Outcomes

Skill retention at completion of training

Face mask leak (Important)

Evidence from RCTs:

• The use of RFM with screen visible during training probably reduced the mean percentage of mask leak (measured as a proportion of inspired VT) when participants were assessed at the completion of training. Mean mask leak was 43.8% in participants when the RFM screen was concealed and absolute risk difference (ARD) was 21% lower (95% confidence intervals (CI) 32% lower to 9% lower) when the RFM screen was visible in 2 RCTs including 499 participants; moderate certainty evidence, downgraded for serious inconsistency. {Dvorsky 2023 e2022059839, O'Currain 2019 F582}.

Evidence from non-RCTs and cross-over RCTs:

• The use of RFM with screen visible during training probably reduced the mean percentage of mask leak (measured as a proportion of inspired VT). Mean mask leak was 37.2% when the RFM screen was concealed and ARD was 7% lower (95% CI 14% lower to 1% lower) when the RFM screen was visible in 3 non-randomized studies including 108 participants; moderate certainty evidence, downgraded for serious imprecision. {Law 2024 217, Ní Chathasaigh 2025 100937, Wood 2008 F380}

Tidal volume (VT) (Important)

Evidence from RCTs:

The use of RFM with screen visible during training probably increased the delivered VT (measured as expiratory VT in mL). Mean VT was 18.2 mL when the RFM screen was visible vs 14.9 mL when the screen was concealed, (mean difference (MD) 3.5 mL, 95% CI 2.4 mL higher to 4.6 mL higher) in 1 RCT including 388 participants, moderate certainty evidence, downgraded for serious imprecision. {O'Currain 2019 F582}

Peak Inflation Pressure (PIP) (Important)

Evidence from RCTs:

• Benefit or harm could not be ruled out for delivered PIP when the RFM screen was visible (MD was 1.6 cm H2O higher 95% CI 5 1.6 cm H2O lower to 1.7 cm H2O higher) in 2 RCTs including 499 participants, very low certainty evidence, downgraded for very serious inconsistency and serious imprecision. {Dvorsky 2023 e2022059839, O'Currain 2019 F582}

Evidence from non-RCTs:

• The use of RFM with screen visible during training probably did not improve the delivered PIP when compared with use of an RFM with the screen concealed (MD 0.2 cm H2O higher, 95% CI 0 cm H2O to 0.4 cm H2O higher) in 3 non-RCTs including 108 participants, moderate certainty evidence, downgraded for serious imprecision. {Law 2024 217, Ni Chathasaigh 2024 , Wood 2008 F380}

Time to effective ventilation (adequate rate, absence of significant leak and airway blockage), duration of sustained effective ventilation and time to correct airway assessment

One study reported on these outcomes (all outcomes measured in seconds) {Data 2023 e2022060599}

• The use of RFM with screen visible during training probably achieved a faster time to (author defined) effective ventilation, (MD 14 seconds shorter, 95% CI 21 seconds shorter to 7 seconds shorter); a longer period of effective ventilation, (MD 24 seconds longer (95% CI 16 longer to 32 longer),) and a shorter time to correct assessment of airway problems, (MD 12 seconds shorter (95% CI 17 seconds shorter to 7 seconds shorter)) in one RCT including 204 participants, moderate certainty evidence for all three outcomes, downgraded for serious imprecision. {Data 2023 e2022060599}

Skill retention at follow-up (3 months) (important)

The use of RFM with screen visible to participants both during initial training and at follow-up at 3 months was associated with similar mean proportion of mask leak (measured as a proportion of inspired VT) and VTE (in mL) at follow-up when compared to the training phase, in term and preterm manikins in one RCT including 50 participants; low certainty evidence, downgraded for serious risk of bias and serious imprecision. {Dalley 2024 100535}.

Comparison 2: RFM screen concealed during a baseline phase, visible to the participants during a training phase, and concealed again in the outcome assessment phase. The outcome phase was compared to the baseline phase, to measure transfer of skills to performance when no RFM was available.

Transfer of skills, measured at completion of training (important)

Three single arm (pre- and post-training) studies including a total of 463 participants, {Mazza 2017 e0186731, Ni Chathasaigh 2024 F505, Wood 2008 F380} measured this outcome.

Face mask leak (Important)

• The use of RFM during training had inconclusive effects on mean mask leak after training compared to before training, both with RFM concealed (MD; face mask leak as a percentage of inspired VT was 17 % lower, 95% CI 35% lower to 2% higher) in two studies including 437 participants; very low certainty evidence, downgraded for very serious inconsistency and for serious imprecision. {Ni Chathasaigh 2024 F505, Wood 2008 F380}

• The use of RFM during training possibly decreased the proportion of inflations with a mask leak of more than 25% after training compared to before training, both with RFM concealed (MD 27 % of inspired VT lower, 95% CI 29% lower to 25% lower) in one study including 26 participants; very low certainty evidence, downgraded for serious risk of bias and very serious imprecision. {Mazza 2017 e0186731}

Tidal volume (VT) (important)

• The use of RFM during training probably improved delivered VT (or VTE) after training compared to before training, both with RFM concealed (MD 3.7 mL higher, 95% CI 3.1 mL higher to 4.3 mL higher) in one non-RCT including 412 participants; moderate certainty evidence, downgraded for serious risk of bias. {Ni Chathasaigh 2024 F505}

Peak Inflation Pressure (PIP) (important)

• The use of RFM during training probably slightly increased the delivered PIP, after training compared to before training, both with RFM concealed (MD 0.5 cm H2O higher, 95% CI 0.1 cm H2O higher to 0.8 cm H2O higher) in two non-RCTs including 437 participants; moderate certainty evidence, downgraded for serious imprecision. {Ni Chathasaigh 2024 , Wood 2008 F380}

• The use of RFM during training possibly increased the proportion of inflations delivered using a self-inflating bag within a PIP range of 20-35 cm H2O after training compared to before training, both with RFM concealed (MD 20 % higher, 95% CI 18% higher to 23% higher) in one non-RCT including 26 participants; very low certainty evidence, downgraded for serious risk of bias and very serious imprecision. {Mazza 2017 e0186731}

One non-RCT study including 37 participants assessed whether use of RFM improved the proportion of PPV inflations provided using a self-inflating bag to an intubated preterm manikin using an author-defined ‘safe’ range after training compared to before training, both measured with RFM concealed. All three variables changed after training using RFM, in a direction considered by the authors to be favorable.; (VT MD 2.4 mL lower, 95% CI 3.1 mL lower to 1.7 mL lower, PIP MD 11 cm H2O lower, 95% CI 14 cm H2O lower to 8 cm H2O lower, ventilation rate MD 24 inflations per minute faster, 95% CI 38 inflations faster to 10 inflations faster) after training compared to before training, both with RFM concealed; very low certainty evidence, downgraded for very serious risk of bias and very serious imprecision. {Kelm 2012 583}

Skill transfer and retention at follow-up

A single arm study including 10 participants assessed self-inflating bag and mask ventilation on a preterm manikin to measure whether there was transfer from skill training including an RFM with its screen visible and instructor feedback to a simulation scenario 2 months later with neither. {Rød 2022 886775} The study results suggested that optimal transfer and retention were not achieved; the mean proportion of mask leak possibly increased at two months after initial training compared to during training (medians 30% and 70% respectively, MD 38 % of inspired VT higher, 95% CI 36% higher to 40% higher), delivered VT was probably lower at two months after initial training compared to during training (target Vt 4-6 mL/kg, medians 6 and 4 mL/Kg respectively, MD 2 mL/kg lower, 95% CI 2.2 mL/kg lower to 1.8 mL/kg lower), ventilation rate probably increased at two months after when compared to during training, (target 30 inflations/min, medians 32 and 42 inflations per minute respectively, MD 10 per minute higher (95% CI 9 inflations per minute higher to 11 inflations per minute higher), and there were no significant changes in PIP; very low certainty evidence, downgraded for very serious risk of bias and very serious imprecision. {Rød 2022 886775}

Comparison 3: Inclusion of instructor or team leader’s feedback utilising RFM versus no feedback: Two studies were included for this comparison. The first was a crossover study which aimed to determine the best method to train participants to continue to deliver effective PPV via a face mask during chest compressions, using a T-piece device. The participants were neonatologists, registrars and neonatal nurses who were each randomly assigned to the order of four conditions: 1. RFM screen concealed, T-piece manometer concealed, no verbal feedback to participants from a team leader in the simulation, 2. RFM screen visible, T-piece manometer concealed, no verbal feedback, 3. RFM screen concealed, T-piece manometer visible, no verbal feedback, and 4. both the RFM screen and T-piece manometer were concealed, but verbal feedback from team leader who could visualize the RFM screen. In all groups, the manikin was receiving chest compressions. {Binder 2014 R120} This study provided inconclusive evidence as to whether verbal feedback guided by RFM alone when compared to concealed RFM improved face mask leak, VT or PIP (condition 4 vs 1), very low certainty evidence, downgraded for risk bias, inconsistency, indirectness and imprecision by 1-2 levels each. {Binder 2014 R120}

The second study included data from 167 medical students who had little or no prior experience with face mask ventilation or simulation training. {Dvorsky 2023 e2022059839} The simulation scenario was an infant being prepared for surgery, not a newborn requiring resuscitation. The study bundled two interventions, an RFM and a video laryngoscope (VL). The students were randomized to three groups; In group A, the RFM and VL screens were concealed from both participant and instructor. In group B, the RFM and VL screens were visible to the instructor only, who provided verbal advice to the participant. In group C, RFM and VL screens were visible to both the participant and the instructor. Group C achieved the highest proportion of inflations within a VT target range and lowest mean mask leak (during the phase of face mask ventilation, although the percentage of inflations within a target range (4-8 mL/kg) was only 64% and mean mask leak was 34.9%. The study suggested that a visible RFM may improve inflations within a target range and reduce mask leak, with greater improvement when verbal feedback from a supervisor is added; very low certainty evidence, downgraded for risk of bias, inconsistency, indirectness and imprecision by 1-2 levels each.

Cost-effectiveness of RFMs when used as an adjunct in conventional neonatal resuscitation training

No studies reported the cost-effectiveness of using RFM during training on either training outcomes or clinical outcomes.

Sub-group analyses

There were insufficient data reported in any study for any of the preplanned subgroup analyses.

Treatment recommendations

• In training health care providers to perform neonatal resuscitation during simulation with manikins, where resources permit, respiratory function monitoring may be used as an adjunct to improve face mask ventilation skills at the end of training (conditional recommendation, very low certainty evidence).

Justification and Evidence to Decision Framework highlights

• In making this recommendation, the Task Force considered there was moderate certainty evidence for use of RFM in training to improve performance at the completion of training, specifically reduction of face mask leak and improved tidal volume delivery, and low to moderate certainty evidence of improvement in knowledge.

• The evidence was inconclusive in regard to retention of skills, or transfer to a setting where no RFM was available. There was no evidence to confirm whether skills are transferred to clinical resuscitation practice, or to determine whether use of RFM in training improves the outcomes of infants requiring resuscitation.

• A conditional recommendation was made because the resources to include RFM in routine neonatal resuscitation training, and the cost-effectiveness are uncertain. RFM may not be affordable in all locations where neonatal resuscitation is taught.

• None of the studies examined potential adverse outcomes of RFM use in training. These outcomes might include cognitive overload or excessive task load complexity, that could paradoxically lead to reduced overall retention of resuscitation knowledge and skills.

• RFM use in neonatal resuscitation training is probably acceptable to stakeholders, and is probably feasible if resources allow, but effects on equity are unknown.

• The role of feedback from an instructor who can observe an RFM (either with or without visibility of the RFM screen to the trainee) is uncertain.

Knowledge gaps

• The best user-interface and location for display of RFM information

• Whether follow-up with high frequency, short duration reinforcement skill stations using an RFM improve transfer (both to skills without an RFM and to clinical settings) and retention, with or without enhancement by an instructor

• Whether the added cognitive load of having RFM data displayed affects overall operator or team performance during simulation

• Costs and cost-effectiveness of routine use of RFMs in neonatal resuscitation

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