Highlights
In an eight-bed brain-dead donor care ICU, all routine respiratory therapy care, including ventilator management, was delivered remotely over 12 months using a telecritical care platform.
Remote respiratory therapists completed 3,872 procedures and provided 1,782 hours of care, while in-person support accounted for only 119 hours, or 6.1% of total respiratory therapy time.
No airway losses, emergency respiratory therapy activations, cardiac arrests, delays in care, or deaths attributable to remote respiratory management were reported.
The model was associated with an estimated reduction of 2.2 full-time equivalent respiratory therapist positions and $306,952 in avoided labor costs, while donor organ recovery remained favorable, with an observed-to-expected recovery ratio of 1.19.
Background
Mechanical ventilation is foundational to modern intensive care, but skilled bedside respiratory therapy staffing is increasingly difficult to maintain, particularly in highly specialized or geographically centralized critical care environments. Donor management is one such environment. Brain-dead organ donors require protocolized ventilator care, bronchoscopy support, airway suctioning, recruitment maneuvers, oxygenation assessment, transport coordination, and rapid response to changes in pulmonary mechanics. At the same time, these units often operate with small patient volumes, atypical workflows, and a narrow mission focused on preserving transplantable organs rather than conventional ICU recovery.
These operational realities make donor care units a useful setting in which to test remote respiratory therapy. Telecritical care programs have expanded for intensivist oversight, nursing support, and continuous monitoring, but comprehensive remote respiratory therapy, especially direct ventilator management, remains uncommon. One reason is technical: safe remote ventilator interaction requires robust audiovisual systems, reliable data transmission, and secure device interfacing. Another is regulatory: policies governing remote access to life-support equipment remain underdeveloped. The study by Ghio and colleagues therefore addresses an important implementation question at the intersection of critical care operations, respiratory care, and organ donation systems.
The clinical stakes are substantial. Donor lung management influences oxygenation, infection control, atelectasis prevention, and ultimately organ utilization. Prior donor management research has shown that protocol-driven ventilator strategies and expert critical care oversight can improve donor lung procurement and broader organ recovery. If remote respiratory therapy can deliver equivalent safety and process performance while reducing staffing burden, it may offer a scalable workforce solution not only for donor centers but potentially for selected ICU settings with predictable respiratory workflows.
Study Design
Structure and setting
This was a prospective observational study conducted from October 2023 through October 2024 in a dedicated eight-bed brain-dead donor care ICU. The unit used a telecritical care platform with real-time audiovisual monitoring and remote ventilator interface capability, allowing respiratory therapists to assess patients continuously and directly manage ventilator settings from a remote location.
Population
The study included 182 organ donors managed during the 12-month study period. Because the setting was a donor care ICU, the patient population was highly specialized and relatively homogeneous compared with a general medical-surgical ICU.
Intervention
The intervention was comprehensive remote respiratory therapy, described by the authors as including full ventilator management and procedural support. Remote respiratory therapists delivered all routine respiratory care. In-person respiratory therapy support remained available when needed, particularly for functions that still required bedside physical presence, such as transport-related tasks and advanced airway interventions.
Outcomes assessed
The investigators evaluated feasibility, safety, and operational impact. Recorded measures included procedural workload, in-person respiratory therapist utilization, adverse safety events, donor outcomes, and full-time equivalent labor requirements. The study did not include a concurrent bedside respiratory therapy control group; rather, the analysis was descriptive and implementation-focused.
Key Findings
Procedural volume and remote workload
During the study period, the remote respiratory therapy team completed 3,872 respiratory procedures, representing 1,782 hours of remote care. This level of activity suggests that the intervention was not limited to passive monitoring or occasional consultation. Instead, the program functioned as a fully operational respiratory therapy service, with routine responsibility for ventilator management and other respiratory tasks.
For clinicians assessing feasibility, this is one of the study’s most important observations. Many tele-ICU interventions appear workable only because bedside clinicians still perform the majority of tasks. Here, the reported workflow indicates that remote staff handled the bulk of respiratory care, implying a genuine substitution model rather than an adjunct-only model.
Need for in-person respiratory therapist support
In-person respiratory therapy support totaled 119 hours, which accounted for only 6.1% of overall respiratory therapy time. The need for bedside assistance was concentrated in areas where hands-on presence remains inherently necessary, especially transport and advanced airway procedures.
This division of labor is clinically intuitive and operationally valuable. It suggests that remote respiratory therapy can absorb most cognitive, monitoring, and device-management tasks, while a smaller on-demand bedside workforce covers tasks that cannot be virtualized. Such a model may be especially attractive in resource-constrained systems or specialty units that cannot justify continuous onsite respiratory therapist presence.
Safety outcomes
No airway losses, emergency respiratory therapy activations, cardiac arrests, or delays in care were reported. In the context of remote ventilator management, these are reassuring findings. Airway security and rapid recognition of deterioration are the core safety concerns that often limit enthusiasm for virtual respiratory care. The absence of these events does not prove equivalence to conventional bedside care, but it strongly supports implementation feasibility within this controlled environment.
The reported safety profile also implies effective escalation pathways. A successful remote respiratory therapy service depends not only on remote expertise and technology but also on clear criteria for bedside deployment. The low but targeted use of in-person support suggests that the program identified these thresholds appropriately.
Donor and organ recovery outcomes
The unit procured 520 organs during the study period. The observed-to-expected recovery ratio was 1.19, indicating organ recovery performance above expected benchmarks. Although this metric cannot be attributed solely to respiratory therapy, it is a clinically meaningful signal that the remote care model did not compromise the donor management mission.
This matters because donor care quality is judged not only by the absence of adverse events but by preservation of transplantable organ function. Ventilator strategy, secretion management, oxygenation, and pulmonary recruitment directly affect lung suitability and indirectly reflect broader quality of ICU care. Favorable organ recovery in this study supports the idea that remote respiratory therapy can be integrated into high-performance donor management systems without obvious degradation in outcomes.
Staffing and economic impact
The operational impact was substantial. The authors estimated savings of 2.2 full-time equivalent respiratory therapist positions and $306,952 in avoided labor costs. Given persistent respiratory therapy workforce shortages in many hospitals, these data may be as influential as the clinical outcomes.
However, the economic interpretation should remain measured. Avoided labor cost is not the same as net savings. Telecritical care platforms require capital investment, technical support, cybersecurity measures, licensing compliance, and often dedicated command-center staffing. The article abstract does not provide a full cost-effectiveness analysis, so the reported figure is best understood as direct labor offset rather than comprehensive budget impact. Even so, this magnitude of labor reduction is notable for a small eight-bed unit.
Clinical Interpretation
Why this model likely worked in a donor care ICU
The donor center ICU is unusually well suited for remote respiratory therapy. Patients are intubated, closely monitored, and managed according to standardized donor optimization pathways. Clinical goals are clear, turnover is structured, and unexpected rehabilitation-oriented decisions are absent. This reduces some of the variability seen in general ICUs and makes remote protocol-driven management more practical.
In addition, the telecritical care platform offered two capabilities that are essential for success: real-time audiovisual monitoring and remote ventilator interface access. Many hospitals have tele-ICU cameras, but far fewer have secure, interactive access to respiratory devices. The latter is what transforms virtual observation into active respiratory care delivery.
Relevance to the broader ICU workforce crisis
This study speaks directly to staffing fragility in critical care. Respiratory therapists are indispensable across emergency departments, ICUs, transport teams, and procedural areas. Remote models may help hospitals deploy experienced therapists across multiple sites, reserve bedside presence for procedures and unstable transitions, and extend specialty expertise into lower-volume units.
Still, generalization should be cautious. A donor center ICU is not a typical mixed ICU with agitated patients, frequent extubations, bedside proning, noninvasive ventilation troubleshooting, family communication demands, and rapid shifts in goals of care. The closer a unit resembles the donor care setting in terms of standardization and procedural predictability, the more transferable this model may be.
Regulatory and technical implications
The authors appropriately emphasize the need for regulatory pathways enabling secure remote ventilator access. This may be the most important systems-level message in the paper. Remote interaction with a life-support device raises questions about device authorization, responsibility assignment, cybersecurity, alarm management, documentation, licensure across jurisdictions, and contingency planning during connectivity loss.
As telecritical care matures, policymakers and hospital leaders will need standards that distinguish passive viewing from active remote control. Any future expansion of remote ventilator management should include device-specific validation, downtime procedures, competency frameworks, and audit mechanisms.
Strengths and Limitations
Strengths
The study’s main strengths are its prospective design, real-world implementation setting, and highly practical outcome measures. Rather than focusing on narrow physiological endpoints, the investigators assessed the issues administrators and ICU leaders actually need to know: How much work can be done remotely, when bedside help is still needed, whether safety events occur, and what staffing savings are plausible.
Another strength is that the intervention was comprehensive. The program did not merely add remote expertise to a fully staffed bedside team. It substantially replaced onsite respiratory therapy labor, making the findings more actionable for operational planning.
Limitations
The limitations are equally important. First, this was a single-center observational study without a contemporaneous comparator group. It cannot establish that remote respiratory therapy is superior or noninferior to conventional bedside staffing. Second, the specialized donor population limits external validity. Third, the abstract does not report granular donor characteristics, ventilator parameters, procedure mix, or subgroup outcomes such as lung procurement rates, donor PaO2/FiO2 trajectories, or time-to-intervention metrics.
Fourth, the absence of major adverse events is reassuring but should be interpreted in the context of sample size. Rare safety problems may not emerge in 182 donors. Fifth, the labor-cost estimate does not fully capture the broader economics of telecritical care infrastructure. Finally, the success of this model likely depended on local workflow design, culture, escalation policies, and technical integration, all of which can be difficult to reproduce.
Practice Implications
For centers considering a similar model, several operational lessons can be inferred. First, remote respiratory therapy is most viable when patient selection and workflow are standardized. Second, technology must allow not only monitoring but secure, responsive device interaction. Third, escalation criteria for bedside deployment should be explicit, especially for transport, airway procedures, and sudden instability. Fourth, continuous quality surveillance is essential, including tracking alarm response time, unplanned bedside interventions, ventilator-associated events, and organ recovery metrics.
This work may also encourage broader thinking about remote allied health practice in intensive care. As hospitals invest in telecritical care platforms, remote respiratory therapy could become one component of a larger virtual support ecosystem that includes intensivists, pharmacists, nurses, and data specialists. The donor ICU may serve as a proof-of-concept environment before expansion into stepwise applications in other ICU populations.
Conclusion
Ghio and colleagues provide compelling early evidence that comprehensive remote respiratory therapy, including full ventilator management, can be safely implemented in a dedicated donor care ICU. The program handled nearly all respiratory care remotely, required only limited bedside respiratory therapist support, produced no reported major respiratory safety events, and was associated with meaningful labor savings. Organ recovery performance remained favorable, suggesting that the donor management mission was preserved.
The study does not settle whether remote respiratory therapy should replace bedside staffing in broader ICU practice, but it clearly establishes that such a model is feasible in a tightly organized donor center environment. The next steps are multicenter validation, more detailed outcome reporting, formal economic evaluation, and regulatory progress on secure remote access to life-support devices. For critical care leaders confronting workforce shortages, this study offers a practical and increasingly relevant model of how telecritical care can move from oversight to direct therapeutic delivery.
Funding and Trial Registration
No funding source or ClinicalTrials.gov registration number is provided in the abstract.
References
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