{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T15:02:25Z","timestamp":1786978945338,"version":"build-2736575974"},"reference-count":24,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100014188","name":"Ministry of Science and ICT","doi-asserted-by":"publisher","award":["RS-2025-00514272"],"award-info":[{"award-number":["RS-2025-00514272"]}],"id":[{"id":"10.13039\/501100014188","id-type":"DOI","asserted-by":"publisher"}]},{"award":["RS-2025-00514272"],"award-info":[{"award-number":["RS-2025-00514272"]}],"id":[{"id":"https:\/\/ror.org\/01wpjm123","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Bioengineering"],"abstract":"<jats:p>Background: Manual bag-valve ventilation is a fundamental intervention in prehospital and emergency care but remains highly operator-related and frequently associated with inappropriate tidal volume delivery. Excessive or insufficient ventilation may adversely affect hemodynamics and clinical outcomes. Although real-time tidal volume monitoring has the potential to improve ventilation quality, its measurement performance across different airway conditions has not been sufficiently evaluated. Methods: This simulation-based repeated-measures study evaluated the measurement agreement and reliability of a newly developed tidal volume monitoring device during manual ventilation using an adult airway management manikin. Twenty emergency medical technicians performed bag-valve ventilation across three airway scenarios: face mask ventilation, endotracheal tube (ETT) intubation, and supraglottic airway (I-gel) insertion. For each scenario, 10 repeated breaths were recorded. Tidal volumes measured by the test device were compared with simulator-derived reference values. Measurement agreement was assessed using paired t-tests, Pearson correlation coefficients, effect sizes, and Bland\u2013Altman analysis, while measurement reliability was evaluated using intraclass correlation coefficients (ICC). Mixed repeated-measures ANOVA was performed to examine interaction effects between airway scenario and operator characteristics. Results: The test device consistently overestimated tidal volume compared with the simulator reference across all airway scenarios (p &lt; 0.001). Correlation between measurements was weak during mask ventilation (r = 0.174) but strong during ETT (r = 0.854) and I-gel (r = 0.709) ventilation, whereas Bland\u2013Altman analysis demonstrated wider limits of agreement in mask ventilation and narrower limits under intubated conditions. ICC analysis revealed airway-dependent reliability, with minimal agreement in normal BVM ventilation but substantially higher agreement during ET-tube and I-gel intubation. Significant effects of airway scenario and operator characteristics (gender, age group, and clinical experience level) were observed, with notable interaction effects between airway scenario and clinical experience. Conclusions: Despite systematic overestimation, the tidal volume monitoring device demonstrated consistent and repeatable performance, particularly under secured airway conditions. Its primary clinical value may lie in reducing operator-related variability and supporting safer manual ventilation through real-time feedback, rather than replacing gold-standard measurement systems. Further algorithm refinement and clinical validation are warranted.<\/jats:p>","DOI":"10.3390\/bioengineering13080930","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T13:42:17Z","timestamp":1786974137000},"page":"930","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Agreement and Reliability of a Newly Developed Tidal Volume Monitoring Device in Bag-Valve Ventilation and Intubation Scenarios: A Simulation-Based Study"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0404-7255","authenticated-orcid":false,"given":"Yoonsuk","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Gangwon State, Republic of Korea"},{"name":"Research Institute of Hyperbaric Medicine and Science, Wonju College of Medicine, Yonsei University, Wonju 26426, Gangwon State, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eun Young","family":"Lee","sequence":"additional","affiliation":[{"name":"Office of Medical Research Affairs, Yonsei Wonju Health System, Wonju 26427, Gangwon State, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3254-2261","authenticated-orcid":false,"given":"Hee Young","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Wonju College of Medicine, Yonsei University, Wonju 26426, Gangwon State, Republic of Korea"},{"name":"Research Institute of Hyperbaric Medicine and Science, Wonju College of Medicine, Yonsei University, Wonju 26426, Gangwon State, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/S0300-9572(99)00118-5","article-title":"Effects of smaller tidal volumes during basic life support ventilation in patients with respiratory arrest: Good ventilation, less risk?","volume":"43","author":"Wenzel","year":"1999","journal-title":"Resuscitation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"4521767","DOI":"10.1155\/2016\/4521767","article-title":"Evaluation of bag-valve-mask ventilation in manikin studies: What are the current limitations?","volume":"2016","author":"Khoury","year":"2016","journal-title":"BioMed Res. Int."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"866","DOI":"10.4070\/kcj.2021.0127","article-title":"The 10-year trend of out-of-hospital cardiac arrests: A Korean nationwide population-based study","volume":"51","author":"Roh","year":"2021","journal-title":"Korean Circ. J."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1186\/s13054-020-2773-2","article-title":"The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: A systematic review and meta-analysis","volume":"24","author":"Yan","year":"2020","journal-title":"Crit. Care"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e86","DOI":"10.3346\/jkms.2024.39.e86","article-title":"Spatiotemporal analysis of out-of-hospital cardiac arrest incidence and survival outcomes in Korea (2009\u20132021)","volume":"39","author":"Lee","year":"2024","journal-title":"J. Korean Med. Sci."},{"key":"ref_6","unstructured":"Bucher, J.T., Vashisht, R., and Cooper, J.S. (2025). Bag-valve-mask ventilation. StatPearls, StatPearls Publishing."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"583","DOI":"10.3390\/pathophysiology31040042","article-title":"Pathophysiology and prevention of manual-ventilation-induced lung injury (MVILI)","volume":"31","author":"White","year":"2024","journal-title":"Pathophysiology"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"109994","DOI":"10.1016\/j.resuscitation.2023.109994","article-title":"Effect of stomach inflation during cardiopulmonary resuscitation on return of spontaneous circulation in out-of-hospital cardiac arrest patients: A retrospective observational study","volume":"193","author":"Naito","year":"2023","journal-title":"Resuscitation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"175","DOI":"10.3758\/BF03193146","article-title":"G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences","volume":"39","author":"Faul","year":"2007","journal-title":"Behav. Res. Methods"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.3758\/BRM.41.4.1149","article-title":"Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses","volume":"41","author":"Faul","year":"2009","journal-title":"Behav. Res. Methods"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"S366","DOI":"10.1161\/CIR.0000000000000916","article-title":"Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care","volume":"142","author":"Panchal","year":"2020","journal-title":"Circulation"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"S337","DOI":"10.1161\/CIR.0000000000000918","article-title":"Adult Basic and Advanced Life Support, Pediatric Basic and Advanced Life Support, Neonatal Life Support, Resuscitation Education Science, and Systems of Care Writing Groups. Part 1: Executive summary: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care","volume":"142","author":"Merchant","year":"2020","journal-title":"Circulation"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"115","DOI":"10.1016\/j.resuscitation.2021.02.010","article-title":"European resuscitation council guidelines 2021: Adult advanced life support","volume":"161","author":"Soar","year":"2021","journal-title":"Resuscitation"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"100130","DOI":"10.1016\/j.resplu.2021.100130","article-title":"The impact of introducing real-time feedback on ventilation rate and tidal volume by ambulance clinicians in cardiac arrest simulations","volume":"6","author":"Charlton","year":"2021","journal-title":"Resusc. Plus"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1186\/s13049-019-0674-7","article-title":"Ventilation feedback device for manual ventilation in simulated respiratory arrest: A crossover manikin study","volume":"27","author":"Khoury","year":"2019","journal-title":"Scand. J. Trauma Resusc. Emerg. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e70139","DOI":"10.1111\/ped.70139","article-title":"Comparison of tidal volume and airway pressure during neonatal resuscitation in mask leaks","volume":"67","author":"Takatori","year":"2025","journal-title":"Pediatr. Int."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Santos-Folgar, M., Lafuente-Filgueira, P., Otero-Agra, M., Fernandez-Mendez, F., Barcala-Furelos, R., Trastoy-Quintela, J., Aranda-Garc\u00eda, S., Fern\u00e1ndez-M\u00e9ndez, M., and Rodr\u00edguez-N\u00fa\u00f1ez, A. (2022). Quality of ventilations during infant resuscitation: A simulation study comparing endotracheal tube with face mask. Children, 9.","DOI":"10.3390\/children9111757"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"110584","DOI":"10.1016\/j.resuscitation.2025.110584","article-title":"Effect of different airway devices on ventilation during cardiopulmonary resuscitation","volume":"210","author":"Segond","year":"2025","journal-title":"Resuscitation"},{"key":"ref_19","first-page":"56","article-title":"Supraglottic airway devices: Recent advances","volume":"11","author":"Cook","year":"2011","journal-title":"Contin. Educ. Anaesth. Crit. Care Pain"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"S70","DOI":"10.1097\/00001888-200410001-00022","article-title":"Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains","volume":"79","author":"Ericsson","year":"2004","journal-title":"Acad. Med."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"553","DOI":"10.1016\/j.resuscitation.2014.01.015","article-title":"A randomised controlled trial of prompt and feedback devices and their impact on quality of chest compressions: A simulation study","volume":"85","author":"Yeung","year":"2014","journal-title":"Resuscitation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"110895","DOI":"10.1016\/j.resuscitation.2025.110895","article-title":"Manual bag-valve-mask ventilation during out-of-hospital cardiopulmonary resuscitation: A prospective observational study","volume":"196","author":"Lemoine","year":"2025","journal-title":"Resuscitation"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"100082","DOI":"10.1016\/j.resplu.2021.100082","article-title":"Higher resuscitation guideline adherence in paramedics with use of real-time ventilation feedback during simulated out-of-hospital cardiac arrest: A randomised controlled trial","volume":"5","author":"Lyngby","year":"2021","journal-title":"Resusc. Plus"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1186\/s12245-020-00276-y","article-title":"Manual ventilation quality is improved with a real-time visual feedback system during simulated resuscitation","volume":"13","author":"Gould","year":"2020","journal-title":"Int. J. Emerg. Med."}],"container-title":["Bioengineering"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2306-5354\/13\/8\/930\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T14:11:58Z","timestamp":1786975918000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2306-5354\/13\/8\/930"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":24,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["bioengineering13080930"],"URL":"https:\/\/doi.org\/10.3390\/bioengineering13080930","relation":{},"ISSN":["2306-5354"],"issn-type":[{"value":"2306-5354","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]}}}