Critical care medicine in the United States emerged from the combined activities of 4 specialties: anesthesiology, internal medicine, pediatrics, and surgery. 1 Later, respiratory medicine began to play a strong role. The importance of respiratory medicine in critical care has grown in the United States to the point where many respiratory medicine training programs offer accreditation in both pneumology and critical care medicine. 1 The situation of critical care medicine in European countries is much more complex. 1 Here, particularly in Spain, this specialty has developed without the involvement of respiratory medicine. In the Scandinavian countries and the United Kingdom, anesthetists have been leaders in critical care medicine from the outset, yet in Italy, it can be practiced “legally” only by anesthetists and in Spain (and in the United Kingdom since 2000) it recognized as a specialty in its own right. As early as 2002, the European Respiratory Society (ERS), made reference to obstacles that stood in the way of greater involvement in critical care on the part of respiratory medicine specialists in Europe. 1 A typical pneumology unit in Spain includes a hospital ward, a respiratory endoscopy unit, a lung function laboratory, a sleep unit, and, in some cases, specialized clinics (smoking cessation, pulmonary hypertension, tuberculosis, etc). With few exceptions, however, it does not include units for the treatment of critical respiratory patients. This situation is now beginning to change. The ongoing development of noninvasive ventilation (NIV) has led to increased interest in and use of this technique on the part of our specialists. This has led to our management of care for more complex patients, and this in turn has generated needs that heretofore had been limited to the critical care setting. As a result, pneumology departments in many European countries, including Spain, have begun to incorporate specialized units for monitoring patients with severe disease who require NIV: respiratory intermediate care (or high dependency) units (RICUs). A key argument in favor of RICUs is based on the observation that many patients admitted to conventional intensive care units (ICUs) neither require nor benefit from the large staff or close monitoring that such units provide. Nevertheless, such patients could not be adequately managed on a conventional hospital ward either, and RICUs would therefore be the best place to treat them. According to a European Respiratory Society task force, there were 42 RICUs in Europe as of 2002, and of those, 28 were in Italy and Germany (13 and 15, respectively) and only 1 in Spain. 2 The same task force described 3 levels of care for patients with severe respiratory diseases: the highest level comprised respiratory ICUs; the second highest, the intermediate units, or RICUs; and the lowest level, respiratory monitoring units. In Spain there was only 1 respiratory ICU at the time and the establishment of critical care medicine as a specific specialty makes it unlikely that more will be set up in the short or medium term. The Working Group on Intermediate Respiratory Care of the Spanish Society of Pulmonary and Thoracic Surgery (SEPAR)defines the RICU as an area for monitoring and treating patients with acute or exacerbated chronic respiratory failure caused primarily by a respiratory disease. 3 According to this working group, the objectives of such units are a) cardiorespiratory monitoring or treatment of respiratory failure with NIV; b) continuous monitoring of patients following thoracic surgery and of tracheostomized patients; and c) treatment of critical patients whose weaning from invasive ventilation is difficult. The “ideal” RICU will have to be adjusted to the needs and peculiarities of the particular health care facilities and pneumology departments that create them. It will also need to have specialized nurses and, if possible, physical therapists who are available around the clock, have had experience in applying NIV, and have had sufficient training so that they can apply emergency techniques such as tracheal intubation successfully. 4 RICUs should also contribute to improved cooperation and coordination with other hospital departments. An advantage of a RICU over a conventional ward is that it allows for continuous noninvasive monitoring at a lower nurse-to-patient ratio per shift (1:3 or 1:4). 3 Such care can help to reduce the NIV failure rate. An advantage of a RICU over an ICU is that the intermediate unit can make it possible to avoid unnecessary ICU admissions (thus reducing costs and complications derived from such care) and to deal more effectively with patients who are highly dependent on nursing or rehabilitation care or those who require closer monitoring of a noninvasive nature. 3 RICUs Correspondence: Dr. E. Sala Servei de Pneumologia, Hospital Universitari Son Dueta Andrea Doria, 55 07014 Palma Mallorca, Spain E-mail: esala@hsd.es Manuscript received June 22, 2007. Accepted for publication July 3, 2007. Arch Bronconeumol. 2008;44(1):1-2 1 EDITORIAL Respiratory Intermediate Care Units Ernest Sala Llinàs Servei de Pneumologia, Hospital Universitari Son Dureta, Palma de Mallorca, Fundació Caubet-Cimera Bunyola, Illes Balears, Spain