Mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS) requires balancing competing physiological goals, including oxygenation, lung protection, and acid-base homeostasis. However, current data-driven methods, especially those imitating retrospective Electronic Health Records (EHR), often suffer from imitation bias. They may capture superficial correlations from inconsistent clinical demonstrations, such as associating passive ventilator settings with survival because such settings are common in stable patients, and thus fail to generalize to volatile or out-of-distribution phenotypes. Standard Reinforcement Learning (RL) methods also struggle with the adversarial trade-offs of critical care and often produce opaque policies with limited clinical interpretability. To address these limitations, we introduce VentAgent, a hierarchical framework in which Large Language Models (LLMs) act as transparent arbitrators for mechanical ventilation. We reformulate ventilation control as a dynamic Multi-Objective Arbitration process rather than single-objective optimization. VentAgent decomposes decision-making into three interpretable stages: Perception, Planning, and Orchestration. By leveraging the semantic reasoning capabilities of LLMs, it synthesizes strategies from heterogeneous experts and resolves conflicting clinical priorities through an explicit coordination mechanism. Evaluations on a high-fidelity physiological simulator show that VentAgent outperforms state-of-the-art RL and classical control baselines. Moreover, it converts control decisions into human-readable reasoning chains, offering a safer, more interpretable, and adaptable paradigm for critical care automation.
Ventilator decision support requires sequential decisions that track evolving physiology and disease trajectories while respecting safety boundaries and clinician specific tuning styles. Rule based approaches rarely generalize personalization, and end to end reinforcement learning or single large language model systems remain difficult to control and audit. We propose the Ventilator Decision Support System (VDSS), a human in the loop multi agent framework that coordinates modular decision components through contract driven structured interfaces and produces traceable evidence for review. VDSS performs online preference adaptation with a contextual bandit, updating clinician specific preferences from the final accepted decision at each adjustment cycle and using them to guide subsequent recommendations. Structured rejection feedback triggers targeted replanning to reduce unproductive iterations and improve interaction stability. Retrospective ICU trajectory replay with expert review indicates higher recommendation acceptability and fewer interaction rounds to reach an acceptable plan, supporting clinically deployable human AI collaboration.
Recent literature shows that large language models (LLMs) are useful for general-purpose tasks yet perform poorly on specific domain ones. One reason is the difficulty of supplying narrow context to a general-purpose model and of bounding the task it is asked to perform. It is possible to hypothesise that a multi-agent reformulation under process-control principles offers a route to address those points, since control theory provides a discipline of decomposing a system into elements of contained scope, each defending one controlled variable, with conflicts resolved by structural priority: MIN/MAX selector networks for CV-CV switching and split-range (split-parallel) logic for MV-MV switching. The present work proposes such a reformulation, derived from Advanced Regulatory Control (ARC) theory. Each feedback loop in the ARC chain is mapped to one specialised LLM operator agent carrying the loop's control-theoretic context (controlled variable, setpoint, chain priority, selector kind). The chain's interaction logic (MIN/MAX selectors, override paths) is encapsulated as a single orchestrator agent. Two orchestrator variants are tested: a deterministic rule chain, and a Claude-based LLM orchestrator at a slower tier. The control principles limit each agent's task and inform how its limitations are handled. The multi-agent system inherits the safety property of the ARC chain: every constraint conflict is resolved deterministically by the orchestrator, regardless of the LLM output. Evaluated on a dairy-barn ventilation case over a 4-day mixed-season scenario, Qwen 2.5 7B Instruct operator agents running offline on a 24 GB consumer GPU at a 5-minute cadence produce auditable trajectories, each paired with an operator-voice rationale that supports a control campaign logbook.
Sepsis management in the ICU requires sequential treatment decisions under rapidly evolving patient physiology. Although large language models (LLMs) encode broad clinical knowledge and can reason over guidelines, they are not inherently grounded in action-conditioned patient dynamics. We introduce SepsisAgent, a world model-augmented LLM agent for sepsis treatment recommendation. SepsisAgent uses a learned Clinical World Model to simulate patient responses under candidate fluid--vasopressor interventions, and follows a propose--simulate--refine workflow before committing to a prescription. We first show that world-model access alone yields inconsistent LLM decision performance, motivating agent-specific training. We then train SepsisAgent through a three-stage curriculum: patient-dynamics supervised fine-tuning, propose--simulate--refine behavior cloning, and world-model-based agentic reinforcement learning. On MIMIC-IV sepsis trajectories, SepsisAgent outperforms all traditional RL and LLM-based baselines in off-policy value while achieving the best safety profile under guideline adherence and unsafe-action metrics. Further analysis shows that repeated interaction with the Clinical World Model enables the agent to learn regularities in patient evolution, which remain useful even when simulator access is removed.