- CRT credential
- Certified Respiratory Therapist — the NBRC entry-level credential earned by passing the TMC Exam at the low cut score.
- RRT credential
- Registered Respiratory Therapist — earned by passing the TMC at the high cut score AND passing the Clinical Simulation Examination (CSE).
- TMC Exam
- Therapist Multiple-Choice Examination — 160 items (140 scored + 20 pretest) in 3 hours; one exam, two cut scores (CRT low, RRT-eligibility high).
- CRT vs RRT cut score
- Low cut earns the CRT; high cut earns the CRT plus eligibility for the CSE toward the RRT.
- CoARC
- Commission on Accreditation for Respiratory Care — accredits the degree programs whose graduates are eligible to sit NBRC exams.
- 5-step ABG method
- pH (direction) → PaCO2 (respiratory) → HCO3 (metabolic) → match the value moving with the pH → assess compensation.
- Normal pH range
- 7.35–7.45; below is acidemia, above is alkalemia.
- Normal PaCO2
- 35–45 mm Hg; high = respiratory acidosis driver, low = respiratory alkalosis driver.
- Normal HCO3
- 22–26 mEq/L; low = metabolic acidosis driver, high = metabolic alkalosis driver.
- Respiratory acidosis
- Low pH (< 7.35) with a high PaCO2 (> 45) from hypoventilation — COPD, sedation, neuromuscular weakness.
- Respiratory alkalosis
- High pH (> 7.45) with a low PaCO2 (< 35) from hyperventilation — anxiety, pain, pulmonary embolism, hypoxia.
- Metabolic acidosis
- Low pH (< 7.35) with a low HCO3 (< 22) — DKA, lactic acidosis, renal failure, diarrhea.
- Metabolic alkalosis
- High pH (> 7.45) with a high HCO3 (> 26) — vomiting, diuretics, nasogastric suction.
- Acute vs chronic respiratory acidosis
- Acute = high PaCO2 with a near-normal HCO3 (no compensation); chronic = high HCO3 pulling pH toward normal (COPD baseline).
- ABG pH 7.30 / PaCO2 58 / HCO3 27
- Acute (uncompensated) respiratory acidosis — low pH, high PaCO2, near-normal HCO3.
- Anion gap
- Na − (Cl + HCO3), normally ~8–12 mEq/L; a high gap signals unmeasured acids (ketoacids, lactate).
- Anion gap: Na 140, Cl 100, HCO3 10
- 140 − (100 + 10) = 30 — a high-anion-gap metabolic acidosis (e.g., DKA).
- Winter's formula
- Expected PaCO2 for a metabolic acidosis ≈ 1.5 × HCO3 + 8 (±2); checks adequate respiratory compensation.
- Winter's formula: HCO3 14
- 1.5 × 14 + 8 = 29 mm Hg — the expected PaCO2 if the lungs are compensating appropriately.
- Fully compensated chronic respiratory acidosis
- Near-normal pH (e.g., 7.38) with a high PaCO2 (60) and a high HCO3 (35) — the stable COPD pattern.
- P/F ratio
- PaO2 ÷ FiO2 (decimal); Berlin ARDS severity — 200–300 mild, 100–200 moderate, ≤100 severe (PEEP ≥ 5).
- P/F ratio: PaO2 60 on FiO2 0.60
- 60 ÷ 0.60 = 100 — moderate-to-severe oxygenation impairment.
- A–a gradient
- Alveolar PO2 minus arterial PaO2; normal with hypoxemia = hypoventilation, widened = gas-exchange problem (V/Q mismatch, shunt, diffusion).
- Normal A–a gradient with hypoxemia
- Points to pure alveolar hypoventilation — a ventilation (CO2) problem, not a gas-exchange defect.
- Carboxyhemoglobin
- Hemoglobin bound to carbon monoxide; can't carry O2 and is missed by pulse oximetry (falsely normal SpO2) — use CO-oximetry.
- CO poisoning treatment
- 100% oxygen by nonrebreather to speed CO elimination; hyperbaric oxygen in severe cases.
- Methemoglobin
- Ferric (Fe3+) hemoglobin that can't bind oxygen; cyanosis with SpO2 stuck near 85% that doesn't improve on O2 — detect by CO-oximetry.
- Normal carboxyhemoglobin (nonsmoker)
- About 1–2% is a normal baseline in a healthy nonsmoker; higher in smokers.
- Capnography
- Continuous exhaled-CO2 measurement; a normal square waveform after intubation confirms tracheal placement.
- Sudden ETCO2 rise during CPR
- Indicates return of spontaneous circulation as pulmonary blood flow is restored.
- Increased alveolar dead space sign
- A widened gap between end-tidal CO2 (e.g., 30) and arterial PaCO2 (e.g., 42), as in pulmonary embolism.
- FEV1/FVC ratio
- Fraction of FVC exhaled in 1 second; below ~0.70 defines an obstructive pattern (asthma or COPD).
- Obstructive PFT pattern
- Reduced FEV1/FVC ratio with a normal or increased total lung capacity (air trapping).
- Restrictive PFT pattern
- Normal or high FEV1/FVC ratio but a reduced total lung capacity — confirm with lung volumes.
- Significant bronchodilator response
- FEV1 improves ≥12% AND ≥200 mL after a bronchodilator (reversible obstruction = asthma).
- DLCO
- Single-breath diffusing capacity; low when gas-exchange surface is lost (emphysema, interstitial, pulmonary vascular disease).
- DLCO: emphysema vs asthma
- Low in emphysema (alveolar wall destruction) but normal or high in asthma — helps separate the two.
- Functional residual capacity (FRC)
- Volume of gas left in the lungs after a normal resting exhalation (ERV + RV).
- Elevated residual volume, normal TLC
- Indicates air trapping and hyperinflation from obstructive disease.
- Air bronchogram
- Air-filled bronchi outlined within consolidated (fluid-filled) alveoli on a chest film.
- Tension pneumothorax signs
- Absent breath sounds, tracheal deviation away from the affected side, hypotension — a respiratory emergency.
- Fine late-inspiratory crackles
- Discontinuous popping sounds at end-inspiration, as in pulmonary edema or fibrosis.
- Wheeze vs rhonchus
- Wheezes are high-pitched and musical; rhonchi are low-pitched, snore-like, and often clear with secretion mobilization.
- Stridor
- High-pitched crowing heard mainly on inspiration, localizing to upper-airway obstruction (e.g., epiglottitis, post-extubation edema).
- Mallampati classification
- Predicts intubation difficulty by visible oropharyngeal structures; Class I favorable, Class III–IV potentially difficult.
- APGAR scoring times
- Assigned at 1 and 5 minutes after birth (with continued scoring if the neonate is depressed).
- Auto-PEEP
- Trapped intrinsic PEEP from incomplete exhalation; total PEEP minus set PEEP on an expiratory-hold maneuver.
- Auto-PEEP: total 12, set 5
- 12 − 5 = 7 cm H2O of auto-PEEP — reduce it by lengthening expiratory time.
- Dynamic compliance formula
- Tidal volume ÷ (peak pressure − PEEP); e.g., 500 mL ÷ (30 − 5) = 20 mL/cm H2O.
- Plateau pressure
- Measured during an inspiratory hold (no flow); reflects compliance and is kept < 30 cm H2O to limit lung injury.
- 6-minute walk test
- An objective marker of functional exercise capacity; terminate and assess the patient for severe dyspnea or desaturation.
- Hyperkalemia on ECG
- Peaked T waves, a widened QRS, and a flattened P wave — a can't-miss electrolyte emergency.
- Low-flow oxygen device
- Cannula, simple mask, nonrebreather — flow is below total inspiratory demand, so FiO2 varies with the breathing pattern.
- High-flow oxygen device
- Venturi mask, high-flow nasal cannula — flow meets or exceeds demand, giving a fixed, predictable FiO2.
- Nasal cannula FiO2 rule
- Roughly 4% per liter from 1–6 L/min (~24–44% FiO2); a low-flow, variable device.
- Air-entrainment (Venturi) mask
- Sets a precise FiO2 by jet size and entrainment ports; raising the set FiO2 LOWERS total flow (less entrainment).
- Venturi mask high-demand pitfall
- At a high set FiO2 the lower total flow may not meet a febrile, tachypneic patient's demand — entrains extra room air.
- Heated high-flow nasal cannula
- Heated, humidified gas up to ~60 L/min; flushes nasopharyngeal dead space and adds a small PEEP-like effect.
- Nonrebreather bag collapsing on inspiration
- Flow is too low — raise it until the reservoir bag stays partially inflated.
- Oxygen concentrator output
- A stationary unit delivers at least roughly 90% oxygen; it is electrically powered, so loss of power halts output.
- Cylinder duration formula
- Minutes = cylinder factor × gauge pressure (psig) ÷ flow (L/min); H factor ≈ 3.14, E factor ≈ 0.28.
- H-cylinder: 2200 psig at 8 L/min
- (3.14 × 2200) ÷ 8 ≈ 860 minutes of oxygen available.
- E-cylinder: 1200 psig at 5 L/min
- (0.28 × 1200) ÷ 5 ≈ 67 minutes — adequate for a 45-minute transport with a small margin.
- Safe cylinder residual pressure
- Change a cylinder at about 200–500 psig rather than running it to empty.
- Back-pressure-compensated Thorpe tube
- Float sits downstream of the needle valve, so a downstream restriction does not falsely lower the flow reading.
- Bourdon-gauge flowmeter
- Position-independent (works in any orientation), making it ideal for transport; reads pressure, not true flow against a restriction.
- Reading a non-rotating skirted float
- Read the flow at the top flat surface of the float.
- Air-oxygen blender check
- Verify FiO2 downstream in the delivered gas; a blender reading 1.0 across the range is faulty — remove it from service.
- Spaulding: critical items
- Enter sterile tissue or the bloodstream (surgical instruments) — must be STERILIZED.
- Spaulding: semicritical items
- Contact mucous membranes or non-intact skin (reusable laryngoscope blade) — at least HIGH-LEVEL DISINFECTION.
- Spaulding: noncritical items
- Touch only intact skin (BP cuff, ventilator surface) — LOW- or intermediate-level disinfection.
- Airborne precautions
- Negative-pressure room + fit-tested N95 for pathogens in small droplet nuclei — tuberculosis, measles, varicella.
- Droplet precautions
- A surgical mask for larger respiratory droplets — influenza, pertussis.
- Contact precautions
- Gown and gloves for spread by touch — MRSA, C. difficile.
- Suspected active pulmonary TB
- Place in a negative-pressure airborne infection isolation room and wear a fit-tested N95 or higher.
- PPE donning order
- Gown, then respirator (mask), then eye protection, then gloves.
- First step after removing PPE
- Perform hand hygiene immediately after doffing gloves and gown.
- VAP prevention bundle
- Head of bed 30–45°, sedation interruption, oral care, and stress-ulcer plus VTE prophylaxis as appropriate.
- Closed (in-line) suction benefit
- Suction without disconnecting the circuit — less contamination and less loss of PEEP/oxygenation.
- Blood gas analyzer two-point calibration
- Sets both the offset (zero) and the slope of each electrode across the measuring range.
- Levey–Jennings chart
- Plots daily quality-control values around the mean to spot shifts and trends in analyzer performance.
- QC shift vs trend
- A shift is an abrupt jump to one side of the mean (new reagent lot); a trend is a gradual drift (aging electrode).
- Out-of-range QC result
- Hold patient results, troubleshoot and correct the analyzer, then repeat the control before reporting.
- Precise but not accurate
- Results are tightly grouped (reproducible) but consistently off the true value — a calibration problem.
- PO2 electrode membrane
- The oxygen channel reads erroneously when the semipermeable membrane through which O2 diffuses to the cathode is damaged.
- Metered-dose inhaler with spacer technique
- One puff at a time with a slow, deep inhalation; inhaling too fast triggers the spacer's flow whistle.
- Dry-powder inhaler technique
- A quick, forceful, deep inhalation creates the turbulence that disperses the powder; keep it dry (moisture clumps it).
- DPI in severe asthma
- May fail because severe bronchospasm lowers inspiratory flow below what the device needs to aerosolize the dose.
- Oxygen titration goal
- Use the lowest flow that keeps SpO2 in the ordered target range (commonly 92–96%), correcting tissue hypoxia.
- Hypoxemia from hypoventilation
- Oxygen corrects the hypoxemia but does not fix the inadequate ventilation — address the cause (e.g., reverse sedation, support ventilation).
- Cannula maxed out, still hypoxemic
- Switch to a higher-concentration device such as a mask system rather than pushing cannula flow higher.
- Nasal cannula at 1 L/min FiO2
- About 0.24 (24%) using the common low-flow estimation rule.
- Tachypnea and effective FiO2
- A fast, shallow breathing pattern dilutes low-flow oxygen with more room air, lowering the delivered FiO2.
- Oropharyngeal airway
- Holds the tongue forward and acts as a bite block in a patient with NO gag reflex; provokes gagging if the gag is intact.
- Oropharyngeal airway too long
- Can push the epiglottis down and worsen the obstruction.
- Nasopharyngeal airway
- Better tolerated by a conscious/semiconscious patient and serves as a conduit for nasotracheal suctioning.
- Nasopharyngeal airway inserted too far
- The tip stimulates the larynx/hypopharynx, causing gagging and coughing — withdraw it slightly.
- Confirming ET tube placement
- Capnography (square waveform) is most reliable; equal bilateral breath sounds, no epigastric sound, and a confirming chest film.
- ET tube tip on chest film
- Should sit about 2–6 cm above the carina.
- ET cuff pressure target
- 20–30 cm H2O — high enough to seal, low enough to avoid tracheal mucosal ischemia.
- Cuff pressure 16 cm H2O
- Below range — add air to bring it into the 20–30 cm H2O window (prevents leaks and aspiration).
- Cuff pressure 38 cm H2O
- Above range — remove air; pressure above tracheal capillary perfusion can cause ischemia.
- High-volume low-pressure cuff
- Seals at a lower pressure over a larger contact area, reducing focal mucosal injury.
- ET suction negative pressure (adult)
- About −100 to −150 mm Hg; higher risks mucosal trauma and atelectasis.
- SpO2 falls during suctioning
- Withdraw the catheter and reoxygenate the patient before any further attempt.
- Routine saline instillation before suction
- Generally discouraged — it can cause desaturation and does not reliably thin secretions.
- Colorimetric CO2 detector in arrest
- May read low despite correct tracheal placement because low pulmonary blood flow reduces delivered CO2.
- Esophageal intubation sign
- Progressive gastric distension, absent breath sounds, and no CO2 waveform.
- Assist-control (A/C) ventilation
- Every breath delivers the full set volume/pressure — maximum support; the mode for a patient with no respiratory drive.
- SIMV
- Synchronized mandatory breaths plus the patient's own spontaneous breaths in between (often with pressure support).
- Pressure support ventilation (PSV)
- Patient triggers every breath; a set inspiratory pressure augments it and the breath cycles off as flow falls.
- High-pressure ventilator alarm
- Obstruction or stiffness — secretions, a kinked/bitten tube, bronchospasm, falling compliance, pneumothorax.
- Low-pressure ventilator alarm
- A leak or disconnection — circuit disconnect, underinflated cuff, loose connection, cuff rupture.
- PEEP
- Pressure held at end-exhalation to keep alveoli open and improve oxygenation, letting you lower the FiO2.
- PEEP main hazard
- Reduced venous return → lower cardiac output and blood pressure (hypotension after a PEEP increase); also barotrauma.
- Best (optimal) PEEP
- The level that maximizes oxygenation and compliance without overdistension or hemodynamic compromise.
- PEEP lets you lower FiO2
- Improved oxygenation from recruited alveoli allows reducing FiO2 (e.g., 0.80 → 0.50) to limit oxygen toxicity.
- CPAP
- One continuous pressure throughout the breath; splints alveoli and the upper airway but does not actively assist ventilation.
- CPAP uses
- Cardiogenic pulmonary edema and obstructive sleep apnea — keeps alveoli and the airway open.
- BiPAP (bilevel)
- A higher inspiratory (IPAP) and lower expiratory (EPAP) pressure; the IPAP–EPAP difference is pressure support.
- Lower PaCO2 on BiPAP
- Widen the IPAP–EPAP gap (raise IPAP) to increase tidal volume and minute ventilation.
- Improve oxygenation on BiPAP
- Raise EPAP — it recruits alveoli like PEEP.
- Bilevel backup rate
- Set for a patient at risk of hypoventilation so the device delivers breaths if the patient's effort fails.
- Spontaneous breathing trial (SBT)
- Low-level pressure support or CPAP to test readiness; abort for tachycardia, desaturation, or distress.
- Daily SBT vs slow wean
- A daily spontaneous breathing trial liberates patients faster than gradually reducing support over many days.
- Extubation readiness
- Passed SBT, stable, oxygenating on minimal support, AND able to protect the airway (intact gag and cough).
- Cuff-leak test
- No leak when the cuff is deflated suggests laryngeal edema and risk of post-extubation stridor.
- Albuterol
- Short-acting beta-2 agonist that rapidly relaxes bronchial smooth muscle — first-line for acute bronchospasm.
- Levalbuterol
- An option when racemic albuterol causes marked tachycardia; the active R-isomer of albuterol.
- Ipratropium
- Short-acting anticholinergic bronchodilator; slower onset than albuterol and often combined with it.
- Tiotropium
- A long-acting anticholinergic (LAMA) for once-daily COPD maintenance bronchodilation.
- Racemic epinephrine
- Constricts upper-airway mucosal vessels to shrink swelling — croup and post-extubation stridor; watch for rebound.
- Dornase alfa
- Recombinant DNase that cleaves DNA-rich cystic-fibrosis sputum; give a bronchodilator first.
- N-acetylcysteine
- A mucolytic that breaks mucus disulfide bonds; can trigger bronchospasm, so it is often paired with a bronchodilator.
- Hypertonic saline (nebulized)
- Draws water osmotically into the airway to improve secretion clearance.
- Heliox
- A low-density helium-oxygen mix that cuts turbulent flow and the work of breathing in severe airway obstruction.
- Heliox 80/20 vs 70/30
- 80/20 is less dense and more effective; benefit shrinks as the oxygen fraction (and density) rises.
- Inhaled nitric oxide
- A selective pulmonary vasodilator; monitor methemoglobin and nitrogen-dioxide (NO2) byproduct.
- Incentive spirometry
- Slow, sustained maximal inspirations by an alert, cooperative patient — high-yield after upper-abdominal or thoracic surgery.
- IPPB vs incentive spirometry
- IPPB (positive pressure) is for patients who cannot take an adequate deep breath on their own.
- Postural drainage
- Positions the affected lung segment uppermost so gravity drains secretions; schedule before meals or 1–2 h after.
- Postural drainage with raised ICP
- Avoid head-down (Trendelenburg) positions, which can further raise intracranial pressure.
- PEP / flutter / Acapella
- Positive-expiratory-pressure and oscillatory devices splint airways open and mobilize mucus.
- High-frequency chest wall oscillation (vest)
- Mobilizes secretions for patients who cannot tolerate manual chest physiotherapy.
- Recruitment maneuver
- A brief sustained high pressure reopens collapsed alveoli in ARDS; follow with adequate PEEP to keep them open.
- Recruitment maneuver complication
- Hypotension from reduced venous return — stop the maneuver if blood pressure drops.