What INO does. Inhaled nitric oxide is a selective pulmonary vasodilator. Administered via the ventilator circuit, it causes local vasodilation without significant systemic effect because it is rapidly inactivated by hemoglobin. In neonates, INO is FDA-approved for hypoxic respiratory failure associated with PPHN. In adults, it is used off-label for refractory hypoxemia in ARDS and pulmonary hypertension.
The neonatal indication. In neonatal PPHN, INO is typically initiated at 20 ppm and response assessed within 30 to 60 minutes. Non-responders at 20 ppm rarely respond to higher doses. Weaning is gradual — too rapid withdrawal causes rebound pulmonary hypertension. RTs managing INO in the NICU are responsible for delivery system setup, NO2 monitoring, and weaning titration based on oxygenation response.
The adult application. In adult ARDS with refractory hypoxemia, INO produces transient oxygenation improvement in approximately 60 percent of patients but has not demonstrated mortality benefit in RCTs. Its value is as a bridge — improving oxygenation while other interventions take effect, or as a diagnostic tool to assess pulmonary vascular reactivity. Response assessment at 30 minutes guides continuation decisions.
If you have never managed INO: Request an in-service from your pharmacy and respiratory therapy team before it is ordered on your patient. Delivery system setup, methemoglobin monitoring, and NO2 alarm management are learnable in a single structured session.
The scale of the problem. More than 80,000 opioid overdose deaths occurred in the United States in 2023. For every death, many more patients present alive but in respiratory failure from opioid-induced respiratory depression. In communities with high opioid burden, RTs manage opioid-related airway presentations daily — often without a specific protocol for this patient population.
What the presentation looks like. Miosis. Decreased respiratory rate — often below 12, sometimes as low as 4 to 6 breaths per minute with normal tidal volume. Decreased LOC. SpO2 declining if untreated. The airway reflex is typically intact in pure opioid overdose — vomiting and aspiration risk are significant. This is not the same presentation as cardiac arrest or pneumonia-driven respiratory failure.
RT role in the protocol. Supplemental oxygen first. BVM ventilation for respiratory rate below 8 or apnea — not intubation as the first response in pure opioid overdose. Naloxone reversal: onset 2 to 5 minutes, duration 30 to 90 minutes — shorter than most long-acting opioids, meaning rebound respiratory depression after naloxone wears off requires continued monitoring.
The monitoring gap: RT capnography during the naloxone observation period detects rebound hypoventilation earlier than pulse oximetry, particularly in patients on supplemental oxygen where SpO2 changes significantly lag behind ventilatory changes. Use it for opioid observation patients if your ED has capnography capability.
What they are. Closed-loop automated oxygen delivery systems — FreeO2 by Oxynov is the most studied — continuously measure SpO2 and automatically adjust delivered FiO2 to maintain a target saturation range. The system replaces manual FiO2 titration with algorithm-driven adjustments every few seconds.
What the evidence shows. FreeO2 clinical trials demonstrate that automated delivery keeps patients in a target SpO2 range a significantly higher percentage of time compared to manual adjustment — reducing both hypoxic episodes and hyperoxic exposure. In COPD patients, where hyperoxia can worsen hypercapnia, maintaining a tighter oxygenation range has direct clinical significance.
Where it fits in RT practice. Closed-loop oxygen delivery on general wards and step-down units reduces RT intervention burden for routine oxygenation maintenance — freeing RT time for higher-acuity assessments. It does not replace RT clinical judgment for patients in distress, weaning decisions, or complex oxygenation management.
Where to learn more: Search FreeO2 COPD clinical trial in PubMed. The technology is coming to U.S. hospitals whether or not RT departments are prepared for it.
The documentation gap is real. Respiratory therapy services are reimbursable under Medicare and most commercial payers through specific CPT codes. Services most commonly underdocumented: therapeutic ventilator management (94660, 94661, 94662), pulmonary function testing with interpretation (94010, 94060, 94070), respiratory therapy services with evaluation (94002, 94003), and remote physiological monitoring (99453, 99454, 99457).
What good documentation captures. Every patient encounter should document the clinical indication, the specific intervention performed, the patient response, the RT clinical assessment and recommendation, and any plan modifications. Vague notes do not support billing. A note documenting pre- and post-treatment SpO2, breath sounds, patient technique, and clinical reasoning is billable and demonstrates clinical thinking.
Why it matters beyond billing. RT documentation is the primary evidence base that hospital administrators use when evaluating department value during budget cycles. Departments with detailed outcome-linked documentation have the data to argue for staffing. Departments with minimal documentation have no defense.
One practical step: Pull three of your own recent patient notes. Read them as if you are a hospital administrator who does not know what an RT does. Do they demonstrate clinical assessment, decision-making, and patient outcomes? If not — that is the gap to close, starting with your next patient encounter.
Next: Lung transplant — the RT's full role before, during, and after transplantation.
Soon: Esophageal pressure and transpulmonary pressure monitoring — what it tells you that nothing else does.
On deck: NBRC 2026 updates and what changed for RRT recertification this year.
Staying at the vent,
15 years across academic medical centers & community hospitals
