The work. In neuromuscular disease, respiratory function declines on a curve. Managing that curve skillfully, for as long as possible, is some of the most demanding and meaningful work in the field — and it’s chronically underrepresented in RT training.
The toolkit. Lung volume recruitment (breath stacking), manually assisted cough, mechanical insufflation-exsufflation (CoughAssist), and noninvasive ventilation — usually BiPAP titrated to symptoms, CO₂, and sleep quality. In ALS and Duchenne, FVC below 50% of predicted triggers the NIV discussion; below 30% triggers urgent planning. Peak cough flow below 270 L/min means secretions aren’t clearing well; below 160 L/min is an emergency threshold.
The relationship. The RT who follows these patients over years — adjusting pressures, fixing mask fit, counseling on tracheostomy, coordinating with palliative care — does work no one else can. Goals-of-care conversations in NMD are among the most important any clinician has. ATS and CHEST both publish NMD respiratory guidelines worth reading.
Key thresholds: FVC under 50% → start the NIV discussion. PCF under 270 L/min → start MI-E training. PCF under 160 L/min → secretion crisis. Know these before you walk in the room.
What it tells you. Point-of-care lung and diaphragm ultrasound answers bedside questions in real time: Is there consolidation? An effusion? Is the diaphragm moving? Is this a pneumothorax?
What you need to learn. The RT-relevant findings fit in a structured 8-hour course: A-lines (normal aeration), B-lines (interstitial edema), consolidation, lung sliding (rules out pneumothorax), and diaphragm excursion during SBTs. Diaphragm excursion under 1 cm during spontaneous effort predicts extubation failure with reasonable sensitivity — information you can’t get from a waveform.
The credentialing gap. AARC has no formal POCUS certification for RTs yet, but ACEP, CHEST, and SCCM all run POCUS training open to allied health. Several large centers already run RT-led ICU ultrasound protocols. At most hospitals the barrier is credentialing, not skill. Push your department to define the pathway before someone else does.
Starting point: CHEST’s Critical Care Ultrasound certificate and the POCUS Atlas online resources are both RT-accessible. Find a physician or NP in your ICU who will scan with you. Supervised reps build the skill fastest.
The problem. Patients with asthma or COPD have used the same inhaler for years and been told they’re doing it right — and the medication still isn’t reaching their lungs. The result: uncontrolled symptoms, unnecessary escalation, preventable ED visits.
The errors, by device. MDIs: not shaking, actuating before inhaling, inhaling too fast, skipping the breath-hold. DPIs: not exhaling fully first, inhaling too slowly (DPIs need a sharp, fast breath). Respimat: rotating the wrong way, covering the air vents. Each error cuts lung deposition by 30–80%. A spacer nearly eliminates MDI coordination errors.
What works. Teach-back with demonstration. Don’t ask “do you know how to use it?” — ask them to show you, correct errors in real time, and have them show you again. One structured session reduces rescue inhaler use by 20–30% at four weeks. It takes under five minutes.
Script it: “Before I let you go, can you show me how you use your inhaler at home?” Then watch. Correct one error at a time, have them repeat, recheck. That’s it.
The science. After 17 hours awake, cognitive performance matches a blood alcohol level of 0.05%. At 24 hours, it matches 0.10%. RTs on 12-hour nights and rotating schedules make vent titrations, extubation calls, and rapid response decisions inside those windows.
Why 3am is different. Error rates in nursing and medicine spike between 2 and 4am regardless of workload. For RTs it’s worse: many night-shift RTs work with minimal physician oversight, so there’s no second check on a fatigued decision. Mode changes, NIV adjustments, and extubation calls at 3am deserve to be treated as high-risk moments.
What helps. A 90-minute nap before a night shift. Caffeine timed 30 minutes before your hardest hours and stopped at least 6 hours before you plan to sleep. Bright light at shift start; a dark, cold room for daytime sleep. But individual habits can’t fully offset schedules that rotate, stack back-to-back nights, or flip staff from nights to days within 48 hours.
The ask: If your department rotates shifts, push for fixed schedules — or at minimum 48 hours between a night block and a day block. Frame it as patient safety, because it is.
Next: INSURE, LISA, MIST — which surfactant technique your NICU should be using in 2026.
Soon: Pulmonary rehab in heart failure — powerful, underused, and RT territory.
On deck: The per-diem trap — why float pool scheduling drives RTs out.
Staying at the vent,
15 years across academic medical centers & community hospitals
