What it is. The Neonatal-Perinatal Specialist credential is a post-RRT specialty credential from the NBRC demonstrating advanced competency in neonatal and perinatal respiratory care: premature lung disease, surfactant therapy, HFOV, neonatal transport, and congenital cardiopulmonary conditions. Recognized by most major children’s hospitals and NICUs as the standard for advanced neonatal RT practice.
The salary reality. RTs with NPS credentials at major academic children’s hospitals earn 15 to 20 percent above the RT median at those facilities. More importantly, NPS-credentialed RTs are the practitioners facilities compete for in a market where neonatal-specialized RTs are genuinely scarce.
Who should pursue it. Any RT with at least one year of NICU experience who wants to specialize. The NBRC provides a detailed content outline. Most candidates who work regularly in the NICU find 60 to 70 percent of the content already familiar from daily practice. The remaining 30 percent is what 3 to 6 months of structured study covers.
How to start: Go to nbrc.org and download the NPS examination detailed content outline. Identify your gaps against current NICU practice. Then build a 90-day study plan. Most candidates who sit the exam with adequate preparation pass on the first attempt.
What VIDD is. Ventilator-induced diaphragm dysfunction is the progressive loss of diaphragm muscle mass and force-generating capacity that occurs when the diaphragm is fully unloaded during controlled mechanical ventilation. Diaphragm atrophy begins within 12 to 18 hours of full ventilatory support. After 5 to 7 days of controlled ventilation, diaphragm strength can be reduced by 50 to 60 percent from baseline.
Why it matters clinically. VIDD prolongs weaning, increases extubation failure rates, and is an independent predictor of ICU mortality. A patient who entered the ICU with normal diaphragm function and required a week of controlled ventilation may now have the respiratory muscle strength of someone with significant neuromuscular disease. The vent created the weaning barrier.
What prevents it. Maintaining spontaneous diaphragm effort during mechanical ventilation rather than fully suppressing it. Pressure support ventilation that allows diaphragm recruitment while providing support, early transition from controlled to support modes when hemodynamically stable, and diaphragm ultrasound monitoring to guide settings are the interventions with strongest current evidence.
The bedside skill worth learning: Diaphragm ultrasound is RT-learnable. Measuring diaphragm excursion and thickening fraction gives you real-time data on diaphragm effort and atrophy that no other monitor provides. If your unit has POCUS access, this is worth adding to your practice.
What changed. Elexacaftor/tezacaftor/ivacaftor — Trikafta — is a CFTR modulator approved for CF patients with at least one F508del mutation, representing approximately 90 percent of the CF population. Since 2019, Trikafta has produced the most significant improvement in CF outcomes ever documented: FEV1 improvements of 10 to 15 percentage points, dramatically reduced exacerbation rates, and weight gain previously unachievable for many patients.
What it means for RT practice. The CF patient presenting in 2026 is fundamentally different from the pre-modulator CF patient. Secretion burden is lower and the disease trajectory has shifted. Aggressive airway clearance that was standard pre-modulator may now be over-treating patients whose secretion burden has decreased significantly on Trikafta. Treatment intensity should be individualized to current clinical status, not to historical CF protocols.
Who is not covered. Approximately 10 percent of CF patients do not have the F508del mutation and are ineligible for Trikafta. These patients continue on traditional therapy and represent the most complex CF patients remaining in pulmonary clinics. The practice gap has widened — the Trikafta population needs less aggressive intervention while the non-modulator population needs the same intensive support as before.
Action: If your department has a CF protocol, review it against your current patient population. Blanket application of aggressive airway clearance to Trikafta patients with low secretion burden may not be indicated. The evidence now supports individualized assessment over protocol-driven treatment frequency.
The honest summary. Most studies show similar efficacy across airway clearance techniques when performed correctly and consistently. Patient preference and adherence are stronger predictors of outcomes than device type. A technique the patient tolerates and performs correctly twice daily beats a theoretically superior technique they skip or perform poorly.
What the evidence supports by setting. In acute care for secretion mobilization, oscillating PEP devices have reasonable evidence and are practical. HFCWO vest therapy has strong evidence in CF and bronchiectasis for outpatient maintenance — less so for acute hospitalized patients. Active cycle of breathing technique requires no device and has equivalent evidence to mechanical methods in patients with adequate capacity.
Where RT clinical judgment matters most. The decision to initiate, modify, or discontinue airway clearance therapy requires RT assessment of secretion characteristics, cough effectiveness, patient effort, and underlying diagnosis. RTs who evaluate the indication before implementing the order — and document that evaluation — are practicing at full scope.
The uncomfortable truth: A significant portion of ordered airway clearance therapy in acute care is ritualistic rather than evidence-based. The RT who evaluates the indication and recommends discontinuation when it is not indicated is doing the job correctly — not the one who executes every order without assessment.
Next: Pulmonary hypertension and what RTs managing ventilated PH patients need to know.
Soon: RSV vaccines in 2026 and the clinical implications for respiratory therapy practice.
On deck: End-tidal CO2 — the clinical applications most RTs are underusing.
Staying at the vent,
15 years across academic medical centers & community hospitals
