The short version. CHEST published the first American College of Chest Physicians clinical practice guideline dedicated to adult bronchiectasis — 13 recommendations across 8 clinical questions, built from a systematic review of 47 studies. Some of it confirms what you already do. One recommendation may make you stop and reconsider.
What’s recommended for airway clearance. Breathing techniques (ELTGOL — expiration with an open glottis in lateral position — and active cycle of breathing), oscillating PEP devices, nebulized hypertonic saline, and high-frequency chest wall oscillation. All four are conditional recommendations on low-certainty evidence, but the benefit-risk balance favors doing something. Respiratory therapists are named alongside physiotherapists as the clinicians who prescribe and deliver these techniques.
What’s not — and this is the headline. The guideline recommends against rhDNase (Pulmozyme) for airway clearance in non-CF bronchiectasis. An RCT of 349 patients found a higher exacerbation rate and greater FEV₁ decline with rhDNase than placebo. If your institution still uses it in non-CF patients, you now have the evidence to flag it.
The medical side, for context. Long-term macrolides and brensocatib — a new DPP-1 inhibitor — are both conditionally recommended for patients with two or more exacerbations a year. In the ASPEN phase 3 trial, brensocatib cut annualized exacerbations by 20%. Statins are not recommended. For P. aeruginosa eradication after a first isolate, the panel says there isn’t enough evidence either way — an honest “we don’t know yet.”
RT takeaway: In non-CF bronchiectasis, PEP plus breathing techniques plus hypertonic saline are your first-line clearance tools. HFCWO is an option. rhDNase is not. Check your protocols against this guideline. Thomson et al., CHEST 2026;170(4):1060–1073.
The finding. Patients with severe obstructive sleep apnea managed by respiratory therapists had outcomes equivalent to physician-managed care — at $34,580 less per quality-adjusted life year. That’s from a randomized controlled trial in CHEST, and it’s the kind of data that ends debates.
How it worked. Penz et al. (2026) randomized sleep-clinic referrals with AHI of 30 or more to an RT-led pathway or standard physician care. RTs ordered diagnostic studies, titrated PAP, and managed follow-up independently. PAP adherence at 6 months, daytime sleepiness, and quality of life were non-inferior on every measure — and wait times were shorter in the RT arm.
Why it matters. This isn’t a retrospective review or an opinion piece. It’s an RCT. At the study’s $50,000/QALY threshold, RT-led care was dominant — better value with no loss in outcomes.
What to do: If every OSA patient at your hospital still waits on a pulmonologist’s schedule, print this study and bring it to your medical director. Penz et al., CHEST 2026.
The study. Shin et al. (2026) interviewed 30 adult patients across three pulmonary clinics about their pulmonary function testing experience. What came back was anxiety, shame, and poor preparation: confusion about what to withhold before the test, embarrassment at missing predicted values, and leaving without understanding the results.
The part that should sting. Several patients said they avoided repeat testing because the experience felt humiliating rather than diagnostic. That’s a missed follow-up caused by the lab, not the disease.
The fix is small. A two-minute scripted pre-test explanation. Normalizing effort variability out loud. A 60-second debrief: “Your FEV₁ is 74% of predicted — here’s what that means for your treatment.” This study is a quiet indictment of how most PFT labs run, and it’s entirely fixable.
Action: Audit your pre-test handout and post-test script. If they don’t address anxiety, withhold periods, and a plain-language summary of results, rewrite them. Shin et al., CHEST 2026.
The evidence. In ventilated patients with ARDS or sepsis-related lung injury, aggressive fluids after the resuscitation phase worsen oxygenation, prolong ventilation, and raise mortality. FACTT showed it over a decade ago: the liberal strategy meant 2.5 more ventilator days with no survival benefit. SMART, PLUS, and real-world ARDS registries back it up.
The practice gap. Conservative fluids — even or slightly negative balance after the first 24 to 48 hours — is the standard on paper. At the bedside, broad fluid orders and reflex boluses for every BP dip still push flooded lungs further positive.
Where the RT comes in. You’re the one titrating PEEP and FiO₂ against a falling P/F ratio. Bring the full picture to rounds: P/F trend, CXR infiltrate progression, cumulative fluid balance, and the vent changes you’ve made. That’s a clinical argument, not a complaint.
Clinical pearl: After resuscitation, a cumulative balance above +4L at 72 hours in a ventilated ARDS patient is associated with significantly worse outcomes. Know your patient’s number before you walk into rounds.
Next: The RT’s role in sepsis — why it starts long before the intubation order.
Soon: Prone positioning logistics — the five-person turn, airway protection, and why proning rates are still too low.
On deck: RTs can do research. Here’s how to actually start without a PhD.
Staying at the vent,
15 years across academic medical centers & community hospitals
