The core physiology problem. Pulmonary hypertension creates a ventilator management problem standard ARDS protocols were not designed for. Positive pressure ventilation increases right ventricular afterload. PEEP that improves oxygenation in ARDS can worsen right heart failure in PH. Hypoxia and hypercapnia both cause pulmonary vasoconstriction and can precipitate acute RV decompensation. The interventions that protect one failing system can destroy the other.
What the evidence supports. Permissive hypercapnia — acceptable in ARDS — is dangerous in PH because CO2-driven pulmonary vasoconstriction increases RV afterload. Normocapnia is the target. PEEP should be titrated carefully — high PEEP compresses pulmonary vasculature and impedes RV outflow. SpO2 above 92 percent to avoid hypoxic vasoconstriction.
The inhaled pulmonary vasodilators. Inhaled nitric oxide and inhaled prostacyclins — epoprostenol and iloprost — are the RT-administered agents for acute pulmonary vasodilation in ventilated PH patients. Inhaled epoprostenol can be delivered via standard nebulization into the ventilator circuit and is increasingly used as a more accessible alternative to INO. Both are RT-managed therapies requiring understanding of the underlying hemodynamics.
Clinical rule: In a PH patient on the ventilator who is deteriorating, check CO2 before you check FiO2. Hypercapnia is frequently the driver of acute RV decompensation and is more immediately correctable than oxygenation failure in this population.
What happened. Three RSV vaccines — Abrysvo (Pfizer), Arexvy (GSK), and mResvia (Moderna) — received FDA approval in 2023 and 2024 for adults 60 and older. The 2025-2026 RSV season showed measurable reductions in severe RSV hospitalizations among vaccinated older adults for the first time at population scale in the United States.
What it changed for respiratory therapy. RSV-related HFNC and NIV admissions in the 2025-2026 winter season showed a downward trend in vaccinated older adult populations. The clinical impact on pediatric RSV burden remains unchanged. Infant RSV protection from maternal vaccination and nirsevimab prophylaxis showed significant reduction in infant hospitalization rates.
What has not changed. RSV remains a major cause of severe respiratory illness in immunocompromised adults, unvaccinated older adults, and premature infants. HFNC as first-line escalation in RSV-driven respiratory failure remains the clinical standard. Vaccination coverage remains approximately 40 percent after the first full season.
RT relevance: Know your patient's RSV vaccination status the same way you know their influenza and COVID history. It affects your differential for winter respiratory admissions and your probability assessment for RSV-driven versus bacterial pneumonia etiology.
Beyond intubation confirmation. EtCO2 capnography is used in most RT departments for one purpose: confirming ETT placement after intubation. That is correct and important. It is also a fraction of what capnography tells you, and most RT departments stop there.
What else EtCO2 tells you. A sudden drop in EtCO2 in a stable ventilated patient should prompt assessment for pulmonary embolism, cardiac output reduction, or circuit disconnect — before the SpO2 drops. Waveform analysis identifies bronchospasm (shark fin pattern), incomplete exhalation and auto-PEEP (rising baseline), and neuromuscular fatigue. In non-intubated patients on HFNC, continuous EtCO2 sampling allows CO2 trending during NIV breaks.
In procedural sedation. AARC and anesthesia guidelines recommend capnography as the standard of care for monitoring sedated non-intubated patients during procedures. EtCO2 detects apnea and hypoventilation 20 to 60 seconds before SpO2 changes in a patient on supplemental oxygen.
One change worth making: If your unit has capnography and only uses it for intubation confirmation, talk to your medical director about implementing continuous EtCO2 trending for ventilated patients. The data is already there. Most units just do not routinely act on it.
What is happening. Emergency departments are expanding RT involvement beyond treatment administration. In a growing number of health systems — particularly those with ED volume exceeding nursing capacity — RTs are leading CPAP and BiPAP initiation protocols independently, managing RSI-adjacent airway support, and running sepsis-associated respiratory support pathways without per-order physician sign-off.
What it requires. ED-based RT practice requires clinical speed and decision-making that differs from ICU practice. The ED patient has no established clinical picture. Every assessment starts from zero. RTs transitioning to ED roles report a steeper learning curve than ICU-to-ICU transitions, with the primary gap being triage-speed clinical decision-making under information constraints.
How to pursue it. Talk to your ED medical director and nursing director together — not just one. ED RT expansion requires buy-in from both sides. Propose a pilot protocol for a specific evidence-backed intervention: BiPAP initiation, HFNC triage for respiratory distress, or procedural sedation monitoring.
The credential that helps most: The ACCS (Adult Critical Care Specialist) credential from the NBRC is the most recognized for ED and ICU advanced practice roles. It signals clinical depth to the ED team before you have established a track record with them.
Next: Inhaled nitric oxide — neonatal and adult clinical applications, delivery systems, and when to wean.
Soon: The opioid overdose patient and RT airway management — what the clinical protocol should look like.
On deck: Closed-loop oxygen delivery systems — what FreeO2 and similar platforms actually do.
Staying at the vent,
15 years across academic medical centers & community hospitals
