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Clinical Simulation Examination

Provider
The National Board for Respiratory Care (NBRC); administered Monday through Saturday at more than 300 assessment centers through the NBRC testing agency PSI
Format
Computer-based clinical simulation examination of patient-management problems with information-gathering and decision-making sections; each section of each problem is classified to a minor content heading of the Detailed Content Outline. Admission requires the CRT and a TMC pass at the high cut score; with the implementation of the Respiratory Therapy Examination the CSE is available only to those who passed the TMC at the high cut score by December 31, 2026, and it ends December 31, 2027
Exam questions
22 problems: 20 scored and 2 pretest
Time limit
4 hours
Passing score
Points associated with the candidate’s set of responses are summed across the whole examination into one score compared with a cut score linked to examination committee decisions on whether each positively-scored option is required as a demonstration of minimal competence
Exam fee
$200 for both new and repeat applicants
Examination outline
  • I. PATIENT DATA
    • I.A. Evaluate Data in the Patient Record — 1. Patient history, for example, history of present illness (HPI), orders, medication reconciliation, progress notes, DNR status / advance directives, social, family, and medical history; 2. Physical examination relative to the cardiopulmonary system; 3. Lines, drains, and airways, for example, chest tube, vascular lines, artificial airway; 4. Laboratory results, for example, CBC, electrolytes, coagulation studies, sputum culture and sensitivities, cardiac biomarkers; 5. Blood gas analysis and / or hemoximetry (CO-oximetry) results; 6. Pulmonary function testing results, for example spirometry, lung volumes, DLCO; 7. 6-minute walk test results; 8. Imaging study results, for example, chest radiograph, CT scan, ultrasonography and / or echocardiography, PET scan, ventilation / perfusion scan; 9. Maternal and perinatal / neonatal history, for example, Apgar scores, gestational age, L / S ratio; 10. Sleep study results, for example, apnea-hypopnea index (AHI); 11. Trends in monitoring results: a. fluid balance; b. vital signs; c. intracranial pressure; d. ventilator liberation parameters; e. pulmonary mechanics; f. noninvasive, for example, pulse oximetry, capnography, transcutaneous; g. cardiac evaluation / monitoring results, for example, ECG, hemodynamic parameters; 12. Determination of a patient's pathophysiological state
    • I.B. Perform Clinical Assessment — 1. Interviewing a patient to assess a. level of consciousness and orientation, emotional state, and ability to cooperate; b. level of pain; c. shortness of breath, sputum production, and exercise tolerance; d. smoking history; e. environmental exposures; f. activities of daily living; g. learning needs, for example, literacy, preferred learning style, social / cultural; 2. Performing inspection to assess a. general appearance; b. characteristics of the airway, for example, patency, Mallampati classification, tracheal shift; c. cough, sputum amount and character; d. status of a neonate, for example, Apgar score, gestational age; e. skin integrity, for example, pressure ulcers, stoma site; 3. Palpating to assess a. pulse, rhythm, intensity; b. accessory muscle activity; c. asymmetrical chest movements, tactile fremitus, crepitus, tenderness, tactile rhonchi, and / or tracheal deviation; 4. Performing diagnostic chest percussion; 5. Auscultating to assess a. breath sounds; b. heart sounds and rhythm; c. blood pressure; 6. Reviewing a chest radiograph to assess a. quality of imaging, for example, patient positioning, penetration, lung inflation; b. presence and position of airways, lines, and drains; c. presence of foreign bodies; d. heart size and position; e. presence of, or change in, (i) cardiopulmonary abnormalities, for example, pneumothorax, consolidation, pleural effusion, pulmonary edema, pulmonary artery size; (ii) diaphragm, mediastinum, and / or trachea
    • I.C. Perform Procedures to Gather Clinical Information — 1. 12-lead ECG; 2. Noninvasive monitoring, for example, pulse oximetry, capnography, transcutaneous; 3. Peak flow; 4. Mechanics of spontaneous ventilation linked to tidal volume, minute volume, maximal inspiratory pressure, and vital capacity; 5. Blood gas sample collection; 6. Blood gas analysis and / or hemoximetry (CO-oximetry); 7. Oxygen titration with exercise; 8. Cardiopulmonary calculations, for example, P(A-a)O2, VD / VT, P/F, OI; 9. Hemodynamic monitoring; 10. Pulmonary compliance and airways resistance; 11. Plateau pressure; 12. Auto-PEEP determination; 13. Spontaneous breathing trial (SBT); 14. Apnea monitoring; 15. Apnea test (brain death determination); 16. Overnight pulse oximetry; 17. CPAP / NPPV titration during sleep; 18. Cuff management, for example, tracheal, laryngeal; 19. Sputum induction; 20. Cardiopulmonary exercise testing; 21. 6-minute walk test; 22. Spirometry outside or inside a pulmonary function laboratory; 23. DLCO inside a pulmonary function laboratory; 24. Lung volumes inside a pulmonary function laboratory; 25. Tests of respiratory muscle strength - MIP and MEP; 26. Therapeutic bronchoscopy
    • I.D. Evaluate Procedure Results — 1. 12-lead ECG; 2. Noninvasive monitoring, for example, pulse oximetry, capnography, transcutaneous; 3. Peak flow; 4. Mechanics of spontaneous ventilation linked to tidal volume, minute volume, maximal inspiratory pressure, and vital capacity; 5. Blood gas analysis and / or hemoximetry (CO-oximetry); 6. Oxygen titration with exercise; 7. Cardiopulmonary calculations, for example, P(A-a)O2, VD / VT, P/F, OI; 8. Hemodynamic monitoring; 9. Pulmonary compliance and airways resistance; 10. Plateau pressure; 11. Auto-PEEP; 12. Spontaneous breathing trial (SBT); 13. Apnea monitoring; 14. Apnea test (brain death determination); 15. Overnight pulse oximetry; 16. CPAP / NPPV titration during sleep; 17. Cuff status, for example, laryngeal, tracheal; 18. Cardiopulmonary exercise testing; 19. 6-minute walk test; 20. Spirometry outside or inside a pulmonary function laboratory; 21. DLCO inside a pulmonary function laboratory; 22. Lung volumes inside a pulmonary function laboratory; 23. Tests of respiratory muscle strength - MIP and MEP
    • I.E. Recommend Diagnostic Procedures — 1. Testing for tuberculosis; 2. Laboratory tests, for example, CBC, electrolytes, coagulation studies, sputum culture and sensitivities, cardiac biomarkers; 3. Imaging studies; 4. Bronchoscopy a. diagnostic; b. therapeutic; 5. Bronchoalveolar lavage (BAL); 6. Pulmonary function testing; 7. Noninvasive monitoring, for example, pulse oximetry, capnography, transcutaneous; 8. Blood gas and/or hemoximetry (CO-oximetry); 9. ECG; 10. Exhaled gas analysis, for example, CO2, CO, FENO; 11. Hemodynamic monitoring; 12. Sleep studies; 13. Thoracentesis
  • II. TROUBLESHOOTING AND QUALITY CONTROL OF EQUIPMENT, AND INFECTION CONTROL
    • II.A. Assemble /Troubleshoot Devices — 1. Medical gas delivery interfaces, for example, mask, cannula, heated high-flow nasal cannula; 2. Long-term oxygen therapy; 3. Medical gas delivery, metering, and /or clinical analyzing devices, for example, concentrator, liquid system, flowmeter, regulator, gas cylinder, blender, air compressor, gas analyzers; 4. CPAP / NPPV with patient interfaces; 5. Humidifiers; 6. Nebulizers; 7. Metered-dose inhalers, spacers, and valved holding chambers; 8. Dry-powder inhalers (DPI); 9. Resuscitation equipment, for example, self-inflating resuscitator, flow-inflating resuscitator, AED; 10. Mechanical ventilators; 11. Intubation equipment; 12. Artificial airways; 13. Suctioning equipment, for example, regulator, canister, tubing, catheter; 14. Blood analyzers, for example, hemoximetry (CO-oximetry), point-of-care, blood gas; 15. Patient breathing circuits; 16. Hyperinflation devices; 17. Secretion clearance devices; 18. Heliox delivery device; 19. Portable spirometer; 20. Testing equipment in a pulmonary function laboratory; 21. Pleural drainage; 22. Noninvasive monitoring, for example, pulse oximeter, capnometer, transcutaneous; 23. Bronchoscopes and light sources; 24. Hemodynamic monitoring a. pressure transducers; b. catheters, for example, arterial, pulmonary artery
    • II.B. Ensure Infection Prevention — 1. Adhering to infection prevention policies and procedures, for example, Standard Precautions, donning/doffing, isolation; 2. Adhering to disinfection policies and procedures; 3. Proper handling of biohazardous materials
    • II.C. Perform Quality Control Procedures — 1. Blood analyzers; 2. Gas analyzers; 3. Pulmonary function equipment for testing a. spirometry results; b. lung volumes; c. diffusing capacity (DLCO); 4. Mechanical ventilators; 5. Noninvasive monitors
  • III. INITIATION AND MODIFICATION OF INTERVENTIONS
    • III.A. Maintain a Patent Airway Including the Care of Artificial Airways — 1. Proper positioning of a patient; 2. Recognition of a difficult airway; 3. Establishing and managing a patient's airway a. nasopharyngeal airway; b. oropharyngeal airway; c. esophagealtracheal tubes / supraglottic airways; d. endotracheal tube; e. tracheostomy tube; f. laryngectomy tube; g. speaking valves; h. devices that assist with intubation, for example, endotracheal tube exchanger, video laryngoscopy; 4. Performing tracheostomy care; 5. Exchanging artificial airways; 6. Maintaining adequate humidification; 7. Initiating protocols to prevent ventilator-associated infections; 8. Performing extubation
    • III.B. Perform Airway Clearance and Lung Expansion Techniques — 1. Postural drainage, percussion, or vibration; 2. Suctioning, for example, nasotracheal, oropharyngeal; 3. Mechanical devices, for example, high-frequency chest wall oscillation, vibratory PEP, intrapulmonary percussive ventilation, insufflation / exsufflation device; 4. Assisted cough, for example, huff, abdominal thrust; 5. Hyperinflation therapy; 6. Inspiratory muscle training
    • III.C. Support Oxygenation and Ventilation — 1. Initiating and adjusting oxygen therapy; 2. Minimizing hypoxemia, for example, patient positioning, secretion removal; 3. Initiating and adjusting mask or nasal CPAP; 4. Initiating and adjusting mechanical ventilation settings a. continuous mechanical ventilation; b. noninvasive ventilation; c. high-frequency ventilation; d. alarms; 5. Recognizing and correcting patient-ventilator dyssynchrony; 6. Utilizing ventilator graphics; 7. Performing lung recruitment maneuvers; 8. Liberating a patient from mechanical ventilation
    • III.D. Administer Medications and Specialty Gases — 1. Aerosolized preparations a. antimicrobials; b. pulmonary vasodilators; c. bronchodilators; d. mucolytics / proteolytics; e. steroids; 2. Endotracheal instillation; 3. Specialty gases, for example, heliox, inhaled NO
    • III.E. Ensure Modifications are Made to the Respiratory Care Plan — 1. Treatment termination, for example, life-threatening adverse event; 2. Recommendations a. starting treatment based on patient response; b. treatment of pneumothorax; c. adjustment of fluid balance; d. adjustment of electrolyte therapy; e. insertion or change of artificial airway; f. liberating from mechanical ventilation; g. extubation; h. discontinuing treatment based on patient response; i. consultation from a physician specialist; 3. Recommendations for changes a. patient position; b. oxygen therapy; c. humidification; d. airway clearance; e. hyperinflation; f. mechanical ventilation; 4. Recommendations for pharmacologic interventions a. bronchodilators; b. anti-inflammatory drugs; c. mucolytics and proteolytics; d. aerosolized antibiotics; e. inhaled pulmonary vasodilators; f. cardiovascular; g. antimicrobials; h. sedatives and hypnotics; i. analgesics; j. narcotic antagonists; k. benzodiazepine antagonists; l. neuromuscular blocking agents; m. diuretics; n. surfactants; o. changes to drug, dosage, administration frequency, mode, or concentration
    • III.F. Utilize Evidence-Based Practice — 1. Classification of disease severity; 2. Recommendations for changes in a therapeutic plan when indicated; 3. Application of guidelines, for example, ARDSNet, NAEPP, GOLD
    • III.G. Provide Respiratory Care Techniques in High-Risk Situations — 1. Emergency a. cardiopulmonary emergencies excluding CPR; b. disaster management; c. medical emergency team (MET) / rapid response team; 2. Interprofessional communication; 3. Patient transport a. land / air between hospitals; b. within a hospital
    • III.H. Assist a Physician / Provider in Performing Procedures — 1. Intubation; 2. Bronchoscopy; 3. Specialized bronchoscopy, for example, EBUS, navigational bronchoscopy (ENB); 4. Thoracentesis; 5. Tracheotomy; 6. Chest tube insertion; 7. Insertion of arterial or venous catheters; 8. Moderate (conscious) sedation; 9. Cardioversion; 10. Withdrawal of life support
    • III.I. Conduct Patient and Family Education — 1. Safety and infection control; 2. Home care and related equipment; 3. Lifestyle changes, for example, smoking cessation, exercise; 4. Pulmonary rehabilitation; 5. Disease / condition management, for example, asthma, COPD, CF, tracheostomy care, ventilator dependent
Examination sources