2026 Is Your Last Year to Take the RRT Clinical Simulation Exam
The National Board for Respiratory Care (NBRC) is making the biggest change to respiratory therapy credentialing in decades. Starting January 2027, the Clinical Simulation Exam (CSE) will be eliminated and replaced with a single combined multiple-choice exam.
If you're pursuing your Registered Respiratory Therapist (RRT) credential, 2026 is the last full year to earn it through the current pathway: TMC Exam (high cut score) → Clinical Simulation Exam (CSE). After December 31, 2026, the rules change significantly.
This guide covers both exams, the 2027 transition timeline, and a study strategy to get your RRT before the deadline.
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The 2027 Transition Timeline: What's Happening and When
| Date | What Happens |
|---|---|
| Now – December 31, 2026 | Current TMC + CSE pathway is fully operational |
| December 31, 2026 | CRT-to-Registry admission pathway eliminated |
| December 31, 2026 | Last day to take the CSE under current rules |
| January 1, 2027 | New single Respiratory Therapy Examination launches |
| Through December 31, 2027 | CSE available ONLY for those who passed TMC at high cut score before January 1, 2027 |
| After December 31, 2027 | CSE permanently discontinued |
Critical deadline: If you pass the TMC at the high cut score before January 1, 2027, you'll still have until December 31, 2027 to complete the CSE. But if you haven't passed the TMC by then, you'll need to take the new combined exam to earn the RRT.
The Current RRT Pathway (2026): TMC + CSE
Step 1: Therapist Multiple-Choice (TMC) Exam
| Detail | Specification |
|---|---|
| Total questions | 160 multiple-choice |
| Scored questions | 140 (20 pretest items) |
| Time limit | 3 hours |
| Low cut score | Scaled score of 86 → earns CRT credential |
| High cut score | Scaled score of 92 → earns CRT + CSE eligibility |
| Low cut pass rate | ~77% of first-time candidates |
| High cut pass rate | ~68% of first-time candidates |
The TMC has two passing thresholds. The low cut score earns you the CRT (Certified Respiratory Therapist) credential. The high cut score earns you CRT plus eligibility to take the CSE for the RRT credential.
The gap matters: Only about 68% of first-time candidates reach the high cut score. If you score between 86 and 91, you get CRT but must retake the TMC to qualify for CSE.
TMC Content Areas
The current TMC content outline (effective through December 31, 2026) covers three domains:
Domain I: Patient Data Evaluation and Recommendations (Scoring Weight)
- Collecting and evaluating patient data
- Patient assessment (interviews, physical examination)
- Diagnostic procedures and test results interpretation
- Recommending modifications to the respiratory care plan
Domain II: Troubleshooting and Quality Control
- Equipment assembly, operation, and troubleshooting
- Quality control procedures
- Monitoring patient-ventilator system
Domain III: Initiation and Modification of Interventions
- Maintaining a patent airway (suctioning, airway adjuncts, intubation assistance)
- Oxygen therapy delivery systems
- Aerosol delivery (MDI, SVN, DPI)
- Mechanical ventilation (modes, settings, weaning)
- Pharmacology (bronchodilators, corticosteroids, mucolytics)
- CPR and emergency response
Step 2: Clinical Simulation Exam (CSE)
The CSE is widely considered one of the most difficult exams in healthcare — and it's the exam going away in 2027.
| Detail | Specification |
|---|---|
| Format | 22 clinical simulation problems |
| Scored problems | 20 (2 pretest) |
| Time limit | 4 hours |
| First-time pass rate | ~62–63% |
| Repeat candidate pass rate | ~47% |
Why the CSE is so hard: Unlike the TMC's multiple-choice format, the CSE presents branching clinical scenarios. At each decision point, you choose what to do next (e.g., order a test, administer a treatment, modify ventilator settings). Your choices determine what information you receive next — and wrong choices can lead you down unproductive paths.
CSE Problem Structure
Each CSE problem follows this flow:
- Patient presentation — You receive clinical data (vitals, ABG results, chest X-ray findings, patient history)
- Decision point — You choose from available actions (order a test, perform an intervention, consult a physician)
- Outcome — Based on your choice, you receive new data
- Repeat — The scenario continues through multiple decision points until the case resolves
Scoring: You receive credit for selecting appropriate actions and lose credit for inappropriate ones. There are typically "must-do" actions (e.g., securing an airway in respiratory failure) and "must-avoid" actions (e.g., administering oxygen to a patient with a pneumothorax without first decompressing).
Free RRT Practice Questions
Our question bank covers TMC content areas and CSE-style clinical reasoning — practice both before your exam.
Key Topics That Appear on Both TMC and CSE
These are the highest-yield study areas because they're tested heavily on both exams:
1. Arterial Blood Gas (ABG) Interpretation
- pH, PaCO₂, PaO₂, HCO₃⁻, SaO₂
- Respiratory acidosis/alkalosis, metabolic acidosis/alkalosis
- Compensated vs. uncompensated vs. partially compensated
- ABG interpretation drives treatment decisions in nearly every CSE scenario
2. Mechanical Ventilation
- Modes: AC (volume and pressure), SIMV, PSV, CPAP, BiPAP
- Initial settings: tidal volume (6–8 mL/kg IBW for ARDS, 8–10 mL/kg for other), rate, FiO₂, PEEP
- Troubleshooting: high pressure alarms, low volume alarms, auto-PEEP
- Weaning criteria: RSBI < 105, NIF ≤ -20 cmH₂O, VT > 5 mL/kg, RR < 25
3. Airway Management
- OPA, NPA sizing and insertion
- Endotracheal intubation (tube sizes, confirmation methods)
- Tracheostomy care and suctioning
- Emergency airway algorithms
4. Oxygen Therapy
- Device selection by FiO₂ needs: nasal cannula (24–44%), simple mask (35–55%), NRB (60–90%), high-flow nasal cannula (21–100%)
- Hypoxic vs. hypercapnic respiratory failure
- Oxygen toxicity risks
5. Pharmacology
- Short-acting bronchodilators (albuterol, levalbuterol)
- Anticholinergics (ipratropium)
- Corticosteroids (budesonide, fluticasone, methylprednisolone)
- Surfactant therapy
- Paralytics for intubation (succinylcholine, rocuronium)
6. Neonatal and Pediatric Respiratory Care
- Neonatal assessment (Apgar scoring, Silverman-Andersen index)
- Surfactant replacement therapy
- CPAP for neonates
- Pediatric airway differences
10-Week Study Plan: TMC + CSE Combined
| Week | Focus Area | Daily Study | Key Activities |
|---|---|---|---|
| Week 1 | ABG Interpretation + Acid-Base | 60–75 min | ABG practice drills, acid-base classification, compensation rules |
| Week 2 | Oxygen Therapy + Airway Management | 60–75 min | Device selection, FiO₂ calculations, intubation protocols, suctioning |
| Week 3 | Mechanical Ventilation — Basics | 60–75 min | Modes, initial settings, ARDS protocol, alarm troubleshooting |
| Week 4 | Mechanical Ventilation — Advanced + Weaning | 60–75 min | Weaning criteria, SBT protocol, auto-PEEP, patient-ventilator synchrony |
| Week 5 | Pharmacology + Aerosol Delivery | 60 min | Drug names/doses/routes, MDI/SVN/DPI technique, medication calculations |
| Week 6 | Neonatal/Pediatric + Pulmonary Function Testing | 60 min | Neonatal assessment, surfactant therapy, PFT interpretation (obstructive vs. restrictive) |
| Week 7 | TMC Full Practice Exams | 90–120 min | 2–3 full-length TMC practice tests (160 questions, 3 hours), analyze wrong answers |
| Week 8 | CSE Clinical Reasoning — Scenario Practice | 60–90 min | Practice branching scenarios, decision-tree exercises, clinical judgment |
| Week 9 | CSE Simulation Practice | 60–90 min | Timed CSE practice problems, focus on "what to do first" and "what to avoid" |
| Week 10 | Combined Review + Weak Area Focus | 90 min | Final review of high-yield topics, retake missed questions, exam logistics |
Total study time: 90–140 hours over 10 weeks
CSE-Specific Strategies (The Exam Going Away in 2027)
1. Think Like a Clinician, Not a Student
The CSE rewards clinical decision-making. Ask yourself: "If this patient were in front of me right now, what would I do first?" The correct answer is almost always the most immediately actionable intervention.
2. Always Assess Before Treating
In nearly every CSE scenario, the first correct action is gathering more data — check ABGs, auscultate, check SpO₂ — before jumping to treatment. Unless the patient is coding, assess first.
3. Know the "Never Do" Actions
Some actions are always wrong regardless of the scenario:
- Don't increase FiO₂ to 100% as a first response (adjust based on SpO₂/PaO₂)
- Don't extubate without meeting weaning criteria
- Don't ignore a tension pneumothorax (needle decompression first)
- Don't administer aerosolized medications during an active bronchospasm without first assessing severity
4. Watch the Clock
4 hours for 22 problems is approximately 11 minutes per problem. Some scenarios are shorter, some longer. If you're spending more than 15 minutes on a single problem, make your best decision and move on.
5. Practice the Branching Format
The CSE's branching format is unique. Standard multiple-choice practice won't prepare you for it. Seek out simulation-style practice problems that show you outcomes based on your choices.
The New 2027 Exam: What Replaces TMC + CSE
| Feature | Current (TMC + CSE) | New 2027 Exam |
|---|---|---|
| Number of exams | 2 separate exams | 1 single exam |
| Format | TMC: 160 MCQ + CSE: 22 simulations | 160 scored MCQ |
| Sessions | TMC: 3 hours + CSE: 4 hours | 2 sessions × 2 hours with 10-min break |
| Cut scores | Low (CRT) + High (CSE eligibility) | Low (CRT) + High (RRT) |
| Clinical simulation | Separate exam | Integrated into MCQ format |
Important for current CRT holders: The CRT-to-Registry admission policy (which allowed CRTs to upgrade to RRT by taking the CSE) will be eliminated on December 31, 2026. After that date, you must be a graduate of a CoARC-accredited program with at least an associate degree.
Respiratory Therapist Career Outlook (2026)
| Metric | Data |
|---|---|
| CRT median salary | $52,000–$58,000/year |
| RRT median salary | $61,000–$72,000/year |
| RRT premium over CRT | $8,000–$15,000/year |
| Job growth (2022–2032) | 13% (much faster than average) |
| Annual job openings | ~8,600 |
| Top settings | Hospitals, sleep labs, pulmonary rehab, home health |
The RRT credential consistently commands higher pay than CRT alone. Many hospitals now require or strongly prefer RRT for advancement into critical care, NICU, and supervisory roles.
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Our comprehensive RRT study course includes:
- All TMC content domains with detailed explanations
- CSE clinical reasoning practice with branching scenario training
- AI-powered study help — get instant explanations for ABGs, vent settings, and pharmacology
- Free forever — no credit card, no trial period
2026 is your last year for the CSE. Don't let the deadline pass without your RRT credential.
Official NBRC Resources
- NBRC Official Site — Registration, eligibility, credential information
- RRT Credential Requirements — Current TMC + CSE pathway details
- CSE Exam Details — Clinical Simulation Exam specifications
- 2027 Examination Changes — Official transition details
- CoARC Accredited Programs — Find accredited respiratory therapy programs
- Bureau of Labor Statistics — Respiratory Therapists — Career outlook data