Airway & Specialty Therapies
21%of exam
Ventilation, Oxygenation & Synchrony
32%of exam
General Critical Care
47%of exam
Quick Facts
- Exam
- ACCS
- Credential
- RRT-ACCS
- Questions
- 170 total
- Scored
- 150 scored
- Pretest
- 20 unscored
- Time
- 4 hours
- Format
- LOFT CBT at PSI
- Fee
- $300 new $250 repeat
- Prerequisite
- RRT for 1+ year
- Pass rate
- 61.0% new 2024
- Blueprint
- August 2026 DCO
Airway Clearance & Difficult Airway
- Airway clearance
- Non-pharm plus pharm therapies
- Difficult airway
- Recognize plus escalate technique
- Bougie
- Blind difficult intubation aid
- Video laryngoscopy
- Improves glottic visualization
- Cricoid pressure
- Reduces aspiration during intubation
- Mallampati class
- Predicts difficult intubation
Artificial Airways
- Subglottic suction ETT
- Reduces VAP risk
- Double-lumen tube
- Independent lung ventilation
- RAE tube
- Oral or nasal surgery
- Wire-reinforced ETT
- Resists kinking
- Exchanging ETT
- Airway exchange catheter
- Speaking trach tube
- Allows phonation cuff down
- T-tube
- Tracheostomy weaning trial
Specialty Inhalants
- Inhaled nitric oxide
- Selective pulmonary vasodilator
- Heliox
- Lower density gas mix
- Nitrous oxide
- Analgesic sedation adjunct
- iNO complication
- Methemoglobinemia risk
- Heliox indication
- Upper airway obstruction
Airway Pharmacology
- Aerosolized TXA
- Controls airway bleeding
- Aerosolized heparin
- Reduces mucus plugging
- Aerosolized antimicrobials
- Targets resistant pathogens
- Instilled epinephrine
- Airway bleeding control
- Instilled lidocaine
- Topical airway anesthesia
DOPE Crash Check
Sudden vent decompensation: check displacement, obstruction, pneumothorax, equipment failure.
Displacement of tubeObstruction or mucus plugPneumothorax tensionEquipment failure or leak
VV ECMO vs VA ECMO
VV ECMO
- Respiratory support only
- Refractory hypoxemia hypercapnia
- No hemodynamic support
VA ECMO
- Respiratory plus cardiac support
- Refractory cardiogenic shock
- Provides hemodynamic support
VA adds circulatory support
ARDS Severity & Rescue Picker
- P/F 200 to 300→Mild ARDS lung protection
- P/F 100 to 200→Moderate ARDS consider prone
- P/F below 100→Severe ARDS prone plus consider ECMO
- Refractory hypoxemia→VV ECMO evaluation
- Rising plateau pressure→Decrease tidal volume
ARDS & Lung Protection
- Tidal volume target
- 6 mL/kg PBW
- Plateau pressure limit
- 30 cmH2O or less
- Driving pressure target
- Below 15 cmH2O
- Permissive hypercapnia
- Accept higher PaCO2
- Mild ARDS
- P/F 200 to 300
- Moderate ARDS
- P/F 100 to 200
- Severe ARDS
- P/F below 100
Driving Pressure vs Plateau
Plateau pressure
- Alveolar distending pressure
- Limit 30 or less
Driving pressure
- Plateau minus PEEP
- Target below 15
Driving reflects lung strain
PEEP & Recruitment Picker
- Hypoxemia persists on FiO2→Increase PEEP per table
- Compliance improves with PEEP→Keep higher PEEP level
- Plateau rises overdistension→Reduce PEEP or volume
- Recruitable atelectasis suspected→Recruitment maneuver trial
- Hemodynamics drop after PEEP→Reduce PEEP fluid bolus
PEEP & Recruitment
- PEEP/FiO2 table
- ARDSNet titration guide
- Recruitment maneuver
- Sustained inflation opens alveoli
- Best PEEP
- Highest compliance or oxygenation
- Overdistension sign
- Rising plateau falling compliance
- Auto-PEEP
- Air trapping incomplete exhalation
Prone vs Recruitment Maneuver
Prone positioning
- Hours-long session
- Improves V/Q matching
Recruitment maneuver
- Brief pressure application
- Reopens collapsed alveoli
Prone is sustained recruitment
Weaning & Liberation Picker
- RSBI below 105→Proceed to SBT
- SBT tolerated 30 minutes→Assess extubation criteria
- Cuff leak absent→Consider steroid or delay
- Adequate cough and mentation→Extubate to support device
- SBT fails→Return to rest settings
Prone Positioning
- Prone criteria
- P/F below 150
- Prone FiO2/PEEP
- FiO2 0.6 PEEP 5+
- Session duration
- At least 16 hours
- Prone complication
- Pressure injury facial edema
ECMO & ECLS
- VV ECMO
- Refractory hypoxemic respiratory failure
- VA ECMO
- Refractory cardiogenic shock
- ECCO2R
- CO2 removal only
- ELSO oxygenation criteria
- P/F below 80
- ELSO Murray score
- Greater than 3
- ELSO pH criteria
- Below 7.25 high PaCO2
Waveforms & Synchrony
- Flow starvation
- Concave inspiratory flow curve
- Double triggering
- Breath stacking short Ti
- Reverse triggering
- Diaphragm follows vent breath
- Missed trigger
- Auto-PEEP blunts effort
- Scalar plateau
- No flow alveolar pressure
Weaning & Liberation
- RSBI
- f/VT below 105
- SBT criteria
- Stable oxygenation and hemodynamics
- SAT/SBT pairing
- Daily sedation and breathing trials
- Cuff leak test
- Predicts post-extubation stridor
- Extubation readiness
- Adequate cough and mentation
Capnography & Monitoring
- EtCO2 normal
- 35 to 45 mmHg
- Phase III
- Alveolar plateau segment
- Lost waveform
- Esophageal tube or arrest
- Transpulmonary pressure
- Esophageal balloon estimate
- NAVA signal
- Diaphragm EMG catheter
- Differential lung vent
- Asymmetric lung disease
RASS Ladder
RASS runs -5 unarousable to +4 combative.
-5 unarousable-2 to 0 target0 alert calm+4 combative violent
CVP vs PCWP
CVP
- Right atrial preload
- Normal 2 to 8
PCWP
- Left atrial preload
- Normal 6 to 12
Right side vs left side
Sedation & Delirium Picker
- RASS above target→Reduce sedation titrate down
- RASS below target→Perform SAT if safe
- CAM-ICU positive→Treat delirium non-pharm first
- Pain suspected nonverbal patient→Use behavioral pain scale
- Daily SAT passes→Pair with SBT same day
Hemodynamics
- CVP normal
- 2 to 8 mmHg
- PCWP normal
- 6 to 12 mmHg
- Mean PAP
- 10 to 20 mmHg
- Cardiac index
- 2.5 to 4 L/min/m2
- SVR normal
- 800 to 1200 dynes
- Preload
- Volume before contraction
- Afterload
- Resistance during ejection
ABCDEF Bundle
ABCDEF: pain, breathing trial, sedation choice, delirium, mobility, family.
A: pain assessmentB: breathing trialC: sedation choiceD: delirium monitorE: early mobilityF: family engagement
SAT vs SBT
SAT
- Stops sedation daily
- Assesses awakening safety
SBT
- Tests spontaneous breathing
- Assesses extubation readiness
Pair SAT then SBT
Hemodynamic Support Picker
- Septic shock MAP low→Norepinephrine first-line vasopressor
- Cardiogenic shock low output→Dobutamine or milrinone
- Refractory cardiogenic shock→Consider IABP or VAD
- Volume responsive hypotension→Crystalloid fluid bolus
- Right heart failure→Avoid excess fluid support RV
Sedation & Delirium
- RASS target
- -2 to 0
- RASS -5
- Unarousable to voice
- RASS +4
- Combative violent danger
- CAM-ICU positive
- Acute change plus inattention
- ABCDEF bundle
- Coordinated wake and breathe
Sepsis 1-Hour Bundle
Lactate, cultures, antibiotics, fluids, vasopressor within the first hour.
Lactate levelBlood cultures firstBroad antibiotics fast30 mL/kg fluidsNorepinephrine if hypotensive
qSOFA vs SOFA
qSOFA
- Bedside 3-criteria screen
- No labs needed
SOFA
- Six organ system score
- Requires lab values
qSOFA screens SOFA scores
Sepsis & Shock
- 1-hour bundle
- Lactate cultures antibiotics fluids
- Fluid bolus
- 30 mL/kg crystalloid
- MAP goal
- 65 mmHg or higher
- First vasopressor
- Norepinephrine per SSC
- qSOFA positive
- 2 of 3 criteria
- Septic shock
- Vasopressors plus lactate above 2
IABP vs VAD
IABP
- Counterpulsation timing dependent
- Needs some native function
VAD
- Continuous flow pump
- Supports failing ventricle fully
VAD replaces more function
Labs & Acid-Base
- pH normal
- 7.35 to 7.45
- PaCO2 normal
- 35 to 45 mmHg
- HCO3 normal
- 22 to 26 mEq/L
- Elevated lactate
- Tissue hypoperfusion marker
- HIT diagnosis
- Platelet drop plus heparin
- D-dimer
- Rules out clot
Non-Pulmonary Systems
- ROX index
- Predicts HFNC failure risk
- IAH threshold
- Above 12 mmHg
- Abdominal compartment syndrome
- Above 20 with dysfunction
- TTM target
- 32 to 36 degrees C
- Brain death exam
- Two exams plus apnea test
- AKI marker
- Rising creatinine falling output
Procedures & Troubleshooting
- Mini-BAL
- Diagnoses VAP without scope
- IABP timing
- Inflate at dicrotic notch
- IABP contraindication
- Severe aortic insufficiency
- Chest tube leak
- Continuous bubbling water seal
- ECMO chatter
- Low preload or hypovolemia
- VAD flow
- Continuous flow reduced pulse
End-of-Life & Ethics
- Ethics items
- At least 5 per minipool
- Brain death
- Irreversible loss of function
- Organ donor care
- Hemodynamic and hormonal support
- START triage
- Rapid disaster sorting
- Withdrawal of support
- Comfort-focused symptom management
Common Traps
Oxygenation vs Ventilation Failure
Oxygenation needs FiO2 or PEEP ≠ Ventilation needs minute volume change
Ethics Items vs Clinical Items
At least 5 ethics items ≠ Embedded within every minipool
Scored vs Pretest Items
150 items count toward score ≠ 20 pretest items look identical
New vs Reapplicant Fee
New applicants pay $300 ≠ Reapplicants pay $250 only
CVP vs PCWP Preload
CVP reflects right heart ≠ PCWP reflects left heart
RASS vs CAM-ICU Purpose
RASS measures sedation depth ≠ CAM-ICU screens for delirium
SAT vs SBT Focus
SAT stops sedation infusion ≠ SBT tests breathing readiness
Last Minute
- 1.170 items: 150 scored + 20 pretest
- 2.4-hour LOFT exam at PSI
- 3.RRT required for 1+ year
- 4.ARDS tidal volume: 6 mL/kg
- 5.Plateau pressure limit: 30 or less
- 6.Driving pressure target: below 15
- 7.Prone criteria: P/F below 150
- 8.VV ECMO: refractory hypoxemia
- 9.VA ECMO: refractory cardiogenic shock
- 10.RSBI below 105 predicts success
- 11.RASS target: -2 to 0
- 12.Sepsis bundle completed within 1 hour
- 13.MAP goal: 65 mmHg or higher
- 14.At least 5 ethics items
- 15.New fee $300, repeat fee $250
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