RRT-ACCS Exam Flashcards

Q: What is the NBRC RRT-ACCS exam format and length?

The ACCS exam has 170 multiple-choice items - 150 scored and 20 unscored pretest questions - delivered as a linear-on-the-fly (LOFT) computer-based exam at PSI test centers. Candidates have 4 hours to complete the exam, and at least 5 items on every form address medical ethics.

Q: What is the RRT-ACCS pass rate?

NBRC's 2024 Examinations in Review reports a 61.0% pass rate for new ACCS candidates and 36.9% for repeat candidates. NBRC does not publish the numeric scaled cut score used to pass an ACCS attempt; it is set through standard-setting methodology.

Q: What happens if I fail the RRT-ACCS exam?

NBRC's repeat-attempt policy allows two attempts with no mandatory waiting period between them. After failing twice, candidates must wait at least 180 days before the next attempt. This 2-attempts-then-180-day rule applies to all NBRC specialty exams, including ACCS.

Q: Who is eligible to sit for the RRT-ACCS exam?

Candidates must hold the NBRC Registered Respiratory Therapist (RRT) credential and must have held it for at least one year before applying for the ACCS specialty exam. There is no separate employer sponsorship requirement.

Q: What are the RRT-ACCS content domains and weights?

Per the August 2026 NBRC content outline, Respiratory Critical Care makes up 80 of 150 scored items (53%) - airway management, ventilation/oxygenation/synchrony techniques, specialty inhalants, and pharmacologic agents - while General Critical Care makes up the remaining 70 items (47%), covering hemodynamics, labs/imaging, sepsis, sedation/delirium, procedures, and end-of-life/ethics.

Question 1

Why is a bougie used during a difficult intubation?

Accepted Answer

A bougie is a flexible introducer passed into the trachea when the glottis is poorly visualized; the endotracheal tube is then railroaded over it. It is a first-line rescue for anticipated or encountered difficult laryngoscopy.

Question 2

What does video laryngoscopy improve over direct laryngoscopy?

Accepted Answer

Video laryngoscopy uses a camera at the blade tip to improve glottic visualization, often achieving a better view than direct laryngoscopy in patients with limited mouth opening or anterior airways, improving first-pass success.

Question 3

What is cricoid pressure intended to do during intubation?

Accepted Answer

Cricoid pressure (Sellick maneuver) compresses the esophagus against the cervical spine to reduce passive regurgitation and aspiration risk during rapid sequence intubation; it should be released if it worsens the laryngeal view.

Question 4

What does the Mallampati classification predict?

Accepted Answer

The Mallampati class (I-IV) is a bedside score based on visible oropharyngeal structures with the mouth open and tongue protruded; higher classes (III-IV) predict a more difficult direct laryngoscopy and intubation.

Question 5

How does a subglottic suction endotracheal tube reduce risk in ventilated ICU patients?

Accepted Answer

It has a separate lumen opening above the cuff that allows aspiration of secretions pooling on top of the cuff, reducing microaspiration into the lower airway and lowering ventilator-associated pneumonia (VAP) risk.

Question 6

When is a double-lumen endotracheal tube indicated?

Accepted Answer

A double-lumen tube isolates the two mainstem bronchi to allow independent lung ventilation or one-lung ventilation, used for unilateral lung pathology such as massive hemoptysis or bronchopleural fistula.

Question 7

What is the purpose of an airway exchange catheter?

Accepted Answer

It is a long, hollow, semi-rigid catheter placed through an existing endotracheal tube before removal, allowing oxygenation and a guided, lower-risk exchange to a new tube if reintubation becomes necessary.

Question 8

What does a tracheostomy T-tube trial assess?

Accepted Answer

A T-piece (T-tube) trial delivers humidified gas to a capped-open tracheostomy without ventilator support, used as a weaning/liberation step to assess readiness for decannulation once ventilator weaning is complete.

Question 9

What tidal volume target defines lung-protective ventilation in ARDS?

Accepted Answer

6 mL/kg of predicted body weight (PBW), calculated from height and sex rather than actual body weight, per the ARDSNet protocol, to limit volutrauma while keeping plateau pressure at or below 30 cmH2O.

Question 10

What plateau pressure limit is targeted in ARDSNet lung-protective ventilation?

Accepted Answer

Plateau pressure (Pplat), measured during an inspiratory hold, should be kept at 30 cmH2O or less to limit alveolar overdistension; tidal volume is reduced further toward 4 mL/kg PBW if Pplat exceeds this limit.

Question 11

What is driving pressure and what is its target in ARDS?

Accepted Answer

Driving pressure equals plateau pressure minus PEEP (Pplat - PEEP), reflecting the pressure actually stretching the lung per breath; keeping driving pressure below 15 cmH2O is associated with lower ARDS mortality.

Question 12

How is the P/F ratio calculated and what does it measure?

Accepted Answer

P/F ratio equals PaO2 divided by FiO2 (FiO2 as a decimal). It quantifies the severity of hypoxemia independent of the oxygen percentage delivered and is the core criterion of the Berlin ARDS definition.

Question 13

What P/F ratio ranges define mild, moderate, and severe ARDS under the Berlin definition?

Accepted Answer

With PEEP/CPAP of 5 cmH2O or more: mild ARDS is P/F 200-300, moderate is P/F 100-200, and severe is P/F below 100. Onset must be within 1 week of a known insult with bilateral opacities not fully explained by effusion or cardiac failure.

Question 14

What is permissive hypercapnia and when is it used in ARDS?

Accepted Answer

Permissive hypercapnia tolerates a higher-than-normal PaCO2 and lower pH as a trade-off for using lower tidal volumes and plateau pressures in ARDS, protecting the lung as long as the acidosis remains hemodynamically tolerated.

Question 15

How is the ARDSNet PEEP/FiO2 table used, and what is a recruitment maneuver?

Accepted Answer

The ARDSNet PEEP/FiO2 table pairs a target FiO2 with a corresponding PEEP level to standardize oxygenation strategy; a recruitment maneuver applies a sustained higher airway pressure briefly to reopen collapsed alveoli before setting maintenance PEEP.

Question 16

What ventilator finding suggests overdistension versus a recruitable lung when adjusting PEEP?

Accepted Answer

If increasing PEEP raises plateau pressure while compliance falls, the lung is being overdistended and PEEP should be reduced; if compliance improves or holds steady as PEEP rises, the higher PEEP is likely recruiting collapsed alveoli.

Question 17

What criteria and settings define candidacy for prone positioning in ARDS?

Accepted Answer

Per the PROSEVA protocol, prone positioning is used for a P/F ratio below 150 on FiO2 of 0.6 or higher with PEEP of 5 cmH2O or more; sessions are sustained for at least 16 hours per day to improve V/Q matching and oxygenation.

Question 18

What are the major complications of prone positioning?

Accepted Answer

Facial and airway edema, pressure injuries at the face/chest/knees, and accidental line or tube dislodgement during turning are the main complications; careful padding and a coordinated turn team reduce risk.

Question 19

How do VV ECMO and VA ECMO differ?

Accepted Answer

VV ECMO provides respiratory support only (oxygenation and CO2 removal) for refractory hypoxemic or hypercapnic respiratory failure without native cardiac support; VA ECMO adds circulatory support for refractory cardiogenic shock or combined cardiopulmonary failure.

Question 20

What ELSO criteria commonly justify initiating ECMO for respiratory failure?

Accepted Answer

ELSO guidance supports ECMO consideration for a P/F ratio below 80, a Murray lung injury score greater than 3, or a pH below 7.25 with an elevated PaCO2 despite optimized conventional mechanical ventilation.

Question 21

What is the Rapid Shallow Breathing Index (RSBI) and what value predicts weaning success?

Accepted Answer

RSBI equals respiratory rate in breaths per minute divided by tidal volume in liters, measured during brief unsupported breathing. An RSBI below 105 predicts a higher likelihood of successful weaning or extubation.

Question 22

What confirms a patient is ready to attempt extubation after passing a spontaneous breathing trial (SBT)?

Accepted Answer

Stable oxygenation and hemodynamics during the SBT, plus adequate cough strength, secretion burden, and mentation to protect the airway; a positive cuff-leak test also lowers concern for post-extubation stridor before removing the tube.

Question 23

How is static compliance calculated, and what does a falling value signal in ARDS?

Accepted Answer

Static compliance equals tidal volume divided by (plateau pressure minus PEEP). It reflects lung and chest-wall stiffness; a falling static compliance in ARDS signals worsening lung stiffness or overdistension.

Question 24

What does a widened alveolar-arterial (A-a) gradient indicate, and what is a normal value?

Accepted Answer

The A-a gradient (PAO2 minus PaO2) estimates how much oxygen transfer is impaired by shunt, V/Q mismatch, or diffusion defect rather than hypoventilation; normal is roughly 5-10 mmHg on room air and widens with age and worsening gas-exchange disease.

Question 25

What is inhaled nitric oxide (iNO) used for, and what is its key complication?

Accepted Answer

iNO is a selective pulmonary vasodilator that improves V/Q matching and reduces pulmonary vascular resistance in refractory hypoxemia or pulmonary hypertension; its key complication is methemoglobinemia, which requires monitoring during prolonged use.

Question 26

When is heliox indicated, and why does it work?

Accepted Answer

Heliox, a helium-oxygen mixture, is indicated for upper airway obstruction such as post-extubation stridor or severe asthma because its lower density reduces turbulent airflow resistance, decreasing the work of breathing.

Question 27

What aerosolized or instilled agents manage airway bleeding or mucus plugging in the ICU?

Accepted Answer

Aerosolized or instilled tranexamic acid (TXA) and epinephrine control airway bleeding; aerosolized heparin reduces mucus plugging; aerosolized antimicrobials target resistant airway pathogens; instilled lidocaine provides topical airway anesthesia.

Question 28

How do CVP and PCWP differ as preload measures?

Accepted Answer

Central venous pressure (CVP, normal 2-8 mmHg) estimates right atrial/right heart preload, while pulmonary capillary wedge pressure (PCWP, normal 6-12 mmHg) estimates left atrial preload; PCWP requires a pulmonary artery catheter and better reflects left-sided filling.

Question 29

What are normal cardiac index and systemic vascular resistance (SVR), and how do preload and afterload differ?

Accepted Answer

Normal cardiac index is 2.5-4 L/min/m2 and normal SVR is 800-1200 dynes-sec/cm5. Preload is the volume stretching the ventricle before contraction; afterload is the resistance the ventricle must overcome during ejection.

Question 30

What does the ROX index predict in patients on high-flow nasal cannula (HFNC)?

Accepted Answer

The ROX index (SpO2/FiO2 divided by respiratory rate) predicts the risk of HFNC failure requiring escalation to noninvasive or invasive ventilation; a lower ROX index signals higher failure risk and warrants closer monitoring.

Question 31

What intra-abdominal pressure defines intra-abdominal hypertension (IAH), and what defines abdominal compartment syndrome (ACS)?

Accepted Answer

IAH is sustained intra-abdominal pressure above 12 mmHg; abdominal compartment syndrome is intra-abdominal pressure above 20 mmHg with new organ dysfunction, which can impair diaphragmatic excursion and ventilation.

Question 32

What target temperature range is used for targeted temperature management (TTM) after cardiac arrest?

Accepted Answer

TTM targets a controlled temperature of 32-36 degrees C for a defined period after arrest to reduce secondary neurologic injury, followed by careful, controlled rewarming and fever avoidance.

Question 33

What lab trend signals acute kidney injury (AKI) as a contributor to critical illness?

Accepted Answer

A rising serum creatinine paired with falling urine output signals AKI, which can be driven by hypoperfusion, sepsis, nephrotoxins, or abdominal compartment syndrome and complicates fluid and drug dosing decisions.

Question 34

What are the normal ranges for arterial pH, PaCO2, and HCO3?

Accepted Answer

Normal ABG values: pH 7.35-7.45, PaCO2 35-45 mmHg, HCO3 22-26 mEq/L. These values are interpreted together to classify respiratory versus metabolic acidosis or alkalosis and assess compensation.

Question 35

What does an elevated serum lactate indicate in a critically ill patient?

Accepted Answer

Elevated lactate is a marker of tissue hypoperfusion and anaerobic metabolism, commonly from sepsis, shock, or severe respiratory failure; trending lactate clearance helps guide resuscitation adequacy.

Question 36

How is heparin-induced thrombocytopenia (HIT) recognized, and how is a D-dimer used?

Accepted Answer

HIT is suspected with a significant platelet count drop occurring days after heparin exposure, often with new thrombosis; a D-dimer helps rule out a clot when pretest probability is low, though it does not diagnose HIT itself.

Question 37

What imaging finding is required to support the Berlin definition of ARDS?

Accepted Answer

Bilateral opacities on chest X-ray or CT that are not fully explained by effusion, lobar or lung collapse, or nodules, appearing within one week of a known clinical insult, are required alongside the P/F ratio and PEEP criteria.

Question 38

What is the first-line vasopressor for septic shock, versus the preferred agents for cardiogenic shock?

Accepted Answer

Norepinephrine is the first-line vasopressor for septic shock per Surviving Sepsis Campaign guidance; dobutamine or milrinone are preferred inotropes for low-output cardiogenic shock to augment contractility without excessive vasoconstriction.

Question 39

How should sedative choice and dosing be guided in a mechanically ventilated ICU patient?

Accepted Answer

Sedatives such as propofol or dexmedetomidine should be titrated to a specific RASS target, often -2 to 0, using validated scales, paired with daily sedation interruption (SAT), to avoid oversedation that prolongs ventilation and delirium risk.

Question 40

What monitoring risk must be tracked when a patient is on a continuous heparin infusion?

Accepted Answer

Continuous heparin requires monitoring of aPTT or anti-Xa levels for therapeutic dosing and platelet counts for early detection of heparin-induced thrombocytopenia, especially after several days of exposure.

Question 41

What is the preferred route and timing for nutrition support in critically ill ICU patients?

Accepted Answer

Early enteral nutrition, started within about 24-48 hours of ICU admission, is preferred over parenteral nutrition when the gut is functional; gastric residual volumes are monitored without over-restricting feeds to reduce aspiration risk while avoiding underfeeding.

Question 42

What must be completed within the Surviving Sepsis Campaign 1-hour bundle?

Accepted Answer

Within the first hour: measure lactate, obtain blood cultures before giving antibiotics, administer broad-spectrum antibiotics, give a 30 mL/kg crystalloid bolus for hypotension or lactate 4 or above, and start norepinephrine if the patient remains hypotensive.

Question 43

What defines septic shock, and what MAP goal guides vasopressor titration?

Accepted Answer

Septic shock is sepsis with persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP) of 65 mmHg or higher, plus a serum lactate above 2 mmol/L despite adequate fluid resuscitation.

Question 44

What two elements confirm a clinical brain death determination?

Accepted Answer

Two separate clinical exams confirming absence of brainstem reflexes and cortical function, plus a formal apnea test showing no respiratory drive despite adequate CO2 stimulus, are required; ACCS content also embeds at least 5 ethics-related items, such as withdrawal-of-support and organ donation discussions, on every exam minipool.

Question 45

What triage framework is used for rapid mass-casualty or disaster sorting?

Accepted Answer

START (Simple Triage and Rapid Treatment) rapidly sorts patients by respirations, perfusion, and mental status into immediate, delayed, minor, or deceased/expectant categories to allocate limited resources during a disaster.

Question 46

What is the respiratory therapist's core contribution during multidisciplinary ICU rounds?

Accepted Answer

The RT reports ventilator settings and trends, weaning progress, airway status, and gas-exchange data, and uses structured communication such as SBAR so the team can adjust the ventilation and sedation plan collaboratively each shift.

Question 47

How does a mini-BAL diagnose ventilator-associated pneumonia (VAP) without bronchoscopy?

Accepted Answer

A mini-bronchoalveolar lavage passes a blind catheter through the endotracheal tube to sample distal airway secretions for quantitative culture, allowing VAP diagnosis at the bedside without a flexible bronchoscope.

Question 48

When should an intra-aortic balloon pump (IABP) inflate and deflate, and what is a key contraindication?

Accepted Answer

The IABP inflates at the dicrotic notch, the start of diastole, to augment coronary perfusion, and deflates just before systole to reduce afterload; severe aortic insufficiency is a key contraindication because inflation worsens regurgitant flow.

Question 49

What does 'chatter' in an ECMO circuit usually indicate, and how does VAD flow differ from native pulsatile flow?

Accepted Answer

ECMO circuit chatter, vibration in the drainage line, usually indicates inadequate venous return from hypovolemia or low preload, requiring volume or cannula repositioning; continuous-flow VADs produce a reduced or absent pulse pressure compared to native pulsatile cardiac output.

Question 50

How is VAP-bundle compliance monitored as a continuous-improvement metric in the ICU?

Accepted Answer

Units track adherence to VAP-prevention bundle elements such as head-of-bed elevation, daily SAT/SBT pairing, oral care, and subglottic suctioning as a process metric, and correlate compliance rates with VAP incidence to drive protocol updates.

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