The Adult Critical Care Specialist examination is the National Board for Respiratory Care (NBRC) specialty examination for registered respiratory therapists caring for critically ill adults: 170 multiple-choice items in four hours, built on a detailed content outline that weights ventilation, oxygenation and synchrony above every other topic and integration above recall. This guide works through the credential in full — the RRT prerequisite, the outline area by area, the patient-condition specifications, and maintenance under the Credential Maintenance Program.
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The credential at a glance
| Item | Verified position |
|---|---|
| Program | Adult Critical Care Specialist (ACCS) — specialty credential displayed with the RRT as RRT-ACCS |
| Certifying body | The National Board for Respiratory Care (NBRC) |
| Examination | 170 multiple-choice items (150 scored and 20 pretest) in 4 hours, computer-based; forms are assembled by a linear-on-the-fly system from the published content outline |
| Passing standard | NBRC does not publish a numeric pass mark for this examination in its candidate-facing material, so none is printed here |
| Eligibility | Hold the Registered Respiratory Therapist (RRT) credential and have held it for at least one year |
| Examination fees (body’s fees) | $300 for new applicants; $250 for re-applicants |
| Credential maintenance | NBRC credentials are maintained through the Credential Maintenance Program (CMP) on a five-year cycle |
| Content outline | NBRC Adult Critical Care Specialty Examination Detailed Content Outline, effective August 2026 — Respiratory Critical Care 80 scored items per form; General Critical Care 70 scored items per form |
| Administrator note | PassProfessor is independent and is not affiliated with NBRC |
The ACCS is best understood as the second examination of a respiratory therapist’s career, not a harder sitting of the first. The entry examinations certify that a therapist can practise respiratory care; the ACCS certifies that an experienced RRT can be the team’s specialist for the critically ill adult. Its eligibility rule states the relationship exactly: the RRT credential, held for at least one year.
Reading the verified facts
Every fact in this guide was pinned to NBRC primary material — NBRC’s published account of the RRT-ACCS credential, the Adult Critical Care Specialty Examination Detailed Content Outline effective August 2026, and NBRC’s Candidate Handbook and Credential Maintenance Program material — and the outline facts were verified on November 10, 2026 against the documents NBRC currently publishes. Three reading rules apply. First, outline vintage is decisive: the August 2026 outline re-weights the examination substantially — Respiratory Critical Care now carries 80 of the 150 scored items per form, against 59 in the superseded specification — so preparation material quoting the old split, however reputable, is teaching a retired paper. Second, where NBRC publishes no figure, the guide prints none: NBRC’s candidate-facing material for this examination states no numeric pass mark, and none appears here. Third, eligibility folklore is not eligibility: third-party pages circulate elaborate ACCS pathways involving thousands of critical care hours or special education programmes; NBRC’s published rule is the RRT credential held for at least one year, and that is the rule this guide states.
The prerequisite, placed correctly
The ACCS route begins a full credential earlier. A respiratory therapist earns the RRT through NBRC’s entry-level examination system for the CRT and RRT credentials, practises as an RRT, and becomes eligible for the specialty examination once the RRT has been held for one year. NBRC’s entry route is itself in transition — a single Respiratory Therapy Examination for the CRT/RRT route takes effect in January 2027 — but that transition concerns how the prerequisite credential is earned, not what the ACCS examines: the specialty examination’s published specification, verified for this guide in November 2026, stands on the August 2026 outline regardless of which entry examination produced the candidate’s RRT. Therapists holding the RRT should count from their RRT issue date, because the one-year holding rule is the only gate between them and this examination.
The route, step by step
Step one — hold the RRT for one year. Confirm the anniversary from the credential record; no additional education programme or experience-hours documentation is part of NBRC’s published ACCS eligibility. Step two — study the current outline before applying. The detailed content outline effective August 2026 is the examination’s specification — per-form item counts by area, cognitive level structure, and the patient-condition specifications described below — and NBRC’s examination preparation guidance in the Candidate Handbook directs candidates to it as the organising document for study. Step three — apply to NBRC and pay the fee: $300 as a new applicant, $250 as a re-applicant. Step four — schedule and sit the examination: 170 multiple-choice items in four hours, computer-based, with forms assembled by a linear-on-the-fly system — each candidate’s form is produced from the outline’s item sampling specifications, so two candidates’ papers differ in items while matching in structure. Step five — on passing, display and maintain the credential: the specialty is displayed with the prerequisite as RRT-ACCS, and maintenance runs through the Credential Maintenance Program on the five-year cycle, taken up in the closing section of this guide.
The outline in full
The detailed content outline effective August 2026 specifies each form at 150 scored items: 80 in Respiratory Critical Care and 70 in General Critical Care. Its cognitive specifications allocate items across recall, application, analysis and integration, with recall a small minority: the bulk of the form asks the candidate to apply, analyse and integrate. What follows states every area and sub-area with its per-form scored-item count.
I. Respiratory Critical Care — 80 items
A. Manage Airways — 24. Airway clearance techniques, in their non-pharmacologic and pharmacologic forms. Difficult airway recognition and techniques — the specialist is examined on seeing the difficult airway coming and on the techniques that answer it. Intubation techniques, with cricoid pressure, video laryngoscopy and the gum elastic bougie as the outline’s named examples. Artificial airways: specialty endotracheal tubes — subglottic suction, double-lumen, wire-reinforced, and Ring-Adair-Elwyn nasal or oral tubes — exchanging endotracheal tubes, and specialty tracheostomy tubes, including speaking tubes, proximal or distal extended-length tubes and the t-tube. At 24 items this is the outline’s second-largest block: airway management is examined as a repertoire, not a single skill.
B. Administer Specialty Inhalants — 4. Nitric oxide, helium-oxygen and nitrous oxide, examined through two tasks: utilisation of clinical protocols — initiation, weaning and liberation — and indications, contraindications and complications. Small in count, absolute in character: these are therapies where protocol discipline is the practice.
C. Apply Techniques to Enhance Ventilation, Oxygenation, or Synchrony — 48. The examination’s core. Initial settings for any invasive or noninvasive technique. Waveform analyses. Rescue techniques: recruitment maneuvers; prone patient positioning, with indications, contraindications and complications; and extracorporeal life support — venovenous ECMO, venoarterial ECMO and extracorporeal carbon dioxide removal. Strategies: liberation from invasive mechanical ventilation; prevention of lung injury from mechanical ventilation; participation in the care of patients who meet diagnostic criteria for ARDS; treatment of patients with traumatic injuries — head, cervical spine, chest, abdomen, long bone fractures, burn and inhalation; mobilisation, exercise and rehabilitation while receiving ventilatory support; PEEP management; and pharmacologic sedation and neuromuscular blockade, including participation in the care of patients experiencing pain, agitation and delirium. Differential or independent lung ventilation, by indications and techniques. And intrahospital transport of unstable and high-risk patients. D. Deliver Pharmacologic Agents — 4. Aerosolised agents other than bronchodilators — vasodilators, heparin, tranexamic acid and antimicrobials — and airway instillations other than for ACLS: epinephrine, prothrombotics and lidocaine. The mirror of the specialty inhalants block: route-specific pharmacology, examined tightly.
II. General Critical Care — 70 items
A. Evaluate Non-Pulmonary Systems to Manage Patient Care — 6. Neurologic presentations — EEG, neuromuscular function, level of consciousness, seizures, respiratory function, stroke, brain death criteria, elevated intracranial pressure, hypoventilation syndromes and targeted temperature management. Cardiovascular and hemodynamics — diagnostic testing and imaging including stress testing, catheterisation and echocardiography, noninvasive assessment of volume status, coronary artery disease, systemic hypertension, dysrhythmias, heart failure, types of shock, and preload, afterload and contractility. Renal — fluid status, urine output, acute kidney injury and renal replacement therapy. Metabolic — respiratory quotient, nutrition and feeding, acid-base balance, electrolyte imbalances and endocrine disorders. Gastrointestinal — intra-abdominal hypertension, feeding tube management, bowel obstruction, gastrointestinal bleeding, ileus and stress ulcer prophylaxis. Hematology — laboratory assessments, heparin-induced thrombocytopenia, venous thromboembolic prophylaxis and treatment, complications of anticoagulants and transfusion-related complications. Musculoskeletal — spinal cord injury, muscle atrophy and rhabdomyolysis. Six items carrying seven systems: the block tests breadth of anticipation, not depth in any one system.
B. Manage Contributors to Respiratory Failure — 15. Difficult airway predictors — airway patency, upper airway anatomy classification, inability to protect the airway, musculoskeletal disorders. Indices of respiratory physiology and mechanics — esophageal manometry and the ratio of oxygen saturation (ROX) index among the named measures. And the primary pulmonary etiologies, named in full: ARDS, aspiration, atelectasis, drug-induced injury, infectious diseases, mechanical airway obstruction, obstructive lung disease, pulmonary embolism, pulmonary hypertension, restrictive lung disease, sleep-disordered breathing and trauma. This is the differential-diagnosis block: the specialist identifies which failure is present before managing it.
C. Anticipate Care Based on Laboratory Results — 9. Complete blood count, including transfusion threshold and transfusion refusal; cardiac biomarkers — troponin and BNP; non-cardiac biomarkers — d-dimer, procalcitonin and lactate; electrolytes, BUN and creatinine; acid-base status with anion and osmolar gaps; coagulation studies; Gram stain, culture and sensitivities; respiratory pathogen studies; hemoximetry; and body fluid analyses — pleural, urine, cerebrospinal and peritoneal. The verb is the content: anticipate. Items give results and ask what care follows.
D. Anticipate Care Based on Imaging and/or Reports of Imaging — 4. Plain radiograph, CT, MRI, ultrasound and angiography, under the same anticipatory frame as the laboratory block.
E. Anticipate Effects of Pharmacologic Agents — 8. Sedatives and hypnotics; opioid and non-opioid analgesia; neuromuscular blocking agents; reversal agents; vasoactive agents; drug toxicities; and diuretics — each across induction and maintenance where applicable, and indications, contraindications and complications — plus the influence of co-morbid conditions on drug metabolism and excretion.
F. Anticipate Care Based on Nutritional Status — 2. Complications of malnutrition, route of feeding, and complications of nutritional support — aspiration, parenteral nutrition complications, catheter infection and refeeding syndrome.
G. Manage Patients with Infections and/or Sepsis — 4. Early recognition and supportive care; source control — removal of unnecessary lines, drains and airways, and drainage by surgical or non-surgical routes; anti-infectives administration; and utilisation of severity scoring systems — MODS, APACHE, SOFA and quick SOFA, and MEWS are the outline’s named instruments.
H. Manage End-of-Life Care — 3. Types of care — symptom-directed care, hospice, advance directives; determination of brain death; procedure for withdrawing life support; and care of the organ donor.
I. Plan for Disaster, Pandemic, and Mass Casualty Events — 2. Procedures for patient movement and patient protection, triage procedures, and equipment and supply management.
J. Advise an Interdisciplinary Team on Management of Challenging Cases — 3. Suggested modifications to the care plan based on the respiratory assessment, and response to modifications proposed by other team members — the outline’s explicit statement that the specialist’s judgement is a team resource.
K. Perform Procedures — 4. Arterial line insertion and removal, mini-bronchoalveolar lavage, esophageal probes including transpulmonary pressure monitoring and neurally adjusted ventilatory assist, and ultrasound assistance.
L. Troubleshoot Systems — 6. Chest tube drainage, bronchoscopy, hemodynamic monitoring — arterial pressure and central venous pressure named — intra-aortic balloon pump, left or right ventricular assist devices, and ECMO circuits. Troubleshooting is examined as its own competency: the system misbehaving, the specialist diagnosing the system.
M. Support Continuous Improvement — 4. The regulatory environment — device classification and failure reporting, institutional review boards, participation in management of sentinel events; policies and procedures — development of local protocols, adherence to national standards, utilisation of evidence-based guidelines; quality improvement initiatives; contribution to research and/or education; and evaluation of research literature.
The patient-condition specifications
The outline adds a second specification layer that candidates routinely miss: beyond content areas, each form is assembled to a patient-condition profile. Per form, the published targets are 47 items on pulmonary conditions — within them, obstructive lung diseases 22, ARDS 15, restrictive lung diseases 4, pulmonary embolism 4, pulmonary hypertension 4, massive hemoptysis 1, drowning 1, and burn or inhalation injury 1 — and 64 items on other medical and surgical conditions, including cardiac 12, post-surgical 10, infection and sepsis 8, trauma 6, immunocompromised 5, obesity 5, geriatric 4, shock 4, metabolic disorders 4, drug toxicity 4, neurologic and neuromuscular 4, toxins 2, psychiatric 2 and transplantation 1, with the balance of the form general. The study consequence is concrete: ARDS alone is specified at 15 items per form — a tenth of the scored paper — and obstructive disease at 22. Preparation weighted only by content area under-prices the conditions the form is guaranteed to keep meeting.
The sitting itself
Four hours, 170 items, computer-based — just under 85 seconds per item, on a form assembled for the individual candidate by the linear-on-the-fly system from the outline’s item sampling groups. The assembly method has one practical consequence: because every form is built to the same specification table, the published per-form counts are a reliable promise about the paper in front of you — the 48-item ventilation block and the 24-item airway block will be there, in something very close to those proportions, whichever form is drawn. NBRC’s Candidate Handbook carries the operational rules for the sitting — admission, identification, testing restrictions, score reporting — and its standing preparation counsel: review the detailed content outline to identify personal strengths and weaknesses before testing, and use NBRC’s published practice and self-assessment materials for format familiarity.
A study plan built on how this examination is actually put together
Build the plan from both specification layers. First, the core block: ventilation, oxygenation and synchrony (48) plus airways (24) — 72 of 150 scored items, nearly half the form — studied as decision practice: initial settings set and defended, waveforms read aloud until the abnormality names itself, liberation criteria applied to worked patients, PEEP and rescue strategies chosen against ARDS physiology, and the trauma, sedation and pain-agitation-delirium strands worked inside ventilator scenarios rather than separately. Second, the condition layer: ARDS (15 per form) and obstructive disease (22) drilled as conditions in their own right, then the cardiac, post-surgical, sepsis and shock clusters. Third, the anticipation blocks — laboratories (9), pharmacologic effects (8), imaging (4) and nutritional status (2) — studied in the outline’s direction, from result to care: given this lactate, this waveform, this drug infusion, what happens next and what does the specialist do about it. Fourth, the systems breadth: contributors to respiratory failure (15) as differential practice, non-pulmonary systems (6) as a structured sweep of the seven named systems, and troubleshooting (6) practised system by system. Fifth, the professional strands — sepsis management, end-of-life care, disaster planning, team advice, procedures and continuous improvement (21 items combined) — cheap marks for the candidate who has covered them deliberately. Close with full-length timed practice at the four-hour specification.
The working method: turning the outline into a performance
Waveform-first sessions. A standing share of every study block opens with ventilator waveforms and scalar data before any question is attempted, because the examination’s largest block assumes waveform fluency. An error log by specification cell. Missed items are recorded by content area, by condition, and by failure type — physiology not known, physiology known but the next action wrong, data misread (waveform, laboratory, imaging), or the specialist’s role missed. After two weeks the log shows which layer of the specification is leaking marks. Anticipation drills. Results without patients: a laboratory panel, an image report, a drug list — and the candidate states the expected course and the respiratory plan before seeing any stem. Timed blocks at true pace. Eighty-five seconds an item across four hours is an endurance discipline; untimed accuracy routinely overstates timed performance by the margin that decides specialty examinations.
The errors this examination is built to catch
Studying the superseded outline. The August 2026 specification re-weighted the paper — Respiratory Critical Care at 80 items, ventilation and synchrony at 48 — and material built to the older 59/91 split misallocates nearly a fifth of preparation. Believing the eligibility folklore. Multi-thousand-hour experience pathways for ACCS circulate on third-party pages; NBRC’s published gate is the RRT held one year, and candidates who delay applying while accumulating imagined requirements are postponing a credential they already qualify to attempt. Preparing recall for an integration paper. Lists of settings and tube sizes are the entry ticket, not the performance; the form’s architecture prices analysis and integration. Ignoring the condition specifications. A candidate can know the content areas and still be ambushed by the form’s guaranteed ARDS and obstructive-disease density. Treating general critical care as garnish. Seventy of 150 scored items — laboratories, pharmacology, sepsis, shock, end-of-life care — sit outside the respiratory core; the credential’s name contains “Critical Care” twice over, and the outline means both halves.
After the sitting: the credential and its maintenance
The successful candidate holds the RRT-ACCS specialty credential and maintains it under NBRC’s Credential Maintenance Program (CMP), the continuing-competency system governing NBRC credentials on a five-year cycle. The CMP’s design is assessment-led: its assessments are deliberately focused on content that changes most rapidly and puts the public at highest risk, and the CMP detailed content outlines are drawn from the same task base as the credentialing examinations — for the ACCS, the maintenance assessments revisit the adult critical care tasks, with NBRC identifying each year’s most-missed concepts from actual assessment performance and publishing them as study intelligence for the next cycle. An explanation and reference citation accompany assessment items, making each assessment a study instrument as well as a check. The holder’s practical obligations are to follow the CMP schedule attached to their credential in the NBRC system — assessment windows, any continuing education documentation the program requires of them, and the program’s fees — and to treat the annual assessment cycle as the profession’s scheduled refresh on exactly the fast-moving critical care content this examination certifies. State licensure runs on its own separate calendar and rules, untouched by the credential’s maintenance cycle.
Frequently asked questions
What is the eligibility requirement, exactly?
Hold the Registered Respiratory Therapist (RRT) credential, and have held it for at least one year. NBRC publishes no additional education-programme or experience-hours pathway for the ACCS in its candidate-facing material.
How many items are on the examination, and how are they divided?
170 multiple-choice items in four hours: 150 scored and 20 pretest. Each scored form carries 80 Respiratory Critical Care items and 70 General Critical Care items under the outline effective August 2026.
Which single topic carries the most items?
Apply Techniques to Enhance Ventilation, Oxygenation, or Synchrony — 48 items per form, nearly a third of the scored examination — covering initial settings, waveform analysis, rescue techniques including prone positioning and extracorporeal life support, liberation and lung-protective strategies, ARDS care, PEEP management, and sedation and neuromuscular blockade in the ventilated patient.
What score passes?
NBRC does not publish a numeric pass mark for this examination in its candidate-facing material, and this guide prints none. Pass figures on third-party pages are not NBRC-published facts.
What does the examination cost?
$300 for new applicants and $250 for re-applicants — NBRC’s fees, payable to NBRC, not PassProfessor charges.
What are the patient-condition specifications?
A second layer of the outline: each form targets 47 pulmonary-condition items (obstructive lung diseases 22, ARDS 15, restrictive diseases 4, pulmonary embolism 4, pulmonary hypertension 4, massive hemoptysis 1, drowning 1, burn/inhalation injury 1) and 64 items on other medical and surgical conditions (cardiac 12, post-surgical 10, infection/sepsis 8, trauma 6, and smaller counts across immunocompromised, obesity, geriatric, shock, metabolic, drug toxicity, neurologic/neuromuscular, toxins, psychiatric and transplantation), with the balance general.
What does linear-on-the-fly assembly mean for me?
Forms are generated for each candidate from item sampling groups built to the outline’s specifications. Item sets differ between candidates; the structure — content counts, condition profile, cognitive mix — is held to the published specification for every form.
How much of the examination is recall?
A small minority. The outline’s per-form cognitive totals allocate the bulk of items to application, analysis and integration; the examination tests managing and anticipating, not listing.
Does the January 2027 entry-examination change affect the ACCS?
NBRC publishes a single Respiratory Therapy Examination for the CRT/RRT entry route effective January 2027. That change concerns how the RRT prerequisite is earned. The ACCS specification in this guide — the August 2026 outline, verified November 10, 2026 — is the specialty examination’s currently published form; candidates should confirm current specs with NBRC when they apply.
How is the credential maintained?
Through NBRC’s Credential Maintenance Program on a five-year cycle: periodic assessments focused on rapidly changing, high-risk content drawn from the same tasks as the credentialing examination, with the holder’s specific schedule, windows and any documentation requirements administered through their NBRC record. State licensure is separate.
What roles do holders point to?
NBRC’s own account names ICU lead or supervisor roles, transport team membership, and ECMO specialist practice among the directions the credential supports — roles in which the team relies on the therapist’s critical care depth.
When was the ACCS introduced?
The examination was first administered in July 2012.
Is PassProfessor affiliated with NBRC?
No. PassProfessor is an independent preparation provider. NBRC alone credentials, and applications are made to NBRC.
When does enrollment open for the PassProfessor program?
The program is in the works and enrollment is not yet open. Leave an email address on this page and PassProfessor will write to you when the program is ready — and only about this program. The companion Adult Critical Care Specialist program page describes what the program will cover.