When a baby arrives months too early or a toddler can no longer breathe effectively on their own, the clinician managing that child's airway and ventilator is often a respiratory therapist (RT). In neonatal and pediatric intensive care units (NICUs and PICUs), RTs make minute-by-minute decisions for patients whose margin for error can be measured in a few milliliters of air.
Take a closer look at why these respiratory care experts are so essential, what they do in each unit and the technical and human skills the work demands.
Caring for the youngest patients requires knowledge well beyond general respiratory care.
The lungs are among the last organs to mature before birth. Infants born very early may arrive before their air sacs have fully formed and before they produce enough surfactant, the substance that keeps those sacs from collapsing. Newborns also have soft, flexible chest walls, rely heavily on breathing through their noses and tire quickly when breathing becomes harder. A ventilation approach that would be routine for an adult can overinflate and injure these underdeveloped lungs.
Children aren't simply scaled-down adults, either. Their anatomy and physiology change from infancy through adolescence, so an RT might care for a 4-kilogram infant and a 70-kilogram teenager in the same shift. The following all depend on specific age and weight:
Children can also appear to compensate well right up until they deteriorate quickly, so pediatric RTs must constantly recalibrate what "normal" looks like for the patient in front of them.
The stakes in these units are uniquely high. RTs care for patients who can't describe their symptoms, often while worried parents watch every move. They attend high-risk deliveries and respond to emergencies as well as sometimes care for children who don't survive. Thriving in this environment calls for composure and resilience alongside a genuine commitment to family-centered care.
A NICU respiratory therapist supports some of the smallest and most medically fragile patients in the hospital.
NICU patients vary widely in size, maturity and diagnosis. Each group presents distinct respiratory challenges.
These infants may weigh less than a pound at birth. Their lungs are structurally immature and short on surfactant. Therefore, many need surfactant replacement, mechanical ventilation or noninvasive breathing support from their first minutes of life.
Babies born closer to term can still struggle with retained lung fluid, infection, aspiration or a difficult transition to breathing air. Their needs may be short-term, but they can escalate quickly.
Congenital heart defects and conditions such as congenital diaphragmatic hernia require RTs to balance oxygenation and ventilation carefully, often in coordination with surgical and cardiology teams.
A neonatal respiratory therapist frequently attends high-risk deliveries, and many complete the American Academy of Pediatrics' Neonatal Resuscitation Program (NRP). Beyond resuscitation, these therapists:
Because a newborn's trachea is so short, a tube that moves even slightly can slip into one lung or out of the airway entirely.
NICU ventilators are engineered to deliver tiny, precise breaths and detect an infant's faint efforts to breathe. RTs manage a range of support, including:
The goal is to provide as much support as the infant needs (and no more) to limit lung injury.
The PICU brings a different set of challenges, with patients ranging from infants to nearly grown teenagers.
PICU RTs care for children whose needs vary dramatically by age, size and diagnosis.
Children recovering from heart, airway, spine or other major surgeries often need ventilator support and careful weaning before breathing on their own.
Pneumonia, viral infections, sepsis and severe asthma can push a child's lungs past the point of compensation, requiring rapid escalation of support.
Head injuries, near-drowning and prolonged seizures can impair a child's drive or ability to breathe. This makes airway protection and precise carbon dioxide control critical.
Some patients live with tracheostomies, home ventilators or chronic lung disease and arrive in the PICU when an illness overwhelms their usual level of support.
In regard to the pediatric airway, young children have relatively large tongues, floppy epiglottises, more anterior larynxes and short tracheas. Infants also have large heads that can flex the neck and block the airway when they lie flat.
Because these features change as a child grows, RTs must adjust positioning, airway devices, tube sizes and intubation technique to each patient's developmental stage. Plus, because pediatric airways are so narrow, even mild swelling can significantly increase resistance to airflow.
PICU RTs use lung-protective ventilation — setting breath sizes based on a child's ideal body weight, titrating positive end-expiratory pressure (PEEP) and limiting airway pressures to prevent further lung injury. They may also manage high-frequency oscillatory ventilation for severe ARDS, noninvasive support to help children avoid intubation and, in some hospitals, patients on extracorporeal membrane oxygenation (ECMO). Just as important is recognizing when a child is ready to wean from the ventilator, which requires daily assessment and close collaboration with the care team.
Beyond bedside skills, neonatal and pediatric RTs rely on specialized clinical knowledge every day.
Nearly all neonatal and pediatric ventilator settings are weight-based. Neonatal volume-targeted ventilation commonly aims for tidal volumes of about 4 to 6 mL/kg; this means a 500-gram infant may receive breaths of just 2 to 3 milliliters. A 50-kilogram child needs roughly 100 times that volume. At the smallest sizes, even the air held in tubing and sensors matters, so RTs must account for equipment dead space and air leaks around the breathing tube.
Infants have highly flexible chest walls and less stable airways than adults, while diseased lungs can be stiff and uneven or prone to trapping air. RTs interpret pressure, flow and volume waveforms to identify problems like overinflation, air trapping or poor synchrony between patient and ventilator, then adjust settings accordingly.
RTs administer inhaled and instilled medications such as bronchodilators, racemic epinephrine and surfactant, many of which are dosed by weight or age. Small calculation errors can have outsized effects in tiny patients, so precision and double-checking are essential.
Blood gas samples in infants may come from umbilical lines, arterial lines or capillary heel sticks, and each method has its own limitations. RTs interpret results against age-appropriate norms — recognizing, for example, that care teams may accept somewhat higher carbon dioxide levels in premature infants to reduce ventilator-related lung injury.
Noninvasive monitoring helps RTs track gas exchange while limiting blood draws in small patients.
A heated sensor placed on the skin continuously estimates carbon dioxide and oxygen levels. RTs rotate sensor sites regularly to protect fragile newborn skin.
End-tidal CO2 monitoring measures exhaled carbon dioxide, helping confirm breathing tube placement after intubation and track ventilation over time.
Too little oxygen can harm a premature baby, but too much can damage developing eyes. In the landmark SUPPORT trial, a lower target range of 85% to 89% reduced severe retinopathy among survivors but was associated with more deaths than a 91% to 95% range. RTs must titrate oxygen carefully to keep each infant within the unit's target range.
Technical expertise is most impactful when paired with abilities like communication, teamwork and emotional resilience.
Parents in the NICU and PICU are often frightened and overwhelmed. In a family-centered care NICU or PICU, parents are treated as partners. RTs support family communication by explaining equipment and alarms in plain language, answering questions honestly and staying calm when a child's condition changes.
Many children go home with:
Before discharge, RTs teach families how to use and troubleshoot equipment, perform suctioning and airway clearance and recognize warning signs.
Contributing during rounds, resuscitations and patient transports, RTs work alongside:
The COVID-19 pandemic showed how central RTs are when they work side by side with doctors and nurses and that teamwork is just as vital in pediatric critical care.
Losing a young patient is among the hardest experiences in healthcare. It’s important for RTs to:
Neonatal and pediatric respiratory care demands precision, deep technical knowledge and compassion — often all at once. RTs who seek to specialize can pursue the National Board for Respiratory Care's Neonatal/Pediatric Specialty (NPS) credential, which requires first earning the Registered Respiratory Therapist (RRT) credential and represents a common next step for a NICU RRT looking to deepen their expertise.
At Nebraska Methodist College (NMC), the Associate of Science in Respiratory Care is a 24-month, CoARC-accredited program that pairs classroom learning with hands-on clinical experience and prepares graduates to pursue their Certified Respiratory Therapist (CRT) and RRT credentials. Practicing RTs can advance further through NMC's RRT to BSRT program.
For those exploring this path, you can:
NMC specializes in healthcare with programs in nursing, allied health and healthcare management. Explore more about our certificate, undergraduate and graduate nursing programs today.