The RT’s Role in the NICU

Respiratory complications are the primary reason infants are admitted to neonatal intensive care units (NICUs). As a result, respiratory therapists play an essential role in helping oversee care and development, including critical decisions about oxygenation and ventilation.

September is NICU Awareness Month, creating an opportunity to recognize affected infants and their families, as well as the healthcare professionals who oversee care and support. For RTs, it also offers a chance to highlight a specialized area of respiratory care that requires technical expertise, collaboration, a deep understanding of neonatal development, and the ability to work with families under extreme distress.

Caring for Developing Lungs

Every year, roughly 1 in 10 U.S. infants are admitted to a NICU, according to the Centers for Disease Control and Prevention. Reasons can include prematurity, birth defects, respiratory and feeding problems, infections, and other medical conditions.

For Traci Wolfe, MS, RRT-NPS, C-NPT, C-ELBW, Manager of NICU Respiratory Care at Silver Cross Hospital, a RT’s day-to-day responsibility begins with monitoring the respiratory stability of NICU patients and intervening when necessary.

“The best place where our expertise is used on a day-to-day basis is with our knowledge of lung development,” Wolfe says. A premature baby’s immature lungs are part of a much larger developmental picture, she adds.

Treatment varies by gestational age, with ventilation and oxygenation strategies changing significantly from a 22-week infant to a 29-week or full-term baby — and continuing to evolve as the baby grows.

“We have to support and protect the lungs, but we also have to protect everything else,” Wolfe says, emphasizing the importance of considering neurological development alongside respiratory needs.

 

Part of a Larger Team

Steven Sittig, RRT, RRT-NPS, FAARC, has watched neonatal respiratory care change considerably over his four-decade-plus career. He points out that early neonatal ventilators were crude by today’s standards: Ventilator breaths were not synchronized, time-cycled, or pressure-limited, and they had few alarms, he says. Sittig adds that, historically, neonatal tidal volumes were evaluated subjectively by observing chest rise versus set delivered tidal volume, as is done today.

Sittig spent much of his career involved in neonatal and pediatric transport, where RTs may manage ventilators, intubate patients, perform point-of-care testing, and monitor infants while traveling by ambulance, helicopter, or fixed-wing aircraft.

“You don’t have a lot of room to operate,” Sittig says. The environment can change from a bouncing ambulance to an aircraft thousands of feet above ground, requiring RTs to understand not only neonatal physiology but how altitude and other transport conditions affect respiratory care.

Whether at the bedside or in transport, both Wolfe and Sittig emphasize that NICU respiratory care is fundamentally collaborative.

“Nothing we do is a one-person job,” Wolfe says. At Silver Cross, RTs join rounds and contribute observations and recommendations to the care plan.

Families are part of that team, too. Wolfe encourages RTs to explain what they are doing in understandable terms and find ways for parents to participate. Something as simple as “containment”— having parents place their hands around their infant to provide comforting, womb-like support—can give parents a meaningful role while helping maintain the baby’s stability.

That human element matters in an environment filled with unfamiliar equipment and uncertainty.

“You have to be empathetic. You have to be inclusive,” Wolfe says. Parents may be experiencing tremendous stress and a loss of control over what is happening to their child. Responding to that experience and their emotions is a major part of providing excellent neonatal care.

Sittig has seen the lasting impact of that care many times over his career. He recalls one particular neonatal transport to a small hospital in Iowa, where he and a neonatal transport nurse he had worked alongside for decades arrived to find an infant struggling to breathe. Sittig prepared to intubate while his colleague started an IV, and together they stabilized the baby for a roughly 40-minute flight. As they worked, “We noticed an older woman walking by the windows and stopping and staring at us,” Sittig recalls.

Before leaving, the team allowed the parents to hold their baby and explained what would happen next. As Sittig prepared the infant for transport, the woman who had been walking by the windows approached the team with a question: How long had Sittig and his colleague been doing this work?

Sittig’s colleague told her they had been flying together for about 27 years. “I thought so,” the woman said. Then she explained why they looked familiar: Years earlier, Sittig and the same nurse had transported her daughter as a newborn. Now, decades later, they were transporting her grandson.

“I still get goosebumps when I tell this story,” Sittig says. “You can make a difference and not really know it. It’s rewarding.”