NPS Section II: critical care and the 30 ventilation items

Map

Section II on one sheet

Section II is the 70-item part of the NPS that only applies once a baby or child is in an ICU. The Detailed Content Outline effective October 1, 2025 splits it into six areas, and the split is lopsided: ventilation alone is 30 items and procedures 17, while the other four areas share 23.

Read the table as a time budget. II-C and II-D together are 47 items; if your review hours do not roughly follow that, they are going to the wrong place. The four small areas still add up to 23 items, more than enough to decide a borderline result, and they are the cheapest points in the section because the facts are finite.

II-C

II-C: neonatal ventilation, modes and the oscillator

Neonatal ventilation questions on the NPS rarely ask you to name a mode. They hand you a gas, a weight or gestational age and the current settings, then ask which single change fixes the problem. Two rules carry most of those items.

1. CO2 belongs to minute ventilation

   A high PaCO2 is fixed by rate or tidal volume (PIP on a pressure mode). Touching FiO2 or PEEP for a pure ventilation problem is the classic distractor.

2. Oxygenation belongs to mean airway pressure and FiO2

   Mean airway pressure rises with PEEP, PIP and inspiratory time. A low PaO2 with a normal CO2 points there, not at the rate.

3. Time constants decide the timing

   A stiff RDS lung empties fast and tolerates short inspiratory times. A meconium lung with high resistance empties slowly; too fast a rate traps gas and builds inadvertent PEEP.

Modes of ventilation in neonates

Most NICU ventilators deliver pressure-limited breaths with patient triggering (patient-triggered ventilation, PTV) through a proximal flow sensor. Volume-targeted ventilation sits on top of that: you pick a target tidal volume and the ventilator raises or lowers the pressure for the next breath to reach it.

How an oscillator works, and how a jet differs

A high-frequency oscillator moves a small gas volume, often smaller than the dead space, back and forth at rates counted in hertz. The piston or diaphragm pushes gas in and actively pulls it out, so expiration is active. A jet ventilator fires short high-velocity pulses down the tube on top of a conventional ventilator that supplies PEEP and sigh breaths, and the baby exhales passively.

Questions about recommended HFOV settings for neonates are really about this logic. Settings are patient and unit specific, and the exam does not ask you to recite them. It asks you to read a chest film: expansion to roughly 8 to 9 posterior ribs is the textbook target for diffuse lung disease, and flat diaphragms with more ribs than that read as overinflation and a mean airway pressure to come down.

II-C

II-C: noninvasive support, weaning, graphics, rescue

Noninvasive support: CPAP, NIPPV and HFNC

Nasal CPAP is the default first support for a preterm baby who is breathing, and Section II items treat intubation as a step taken when CPAP fails, not a reflex. NIPPV adds intermittent inflations through the same prongs or mask. High-flow nasal cannula is used in neonates too, mostly after extubation and as a step-down from CPAP; the catch the exam likes is that the distending pressure it creates is real but not measured, and it changes with flow, leak at the mouth and how tightly the prongs fit. Prongs that fill no more than about half of each nostril leave the leak that keeps that pressure from running away.

PEEP or FiO2 first

When oxygenation improves, the usual order is FiO2 first, then PEEP. A recruited lung holds its volume because of PEEP; drop PEEP early and alveoli close again, and the FiO2 you just saved comes back. Oxygen toxicity is the reason to bring FiO2 down to a non-toxic level before anything else. The exception is a lung or circulation that PEEP is hurting: overinflation on the film, a beak on the pressure-volume loop, or a blood pressure that falls as PEEP rises. In that last case the bank rewards balancing PEEP against hemodynamic support, not snapping PEEP straight back to baseline.

Weaning and extubation readiness

Readiness is judged on stable spontaneous breathing, low ventilator support and acceptable gases, not on a single comfortable hour. A preterm infant is usually extubated to CPAP or NIPPV rather than to room air, often after caffeine has been started. Rising sedation needs or desaturations with every handling are reasons to wait, not reasons to try.

Pulmonary graphics in neonatal ventilation

Rescue: prone positioning and ECMO

Prone positioning appears as an oxygenation rescue for severe pediatric ARDS rather than a routine first move. For neonates the escalation ladder runs through the oxygenation index, OI = mean airway pressure × FiO2 × 100 / PaO2. A rising OI moves the baby to high-frequency ventilation and inhaled nitric oxide; an OI above 40 that persists after both is the textbook ECMO criterion. Venoarterial ECMO supports the heart and lungs, venovenous only gas exchange. Systemic anticoagulation is why very low gestational age, low birth weight and significant intracranial hemorrhage are classic relative contraindications.

II-B

II-B: specialty gases

II-B is 5 items, and nearly all of them hang on three gases. The questions test why each one works and what it can do to the patient, never a dose from memory.

Inhaled nitric oxide for PPHN

Inhaled nitric oxide relaxes pulmonary vessels in ventilated lung units and is inactivated by hemoglobin before it reaches the systemic circulation, which is why it lowers pulmonary vascular resistance without dropping systemic pressure. The classic use is a term or near-term baby with persistent pulmonary hypertension (often an OI around 25 or higher). It is also often tried for pulmonary hypertension after congenital diaphragmatic hernia repair, where the response is less reliable. Before starting it, an echocardiogram rules out structural heart disease: in a duct-dependent left-heart lesion, dropping pulmonary resistance steals systemic flow.

Heliox

Helium is far less dense than nitrogen, so a helium-oxygen mix flows with less turbulence through a narrowed airway (croup, post-extubation stridor, severe asthma). The benefit grows with the helium fraction: an 80/20 mix helps most, and below about 60% helium the effect fades. The catch is oxygen: an 80/20 mix carries only 20% of it, so a child who needs much more oxygen loses most of the helium benefit. On an oxygen flowmeter, an 80/20 mix reads low and the true flow is about 1.8 times the dial; for 70/30 the factor is about 1.6.

Hypoxic gas mixtures

Subambient oxygen (nitrogen blended into the gas) or added CO2 is used before surgery in some single-ventricle babies, such as hypoplastic left heart syndrome, to keep pulmonary resistance up and stop the lungs from stealing systemic flow. It is the one place where Section II expects you to accept a lower saturation on purpose.

II-D

II-D: surfactant administration and other procedures

II-D is 17 items, the second largest area in Section II. Surfactant administration takes the most room in it, followed by airway and chest procedures and transport.

Surfactant administration

Exogenous surfactant lowers surface tension at the air-liquid interface in the alveoli, so they stop collapsing at end-expiration; compliance and gas exchange improve quickly. It does not stimulate the baby's own type II cells, and it is not a pulmonary vasodilator; both show up as wrong options. The products in use are animal-derived (poractant alfa, sold as Curosurf; beractant; calfactant). The trend the exam follows is early CPAP with early rescue surfactant for babies who need it, rather than intubating every very preterm infant for prophylaxis; earlier rescue works better than late.

Surfactant dose for neonates comes from the product label and the unit protocol, by weight; this page does not print doses, and the NPS cares more about what happens after the dose. Expect items on complications of surfactant therapy: transient desaturation and bradycardia while it goes in, pulmonary hemorrhage, and air leak when pressures stay where they were while compliance doubles. Routine suctioning straight after the dose works against it.

Intubation, chest tubes and thoracentesis

When you assist intubation, placement is confirmed with exhaled CO2 detection and then a chest film; after an emergency airway such as epiglottitis, continuous capnography is the monitoring that catches a dislodged tube in seconds. A sudden deterioration in a ventilated neonate means pneumothorax until proven otherwise: transillumination is the fast bedside check, needle aspiration the emergency fix, a chest tube the definitive one. Continuous bubbling in the water-seal chamber means an air leak. In an older child with pneumonia that is not improving and a new effusion, thoracentesis for fluid analysis is the next diagnostic step.

Transport

Transport items reward the boring answer: enough oxygen for the trip plus a reserve, portable oximetry and capnography, a bag and mask that fit, and settings matched to how the patient is doing on the way, not copied blindly from the ICU.

A·E·F

II-A, II-E, II-F: the three six-item areas

II-A, II-E and II-F carry 6 items each. Each is narrow enough to learn completely in an evening, which is rare on this exam.

II-A: evaluate pertinent information (6 items)

The hyperoxia (oxygen challenge) test separates lung from heart: a PaO2 that rises with high FiO2 points to lung disease, one that barely moves points to cyanotic heart disease. A preductal saturation (right hand) higher than the postductal one (a foot) suggests right-to-left shunting across the duct in PPHN. The oxygenation index from the ventilation section belongs here too.

II-E: anticipated effects of medications (6 items)

II-F: end-of-life care (6 items)

These items are about the therapist's role when the team and family move to comfort care: preparing the family for how breathing may look after compassionate extubation, silencing and removing monitors that no longer serve the child, letting the family hold the baby, and working inside the team's plan rather than around it. The right answer is almost always the one that keeps the family informed and the child comfortable.

Traps

Where Section II rows trip people

Section II has 6 recall items, 32 application items and 32 analysis items. Section I, with 80 items, has 17 analysis items. The extra analysis load is why Section II feels slower: most rows give you a patient who already got one intervention and ask for the next.

The 12 rows at the top of this page cover the same ground. Answer them before reading the rationales, then run the Section II chip on the 60-row NPS practice test for a timed mix.

Next

Where to go after Section II

Section I is the other 80 items: the shared-care section guide walks it the same way. For the full review plan see the NPS study guide, and for format, scoring and retakes see the NPS exam overview.

FAQ

Questions people ask