The NBRC has confirmed major pharmacology updates for the upcoming Respiratory Therapy Examination, which launches in January 2027.
These changes reflect newer, evidence-based respiratory treatments that go beyond traditional bronchodilators and mucolytics.
This guide focuses only on the new drugs added to the NBRC blueprint and explains what each does, when it’s indicated, and what outcomes to expect. It also includes sample NBRC-style questions to help you study more effectively.
1. CFTR Modulators
Examples: Elexacaftor / Tezacaftor / Ivacaftor (Trikafta), Lumacaftor / Ivacaftor (Orkambi), Ivacaftor (Kalydeco)
Mechanism of Action
CFTR modulators correct or potentiate the CFTR protein, which regulates chloride and sodium transport across epithelial cells.
- Ivacaftor improves the opening of defective chloride channels.
- Tezacaftor and Elexacaftor improve protein folding and trafficking to the cell surface.
Indications
- Treatment of cystic fibrosis in patients with qualifying CFTR mutations (most commonly ΔF508).
- Must have genotype confirmed by lab testing.
Expected Outcomes
- Improved FEV₁ and overall lung function
- Fewer pulmonary exacerbations and reduced antibiotic use
- Increased weight gain and energy levels
Clinical Tips for RTs
Monitor airway clearance effectiveness, sputum characteristics, and medication adherence. Reinforce that these drugs treat the underlying cause of cystic fibrosis, not just symptoms.
Sample Question 1
A 16-year-old with cystic fibrosis begins therapy with elexacaftor/tezacaftor/ivacaftor. Which outcome best indicates treatment effectiveness?
A. Decreased sputum viscosity after bronchodilator use
B. Improved FEV₁ and fewer pulmonary exacerbations
C. Reduction in bronchospasm immediately after dosing
D. Decreased need for chest physiotherapy
Correct Answer: B
Rationale: CFTR modulators correct the chloride transport defect, leading to better lung function and fewer exacerbations. Airway reactivity and mucus viscosity may improve indirectly but are not the main markers of effectiveness.
2. Biologic Therapy for Severe Asthma
Example: Dupilumab (Dupixent)
Mechanism of Action
Dupilumab is a monoclonal antibody that blocks the IL-4 and IL-13 receptors, reducing the Type 2 inflammatory response responsible for eosinophilic and allergic asthma.
Indications
- Moderate-to-severe persistent asthma uncontrolled by high-dose ICS plus LABA
- Eosinophilic phenotype or corticosteroid-dependent asthma
Expected Outcomes
- Fewer asthma attacks and reduced oral steroid use
- Improved FEV₁ and symptom control
- Decreased airway inflammation
Administration
Subcutaneous injection every 2 weeks.
Clinical Tips for RTs
Document baseline eosinophil count and monitor improvement in peak flow or FEV₁ over time. Reinforce proper inhaler technique alongside biologic therapy.
Sample Question 2
Which statement best describes how Dupilumab improves asthma control?
A. Stimulates beta-2 receptors for bronchodilation
B. Inhibits phosphodiesterase-4 to reduce inflammation
C. Blocks IL-4 and IL-13 pathways to reduce eosinophilic inflammation
D. Increases surfactant production in the alveoli
Correct Answer: C
Rationale: Dupilumab targets the interleukin-4 and 13 pathways, reducing the allergic inflammatory cascade that causes airway hyperreactivity. It does not act as a bronchodilator.
3. Antifibrinolytics
Examples: Tranexamic Acid (TXA), Aminocaproic Acid
Mechanism of Action
Antifibrinolytics inhibit plasmin formation, preventing fibrin clot breakdown and stabilizing existing clots.
Indications
- Hemoptysis or airway bleeding after bronchoscopy, tracheostomy, or trauma
- Post-surgical pulmonary bleeding
Administration
- Nebulized (typically 500 mg in 5 mL NS)
- Direct instillation via ETT under physician order
Expected Outcomes
- Reduced visible airway bleeding
- Stabilized oxygenation and vital signs
Clinical Tips for RTs
Use appropriate nebulizer and PPE. Observe for airway obstruction or bronchospasm. These drugs are contraindicated in patients with active thrombosis or disseminated intravascular coagulation.
Sample Question 3
A mechanically ventilated patient develops airway bleeding after suctioning. The physician orders nebulized tranexamic acid. What is the primary goal of this therapy?
A. Dilate the airway and improve airflow
B. Prevent breakdown of fibrin clots and reduce bleeding
C. Thin secretions to aid mucus clearance
D. Promote cough reflex for secretion removal
Correct Answer: B
Rationale: Tranexamic acid prevents fibrin degradation, stabilizing airway clots and controlling bleeding. It has no bronchodilating or mucolytic properties.
4. Aerosolized Antimicrobials
Examples: Tobramycin (TOBI), Colistin, Amikacin
Although recommending aerosolized antibiotics was removed from the new exam, technique and safety questions may still appear.
Key Points
- Delivered via vibrating mesh nebulizer or PARI LC Plus
- Indicated for chronic Pseudomonas infection in cystic fibrosis or bronchiectasis
- Administer bronchodilator first, then antibiotic
- Strict infection-control cleaning procedures are required
Sample Question 4
When administering aerosolized Tobramycin to a cystic fibrosis patient, which step is most important for the RT to perform first?
A. Administer a bronchodilator treatment
B. Add antibiotic directly into the humidifier
C. Deliver via small-volume jet nebulizer
D. Mix with hypertonic saline for dilution
Correct Answer: A
Rationale: A bronchodilator should be given before the antibiotic to prevent bronchospasm and improve airway deposition. Tobramycin should be administered through specialized nebulizers, not the humidifier.
| Drug Class | Example(s) | Mechanism | Primary Use | Expected Outcome |
|---|---|---|---|---|
| CFTR Modulators | Trikafta, Orkambi | Correct CFTR protein defect | Cystic fibrosis | Improved FEV₁, fewer exacerbations |
| Asthma Biologic | Dupilumab | Blocks IL-4/IL-13 pathway | Severe eosinophilic asthma | Fewer attacks, reduced steroid use |
| Antifibrinolytics | TXA, Aminocaproic Acid | Inhibits plasmin formation | Airway bleeding | Decreased bleeding, improved stability |
| Aerosolized Antimicrobials | Tobramycin, Colistin | Direct lung antibiotic delivery | CF, bronchiectasis | Reduced infection load |
Bottom Line
If your pharmacology notes stop at bronchodilators and steroids, you are behind.
The 2027 NBRC exam now expects you to understand advanced drug mechanisms and clinical applications, particularly CFTR modulators, biologic asthma therapies, and antifibrinolytics.
These represent the direction of modern respiratory care. Respiratory Cram will continue updating its NBRC-style questions and rationales to help you stay ahead of the 2027 exam changes.
Cultural considerations when administering new medications can also affect patient understanding, cooperation, and safety, and the 2027 NBRC exam includes scenarios where these factors influence clinical decisions.
