Wednesday, June 12, 2013

History of the Respiratory T'herapist

The birth of a new profession:

Compared to physicians, who can trace their roots to ancient times, and the modern nursing profession, which can trace their roots to Clara Barton's Civil War heroics, the profession of respiratory therapy is a relatively young profession that can be traced only as far back as 1922.  The device that is often given credit for the birth of this young profession is the oxygen tank.*

Oxygen was discovered in the late 18th century, and methods of producing it and storing it were mastered during the 19th century.  Oxygen was first recommended for asthma and other respiratory disorders by Thomas Beddoes in the late 18th century, yet it wasn't until 1920 that oxygen therapy was accepted by the medical community.

Initially the only equipment available to supply oxygen to patients were nasal catheters, metal nasal cannulas, and rubber oxygen masks invented during WWI.  Aware of the need for a more efficient means of supplying patients with oxygen, Dr. Leonard Hill, introduced his new oxygen tent in 1921.  

While oxygen tents were invented during the 19th century, Dr. Hill invented one that used electricity, and it became the first mass producible oxygen tent.

Doctors initially took up the job of setting up this oxygen equipment.  Yet ultimately it became too much work, so the job was handed over to nurses. They were now responsible for lugging these large oxygen tanks around, setting them up and securing them at the patient's bedside, hooking them up to whatever oxygen delivery device was ordered by the physician, and monitoring the equipment to make sure it was working right.  

They also had to make sure there was enough oxygen in the tanks, and replace the tanks when they were close to being empty.  Considering the Bourdon Oxygen Regulators used back then weren't always accurate, this could be a very stressful task.  The fact it was hot and stuffy for the patient inside the oxygen tent only exacerbated the problem.

And the problem for nurses (our first respiratory therapists) became even worse when the first iron lung was introduced in 1928 when the Dinker and Shaw respirator was introduced to the market. It was a negative pressure ventilator often referred to as the "Iron Lung" because it was a large box made of iron the patient has to lie in.

These devices in and of themselves were difficult to maintain, but they made taking care of the patient inside them even more difficult.  Moving tanks, moving oxygen tents, moving these large iron lungs from one room to another was a very difficult task for these nurses, and this created an opening for another profession.  

The first Inhalation Therapists:

With doctors, and ultimately nurses, overwhelmed with the management and operation of oxygen equipment, strong, males were recruited for this duty during the 1930s.  Most of these males were already working for hospitals as nurses aids.  They took over the duties of taking care of oxygen equipment (which mainly entailed lugging it around).

By the end of the 1930s a new profession was born.  Men were hired to take care of oxygen equipment, and by the 1940s they were referred to as oxygen technicians, inhalation technicians, or inhalation therapists.  Some may even have referred to them as oxygen orderlies or tank jockeys. 

These first inhalation therapists were responsible for any task related to oxygen therapy.  This included lugging around equipment, monitoring this equipment, and on occasion giving breathing ttreatments that were hooked up to the oxygen tanks.  

The nebulizers during this time were large, bulky and made of glass, and the medicine used was either epinephrine or Isoproterenol, which were often referred to as epi and iso.  The electric compressor was invented during this decade and it was quickly accepted by the medical community as an effective means of giving breathing treatments.  In hospitals it was the job of the IT to give breathing treatments either using the electric compressor or hooking the nebulizer up to an oxygen tank.  

With the growing acceptance of oxygen therapy use in hospitals, and the growing acknowledgement of the difficulty of lugging oxygen tanks around, newer hospitals were being built with piped in oxygen systems.  This eliminated the need for oxygen tanks, and created the first scare among inhalation therapists:  would piped in oxygen eliminate their jobs?

Yet the need for maintaining oxygen equipment didn't go away.  And with all the improved technology, the understanding of respiratory therapy equipment and medicine was beyond the scope of doctors, nurses, and even these initial inhalation therapists were were generally people who were trained on the job, or your typical On Job Training (OJT).  

The need for some way to train these inhalation therapists, and garner some respect for this new profession, evolved.  Many hospitals develop their own programs to educate people performing respiratory therapies, with different hospitals creating their own requirements and tests.  Yet most hospitals, particularly smaller hospitals, continued to not have any training at all.  

A Birth of an Inhalation Professional Organization:

With the understanding of respiratory therapy wisdom beyond the scope of most people who work in hospitals, and with training for inhalation therapists varying from one institution to the next, the need arose for a professional organization. 

In 1946 a group of inhalation therapists, nurses and doctors gathered at the University of Chicago and formed the Inhalation Therapy Association (ITA).  The doctor who spearheaded the organization was Dr. Edwin R. Levine.  He understood that knowledge of oxygen therapy was essential to good patient care, and started a program at the University of Chicago for educating inhalation therapists.  He was the key component to establishing the ITA and keeping the organization going during its early years.  He was also the only physician to serve as head of the organization.

In 1947 Dr. Albert Andrews wrote a book, "Manual of Oxygen Therapy Techniques," in which he outlined methods of organizing and structuring respiratory therapy departments.  In 1950 The New York Academy of Medicine published a report, "Standard of Effective Administration of Inhalation Therapy," which initiated the formal education of respiratory therapists. 

In 1944 Dr. Alvin Barach publishes the first book specifically designed to train inhalation therapists called "Principles and Practices of Inhalation Therapy." To become an inhalation therapist a national registry exam is created.  Yet along with passing this exam a person must pass an oral exam, and to many this is very intimidating.  Can you imagine studying for hours to understand respiratory therapy, and then choking under the pressure of being asked questions by a physician?  I can.  

 In 1954 the ITA is renamed The American Association for Inhalation Therapists (AAIT).  In 1966 it was once again changed to American Association of Inhalation Therapy (AAIT).  In 1956 this organization begins publication of a journal, which is now referred to as the Respiratory Care.  In 1950 the "Linde Oxygen Therapy Handbook," is published, another common book used to train ITs.  

The IPPB Revolution:

By the 1950s most hospitals have oxygen piped into the walls, and the profession continues to live on.  I think one of the main changes that occurred during the 1950s that ensured the need for inhalation therapists was improvements in the way operations are done.  Better anesthetics and the AMBU-bag made it possible to perform more surgeries during this decade, particularly abdominal surgeries.  

The reason this created an opening for RTs was due to the invention of the positive pressure ventilator.  In 1952 the Bird Mark I was introduced to the market, and made it possible to ventilate patients during operations.  During surgeries patients were bagged with an AMBU-bag during short operations, and intubated and placed on positive pressure ventilators during long operations.

As the decade progressed, the positive pressure ventilator was improved upon.  In 1952 the Bennett Pressure Breathing Unit was introduced, followed by Bird Mark 7 in 1955.  While these ventilators were useful in surgeries, they were also found useful for ventilating kids with polio, especially during the late stages of the disease when phlegm production increased.  With the patient being intubated, or trached, it made it easier to suction and remove secretions from the airway.  So intubation and managing positive pressure ventilators became a new job for inhalation therapists.

Yet another breakthrough for the inhalation therapist was the "idea" or "theory" that performing Intermittent Positive Pressure Breathing therapies would benefit patients.  This idea originated mainly due to the increase in upper abdominal surgeries.  It was observed many of these patients developed atelectasis and pneumonia, and this complicated care.  It was also proven about this time that a sigh, or deep breath, would help prevent these complications.  So some doctor came up with the idea that IPPB therapy might help.

This was good for respiratory therapists because it gave birth to the IPPB revolution.  Every person who was to have surgery was given IPPB breathing treatments.  And every patient who had surgery was given IPPB treatments.  

Soon the idea was created that since this IPPB therapy does so much for post operative patients that maybe it will help other patients too.  The new theory was that positive pressure breaths would push medicine deeper into the lungs.  For this reason, IPPB treatments were soon given to every patient admitted to hospitals with breathing trouble, including COPD and asthma patients.  

Despite any real evidence it did any good, the IPPB revolution was in full swing.

A growing profession:

By the 1960s a need arose to create a standardize test for all inhalation therapists to pass, and on November 18, 1960, the very first national respiratory therapy exam is administered in Minneapolis.  In 1962 approval is given for the "Essentials for an Approved School of Inhalation Therapy 

In 1963, The Board of Schools of Inhalation Therapy Technicians is formed in Chicago. Then in the AAIT changes its name to the American Association for Inhalation Therapy.  By the mid 1960s becoming a registered therapist was optional, with only a few hospitals making it a regular part of their training. 

Despite the need for educated therapists, only about 10 percent were of inhalation therapist were registered.  Partly due to this reason, and also due to a shortage of therapist, in 1969 the AAIT created the Technician Certification Program to make it easier to get credentials.  Now inhalation therapists, or those wishing to be one, could pass a test on the basic equipment, and therefore it was easier to qualify to get a job.  

It may also have been understood that many people weren't able to pass the registry, and one of the main reasons may have been that many people were intimidated by the oral exams.  This may have been another reason the technician program was created.  

This was basically the beginning of the Certified Respiratory T'herapy Technician program, which was changed to Certified Respiratory Therapist in the early 2000s.  While you could pass a registry and oral exam to become a registered inhalation therapist, you could now pass a technician exam to get the same job.  

Major changes to the RT profession:

So by the 1970s IPPB treatments were ordered on nearly every patient who had surgery.  IPPB treatments were also ordered on nearly every patient admitted with a respiratory disorder.  While this created continued work for the therapist, many of these same ITs noted the frivolous nature of many of these therapies:  Many were ordered for no scientific reason.

Perhaps it was for this reason that insurance companies started questioning the need for IPPB treatments.  They were ordered on nearly every patient, and they were expensive.  This inspired a series of studies that ultimately proved IPPB therapy was indeed being abused.  In essence, the IPPB revolution turned into a major embarrassment to the profession.  

It may also have been for this reason that Congress got involved and created Diagnosis Related Groups (DRGs).  This made it so hospitals were no longer paid for services rendered, and were instead paid a flat fee for a specific diagnosis.  A doctor could still order IPPB on every patient, but the hospital would have to eat the cost.  

So this marked the beginning of the end of the IPPB revolution.  In 1970 the incentive spirometer was invented.  The first IS was an electric device that lighted up when goals were met, although eventually these machines were phased out in favor of smaller, disposable units.  These devices were soon proven to be equally as effective as IPPB treatments to prevent post operative atelectasis and pneumonia, and soon they replaced IPPB therapy altogether.

Another therapy that became more common at this time was chest physiotherapy (CPT).  Many studies were done to show that IS and CPT therapy were equally effective in preventing and treating post operative respiratory complications.  However, it would later be noted that none of these studies conclusively proved any of this therapy was truly effective.  Regardless, both CPT and IS therapy are  very commonly used in hospitals to this day.

Continued growth of the RT professon:

The profession was evolving beyond the need to simply monitor inhalation therapies, which included the inhalation of oxygen and bronchodilators.  As technology improved so too was the need for better educated respiratory therapists.  So the need for another name change had arrived.

It was for this reason that in 1973 the AAIT once again changed it's name to the American Association of Respiratory Therapy (AART).  Part of the reason was to continue to push for improved recognition and acceptance of the increasing abilities and knowledge of the respiratory therapist.

In other words, there was an ongoing attempt by the AART to move the profession beyond being just an ancillary staff just doing a task to a group of professionals trained to work along with nurses and doctors to the benefit of the patient.

In the 1920s the profession was mainly considered a bunch of tank jockeys.  By the 1970s they were considered a bunch of ventilator button pushers and IPPB or nebulizer jockeys.  The goal was to make sure every respiratory therapist earned his or her way through an accredited respiratory therapy program.  The goal was to move beyond the OJT to having all RTs being registered.  This was believed to be the best way of improving respect for the profession.

In an attempt to continue this quest the National Board of Respiratory Therapy (NBRC) is created in 1974.  It's now the role of this organization to create the requirements for becoming a respiratory therapist, and to design and proctor the tests to be given by the many RT schools.

Are RTs ancillary or professional?

From the 1920s through the 1980s inhalation therapists therapist were basically considered just ancillary staff.  Yet as the educational requirements of the profession changed so to did respect for the profession (although there continues to be need for improvement in this regard).

In a continued attempt to improve the image of respiratory therapy amid the medical community, there were various attempts by fellow RTs to create organizations to improve the testing and criteria for becoming a respiratory therapist.  

In 1973 the AAIT became the American Association for Repiratory Therapy (AART).  The inhalation therapist was now a respiratory therapist.  Yet while the name changed, so to did our duties and responsibilities.  

During the 1960s inhalation therapist were mainly considered tank jockeys, now they were neb jockeys.
In 1986 the AART becomes the American Association of Respiratory Care.  Respiratory Therapists are now supposed to be called respiratory therapy care practitioners, but this name never really catches on.  For the most part, respiratory therapists are generally referred to as RTs except for in some journals and textbooks.  At many hospitals they are just ordered to do a procedure and they just did it.

In the 1970s there were some major changes to respiratory therapy profession.  Up until this time hospitals were paid for each service rendered.  If a respiratory therapist did an IPPB treatment the hospital was paid for that service.  Yet after DRGs were created, the RT department is more of a drag on the profits of the hospital.  With modern healthcare laws, many RT procedures are ordered just so the hospital can meet reimbursement criteria.  

So where will this profession go in the future?  Well, perhaps we can answer this by taking a look at the current hospitals that are ahead of the curve.  

*Note:  Nursing actually goes back to the beginning of human existence, with the first mom who took care of her kids and husband.  The first evidence of respiratory therapy may have been when the first herb was tossed on a fire for inhalation.  This article is in reference to the modern professions.  

  1. Glover, Dennis W, "The History of Respiratory Therapy," Indiana, 2010
  2. "AARC Timeline,",
  3. Weilacher, Robert R., "AARC- 50 Years of Service,",
  4. Whitnack, Jeffrey, "The History of Respiratory Therapy," 
  5. "The History of Respiratory Care,",, "Egans, chapter 1, "A History of Respiratory Care."

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