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Friday, March 2, 2012

Five Periods of Respiratory Therapy History

During the 1920s there rose a profession that is now referred to as respiratory therapy.  During our short lived history there were four periods that confirmed the need for our jobs, and four periods that threatened to eliminate our jobs.  The fear today is:  Will a fifth period call for the elimination of our profession once and for all?  Let's investigate.

1.  The oxygen period

With the increased use of therapeutic oxygen in the 1920s arose a profession.  Yet as with anything new in the medical industry, the rise would be slow in the making.  First our work would be added to the already exorbitant tasks of nurses.  They were responsible for setting up large, bulky oxygen tents and operating and maintaining them for the duration of there use, and then cleaning them between patients.  They were also responsible for lugging from room to room large oxygen tanks and timing how long they were in use to make sure they were changed before they became empty.  This job was complicated because regulators were primitive and without gauges.

As better oxygen equipment became available it was made of rubber and vinyl and needed to be maintained while in use and cleaned between patients.  From what I hear the rubber would stick to patient's faces, so there was a need to remove the masks from their faces every few hours to make sure they didn't become permanently attached or break down the skin on the face.  If they weren't directly doing this task, they had to delegate the responsibility to nursing assistants or anyone else up to the task.  All this work became overwhelming for nurses, who had to do all this added work plus their other nursing duties.

By the 1940s the task of lugging around oxygen tanks and maintaining this equipment was delegated to male nursing assistants and a profession was born.  The initial name of these professionals was inhalation therapists and they were members of a profession called inhalation therapy.  Actually they were often poorly trained in respiratory therapy, so they were simply handy folks with on the job training and were simply referred to as ancillary staff.  They were glorified nursing assistants.  Yet organizations were formed, education of these folks greatly improved, and the profession of respiratory therapy was born.

Yet during the 1940s oxygen was piped into the walls of more and more hospitals around the United States, and there was fear among the young profession that they would soon be out of a job.  That fear gave rise to the hypoxic drive theory myth that respiratory therapist had to be around to monitor patients with COPD to make sure they were't getting too much oxygen.  And the profession changed in other ways too with the advent of the IPPB therapy.

2.  The iron lung period

Yet first we must delve into the era of the iron lung.  The first half of the century there were epidemics of poliomyelitis which paralyzed and knocked out the drive to breathe for many young victims.  What was needed was a device to keep these kids alive while the disease ran its course.  Such a device made it's way into circulation with the invention of the Drinker and Shaw Respirator in 1928.  It was an iron lung that was exorbitantly expensive, complicated, noisy and heavy.  It greatly added to the tasks of nurses and may even have become overwhelming for them.  This was another reason for the rise of the respiratory therapy profession.  Someone was needed to set up, monitor, lug, and clean oxygen equipment, yet someone was also needed to set up, monitor, lug and clean iron lungs.  The new Emerson Respirator that was invented in 1931 made this job a little better, yet these devices continued to be a major responsibility.  We were thus titled tank jockeys, although not so much because iron lungs were sometimes called tanks, but because we lugged around oxygen tanks.

Yet then came the poliomyelitis vaccine.  During the late 1950s and early 1960s the vaccine was given to millions of kids.  After a polio epidemic in the early 1950s there weren't any more.  Their was a fear that this vaccine would not just wipe out a crippling and deadly disease, it would wipe out their job.  Yet it didn't.  Just as the vaccine was being invented so too was the Bird Mark 7.

3.  The IPPB period

The scope of this profession also advanced as bronchodilator therapy advanced.  In the 1920s there were primitive glass nebulizers, but by the 1930s nebulized aerosol therapy became increasingly popular. The 1950s brought nasal catheters, oxygen partial rebreathers, non rebreathers, nasal rubber masks, medication aerosolized nebulizers made of glass, modern bronchodilators such as Isuprel, mucolytics such as mucomyst and Alevair, and ethyl alcohol for treating pulonary edema.

Perhaps the most important advancement in inhalation respiratory therapy this decade was the invention of the Bird Mark 7 to provide intermittent positive pressure breathing (IPPB )and provide aerosolized medication to asthma and COPD patients.  The Mark 7 also provided the first portable breathing machine that allowed continuous ventilation of patients.  All of this added to the need for RTs.

Yet then came along the myth IPPB treatments would force medicine deeper into the lungs and open up lungs that were atelectic, and soon every patient with any lung disease or any surgery was getting IPPB therapy.  IPPB was no longer given just when needed, yet whenever the doctor felt it would do some good, even when there was no proof.  RT departments were profitable back then, which meant every procedure done was another dollar earned.  So the more therapies we could do the more money our departments made and the more need there would be to keep our profession alive.  Fake Studies were done that proved showed made up that IPPB therapy would open up closed alveoli and treat atelectasis, and it would force medicine deeper into the lungs.  All these fake studies proved the need for RTs kept our profession around.

Yet during the 1970s insurance companies started questioning the need for all these expensive IPPB therapies.  Likewise, studies were done that showed IPPB aerosolized medication distributed 35 percent less medicine to the lungs than the less expensive nebulizer therapy would .  Studies also showed that less expensive incentive spirometers were much more effective for post operative patients than IPPB therapy.  Soon the IPPB period of respiratory therapy would become the laughing stock of the profession see its decline.  The fear arose that the fall of IPPB orders would end the profession and eliminate our jobs.  Yet this simply gave birth to the myth fact that bronchodilators such as Alupent, Albuterol and eventually Levalbuterol will cure all annoying lung ailments and treat all annoying lung sounds benefit patients.  The era of the nebulizer was born.

4.  The Nebulizer/ DRG Period

So as IPPB therapy was slowly eliminated and quickly replaced with nebulizers.  By the 1990s every patient with any annoying lung sound or lung ailment -- including asthma -- was given bronchodilator therapy we see the rise of bronchodilator nebulized therapy.  While the end of the oxygen period saw the decline of the tank jockey, the rise of the Nebulizer/ DRG period gave birth to the neb jockey.  The latest bronchodilators were deemed so safe that doctors started calling their local respiratory therapist instead of thinking and treating the patient based on science.  Instead of diuretics and heart fixing medicine curing patients with heart failure, these medicines were given in conjunction with a bronchodilator and even while the other medicines fixed the patient the nebulizer was given credit.  This was the same for any lung disease.  Alupent, Albuterol and Levalbuterol were soon to become the most abused medicine in the medical profession, soon even to surpass Tylenol.

We could simply justify this period being called the nebulizer period for not for the intervention of the government to exacerbate the problem (or not a problem if you think getting rid of useless breathing treatment orders will eliminate our profession). In 1965 the Medicare Act was signed into law, yet even though respiratory was an established profession at this time it was not recognized by the law.  For this reason, to this day, since the passing of this law,  many RT services are no longer reimbursed.  The era of making a profit by performing a respiratory therapy service had ended.  So there was another scare the profession would fade away.  Why would any hospital keep RTs around if they weren't profitable?

Hospitals decided that due to the complicated respiratory therapists performed they would still be needed.  Yet if that wasn't enough, the National Board of Respiratory Care would continue to push for the need for respiratory therapists by assuring we graduated with an exceptional education.  Knowledgeable respiratory therapists would be on demand.  The idea was that instead of RTs being seen and treated as ancillary staff (which we still were even though we weren't) we would be seen as part of the team of professionals adept at treating the patient through the critical thinking process and professional experience and knowledge.  Yet as our knowledge grew, old myths ideas were not to be let go of out of fear the government's new law would eliminate the need for RTs altogether.  Since what we were doing was proven to be not needed, we would soon be doing procedures simply to qualify the patient for admission and to meet reimbursement criteria based on a myth rather than fact.

The Health Maintenance Organization Act of 1973 made it so hospitals would only receive a flat fee for each patient admitted.  This meant that for hospitals to make a profit they had to limit therapies given, and this made all respiratory therapy procedures debt procedures or losses.  So at this time there was a fear that many of the tasks RTs did would be phased away or given back to nurses.  Yet the profession lived on.  Again, with all the emphasis of cutting costs, many government agencies, and hospital organizations, are looking for ways to cut costs.  With bronchodilator medicine no longer a high risk therapy, there's no longer to have a babysitter during a treatment.

So to keep us in business to assure they met reimbursement criteria, hospitals started creating order sets that so RT services are automatically ordered not because they are needed but so reimbursement criteria can be met.  Yet the fear is still wide open that the government, insurance companies, or hospital administrators will catch on to the fact that much of what RTs do is not needed and is wasting time and money.  They will create protocols that will allow RTs to do their job and give bronchodilator therapy only to those who need them instead of every patient.  And some hospitals are creating protocols, and their jobs have not been eliminated.  We have other tasks, such as drawing ABGS, critical thinking, maintaining life saving equipment, and so on.  So the fear, as they say, is probably unfounded.  Yet it lives on.

5.  The current/ future period:

Yet the profession will survive.  Surely doctors and nurses can intubate, and lab can draw ABGs, and nurses and patients themselves can do breathing treatments.  Yet we RTs will always be needed to take care of, initiate and monitor complex respiratory equipment such as BiPAPs and microprocessor ventilators, and to make sure CPR is done correctly. Our services will also be needed to educate the community about such diseases as asthma and COPD.  Our wisdom is a wisdom that has yet to be tapped into in this area, yet legislatures are presently considering legislation that would allow reimbursement for RT services outside hospitals and outside the realms of a doctors care.  This is the future of our profession. We will evolve from simple task doers to thinkers and educators.  We will educate and treat patients outside hospitals, teach them how to stay healthy, and keep them from requiring the services of a hospital.

So the role of RT continues to grow, and the profession lives on. I would imagine in the future a fear might develop when baby boomers die off, and their children die off, and there are very few people left who smoke cigarettes.  Deep into the future there may be a day when people take better care of themselves, and medicine has the ability to cure diseases and replace old and tattered hearts, kidneys and lungs.  Perhaps lung diseases will someday be eliminated altogether.  When this time comes, there will be a fear that there will be nothing left for RTs to do.  Yet the profession will evolve once again, new technologies will be developed, new wisdom, and the scope of practice of RTs will change as noted in the above paragraph.

There have been many times in the past where RTs feared their jobs would be phased out.  Yet, despite these fears, the profession lives on.  The profession of RT will continue to live on because we play a vital role in the care of the patient.  We work with -- we do not assist  -- nurses and doctors.  We are a well, respected and vital part of the patient care team.

References for this post:
  1. Glover, Dennis W, "The History of Respiratory Therapy," 2010, Bloomington, Indiana.(this is where I obtained much of my history of respiratory therapy.  I highly recommend reading this book.)
  2. Giordano, Sam P., "Respiratory Drug Delivery: What if?", AARC Times, August 2011, 


Anonymous said...

Very good post. I've often thought about how unnecessary the profession is, and wondered what happened with the IPBB and what's going on with the neb treatments (the unnecessary ones, the fact that the nurse assistant doesn't do it, and that they don't use the MDI instead).

But you're right, the one thing we have to our advantage is our expertise. The trouble is that doctors are doctors and we aren't, so they rarely want to rely on our expertise.

We've actually moved to Q4hour vent checks. With the newer vent monitoring software out there vent charting is soon becoming a 1 button, 1 touch deal. Vent alarms can be monitored from telemetry. The day that doctors can both give a vent setting order and change the vent settings themselves, what happens to the RT? They will think of something for us to do.

Rick Frea said...

Sometimes I wonder if we had RT Driven protocols for breathing treatments that we might just protocol ourselves out of a job. I'm also pretty certain that much of what we do is based on feelings -- it sounds good -- as opposed to scientific fact. It's still a good job, and if it were an ideal profession it would be even better.

Anonymous said...

I come from a department with RT driven protocols and a decent amount of autonomy. I hate to tell you, but we have worked ourselves out of a job. I always thought that demand for RTs would grow, but with new health care changes procedures have been cut, big time. We laid off all our registry staff and regular staff is struggling to keep FTE's. I am desperately looking for a job. I am either overqualified for hospitals that seek "neb jockeys" or not considered for more desirable positions. I am finding that RN's are doing treatments in some hospitals now. My co-workers and I are feeling very demoralized right now. I certainly hope this is just a "phase".

Anonymous said...

Our job has and will continue. We need to realize that the new need of medicine is education. If we embrace what medicare is doing and get furthur educated, we will stay in a well needed profession as consultants to physicians. We have hospitalists at our hospital that love our protocols. But the protocol's don't work by them-selves, they need an intelligent educated person to drive them. The patients still need to be educated in the emergency room, at the bedside and in the homes. We have the expertise and who better to educate the patients then us?

Rick Frea said...

I like the idea of respiratory therapists as educators. I think that role is not utilized enough in our profession, or at least where I work.

Anonymous said...

As a blog for respiratory therapists and in support of respiratory therapy, using the phrase that describes the job as "a waste of time and money." is not very supportive or accurate. To anonymous, a job is a job. Period. It doesn't matter whether you have qualifications above what they are asking just that you meet their requirements. I highly doubt they will turn you away unless you're asking for a ridiculous amount of money in comparison to the job description. Education affords a higher paycheck if you're using the education you received for the job at hand. Still plenty of people finding jobs in my area.

Anonymous said...

Respiratory Therapy is a dying field. Many hospitals have now eliminated all the respiratory therapist.

Basically Respiratory therapist do nothing. I am a nurse and now give a prn breathing treatment. Vents are nothing and some now manage themselves. If a patient needs suctioned due to him coughing and alarming on the vent, just turn up the sedation and play on your phone all day and at the end of your shift go in and suction him and turn the sedation back down. Respiratory is a total waste.

john bottrell said...

I actually believe the opposite is true, that RT are more valuable than most people realize. I think if anything, we are under utilized.