RCPs' education system serves as a model of outcome-oriented education.

Forty years ago, medicine, nursing, and respiratory care were, by today’s standards, technologically unsophisticated and played subservient roles to both the medical staff and hospital administration. In some ways respiratory care had an easier time with the physician’s side of the equation due to our close relationships with our mandated medical directors. These physicians would often act as our advocates and supporters as we embraced new techniques and technologies. At times, nursing and respiratory care were, and still are, at odds where turf battles arise, which are settled, and after a while, new areas of professional overlap occur resulting in new friction. If seen from the prospective of advancing the art and science of patient care, these issues tend in the long run to bring balance to our work environment.

The advance of technology resulted in the need for professionals who understood both the technology and the patient’s needs. From the mid 1980s until now, RCPs have increased our educational standards, become clinical and laboratory researchers, and have developed a strong professional organization. All of these factors make the RCP of today a far cry from the oxygen orderly of yore. We also see that we have a patient advocacy role to play that is distinct from, but overlapping with, those advocacy roles held by nurses and physicians. These roles are related to the RCP’s specific knowledge and skills, which add to the therapeutic mix and encompass a commitment to excellent patient care.

State of the Profession
RCPs have gained licensed status in 40 states plus Washington, DC, and Puerto Rico. The state boards of nursing and the state nursing professional organizations have supported RCP legal credentialing efforts in many of these states. In four other states, RCPs are either registered or certified by the state. In all of the states, members of the nursing profession at all levels have supported these efforts. Physician organizations such as the American College of Chest Physicians, American Society of Anesthesiology, Society for Critical Care Medicine, and American Thoracic Society provide support and advisory board members to the RCP professional organization.

As of January 1, 2002, all RCP education programs must be at the associate degree level or higher. About 10% of the current 473 respiratory care programs are at the bachelor’s level with most awarding a bachelor of science (BS) degree. Several graduate level (MS) programs are in the planning or early implementation stages. Professional credentialing examinations and identification have also undergone change. According to the American Association for Respiratory Care (AARC) Respiratory Therapist Human Sources Study—2000, 82.6% of respiratory therapists have an AS or higher level of education. BS degrees are held by 24.6%, 5.2% hold master’s degrees, and 0.6% hold doctorates.

There are currently no longer any certified respiratory therapy technicians (CRTTs); with the new minimum program length and licensure, the title was changed to certified respiratory therapist (CRT). These are entry-level practitioners; advanced level practitioners (registered respiratory therapists [RRTs]) are and will still retain their titles. The examination process for professional credentialing remains the same as previously. There is a multiple-choice examination for the CRT credential followed by another multiple-choice examination plus a branching logic clinical simulation examination consisting of 10 patient case problems for the RRT credential. These examinations have recently evolved into computer-based examinations allowing flexibility in examination timing and rapid notification of test results. The CRT examination is also utilized as the legal credentialing examination in all states having laws governing the practice of respiratory care. In addition, the majority of today’s RCPs are ACLS, PALS, and/or NALS providers and many are instructors in these areas.

Clinical practice or procedure guidelines, treatment protocols, and evidence-based care schemes have been particularly effective in respiratory care. RCPs—through their national professional organization, AARC (www.aarc.org)—have assumed a leadership role in the development and implementation of these outcome-oriented methodologies. This work has been widely praised, copied, and adopted by other professions and institutions.

New Modes of Administration
Medications administered by RCPs have expanded rapidly by both class of drug and number of agents. Besides the standard bronchoactive agents, mucolytics, and hydrating solutions, RCPs have expanded their menu of pharmaceuticals to include medications such as inhaled nitric oxide for treating pulmonary hypertension and aerosolized morphine sulfate (for palliation of lung cancer and relief of dyspnea). Surfactant is instilled or aerosolized to stabilize the lungs of premature infants and increasingly in selected adult patients. Growing numbers of aerosolized antibiotics, steroids, and antifungal agents are being used to treat pulmonary infection. State licensure acts generally allow RCPs to “administer medications [which affect the heart and lungs] except for the purpose of anesthesia.” Neither the classes of drugs nor the route of administration is specifically cited in most of the state laws, thus allowing a wide latitude of medication delivery practices for RCPs with employer approval.

Mechanical Ventilation
Changes in both theory and practice are permeating mechanical ventilation. Using lung-protective methodologies, we now ventilate many patients at low volumes and pressures to reduce incidence of both baro- and volutrauma. In permissive hypercapnea we let Paco2 rise and are slower to intubate and place people on invasive mechanical ventilation, preferring to use noninvasive ventilation techniques instead. We are also using special fluids, which have a high capacity to carry oxygen, fill portions of patients’ lungs and open both alveoli and airways, and carry oxygen to the alveolar capillary membrane. Partial liquid ventilation is showing great clinical promise.

Ventilators are becoming more compact (some the size of laptop computers) and much more technologically complex. The ventilator monitoring and management tools of choice are ventilator graphic presentations, which allow observation and analysis of the ventilated patient’s interaction on a breath-by-breath basis. This, in turn, allows therapists to fine-tune ventilator management to best fit patients and their physiology.

We are also supporting prolonged intervals between changing ventilator circuits, using closed system suction also with prolonged change intervals to reduce the incidence of nosocomial (ventilator-associated) pneumonia. For the same reasons, we are advocating the use of positional therapy and prone position ventilation in certain ventilated patients. We are also reducing the use of water-filled humidification systems in favor of heat and moisture exchangers—a simple but sophisticated filter-like device, which conserves heat and moisture for when the patient exhales. These are then used to warm and humidify subsequent inspirations.

Expanded Practice
In addition to its role in home care and rehabilitation venues, RCPs have taken assignments in expanded roles of care. Among these are bronchoscopy in both the operator mode for bronchoscopic-assisted suction and airway placement and as an assistant in diagnostic bronchoscopy. In addition, some centers allow RCPs to insert, monitor, and manage central lines, and operate and monitor interaortic balloon pumps. In cardiopulmonary and endoscopy laboratories, RCPs perform stress and exercise tolerance tests and maintain and monitor conscious sedation.

Nationally, it is becoming more common to assign RCPs to the emergency department (ED) full time. Therapists in these positions perform a variety of tasks both traditionally and innovatively. Studies indicate that inclusion of RCPs as ED-dedicated individuals provides increased efficiency and cost-effectiveness, and reduces ED patients’ length of stay. These therapists assess and treat asthmatics and others with respiratory disorders. They also perform electrocardiography and phlebotomies, draw and analyze arterial blood gases, insert IVs, perform intubations, and answer codes.

Sleep disorder laboratories, hyperbaric and wound care clinics, in-services, public health, and continuing education departments are a few of the other areas in which RCPs are providing skilled and innovative services in hospitals. Still others are involved in case management and discharge planning. A fairly large and dedicated group of RCPs is providing respiratory care in home, long-term, and sub-acute care settings. In these sites, patient assessment and respiratory care plan development, implementation, and evaluation are common functions along with medical device procurement, training, and maintenance. Many hospital-based or independent durable medical equipment dealers and home care providers employ RCPs in patient care and in management or administrative roles.

Paul Mathews, PhD, RRT, FCCM, FCCP, is associate professor of respiratory care and physical therapy at the University of Kansas Medical Center, Kansas City.