Respiratory therapy

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Respiratory Practitioner
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Occupation
Names
  • Respiratory Practitioner
  • Respiratory Scientist
  • Respiratory Therapist
Activity sectors Medicine, Allied Health
Description
Education required

Respiratory therapy is a healthcare profession in which specialists work with patients suffering from either acute or chronic respiratory problems. These specialists are termed Respiratory Practitioners in most places internationally but may also be referred to as Respiratory Scientists or Respiratory Therapists. Respiratory practitioners work independently and as part of a team to plan, integrate, and evaluate cardiac and pulmonary care. Respiratory practitioners also recommend intervention and therapeutic methods and serve as a consultation resource for physicians in treatment of patients with respiratory conditions.[1] In the United States oxygen and other medical gas systems, both portable and installed are under the management of the department of Respiratory Care and subsequently by the Respiratory Practitioners within that hospital. A respiratory practitioner is a clinician working along side physicians, nurses, pharmacists and other members of the medical team providing direct patient care. In most parts of the world a respiratory practitioner must have a degree in cardiopulmonary medicine or respiratory care and may be required to hold an appropriate license to practice. However, in some countries a registered nurse or physical therapist may be minimally trained to provide respiratory care.

Contents

[edit] Clinical practice

Respiratory practitioners are found in various sectors of health care. In the hospital setting, Respiratory practitioners evaluate, treat and assist with diagnosis of respiratory/pulmonary diseases. In the United States, Respiratory practitioners with certification as Registered Respiratory Therapists evaluate and treat patients with a great deal of autonomy under the direction of a pulmonologist,[2] In facilities that maintain critical care transport teams respiratory practitioners are a preferred addition to all types of surface or air transport.[3] In other settings respiratory therapists are found in schools as asthma educators, working with teachers and coaches about childhood symptoms of asthma and how to spot an emergency. In the United States, legislation has been introduced several times to allow respiratory practitioners certified as asthma specialists with registered respiratory therapist certification to prescribe and manage previously diagnosed respiratory patients in physician clinics.[4][5] In sleep clinics respiratory practitioners work with physicians in diagnosis of sleep-related illnesses. Respiratory practitioners in the United States are migrating toward a role of autonomy similar to the nurse practitioner or as a physician extender (mid-level) like the physician assistant.[6]

[edit] History

See also: Timeline of respiratory therapy
Physician auscultating.JPG

Respiratory therapy has existed since around 1950 in the United States.[7] Though just as old as other fields of medicine Respiratory Care is regarded as a young practice and specialty because of the lack of an official designation until the advent of the Inhalation Therapy Association. In 2004 Vermont became the 48th state and in 2011 Hawaii became the 49th [8] state in the United States to enact a Respiratory Care Act, allowing for the practice and licensure of respiratory care clinicians in those states leaving Alaska as the remaining state not recognizing respiratory care.

The Roman physician Galen may have been the first to describe mechanical ventilation: "If you take a dead animal and blow air through its larynx [through a reed], you will fill its bronchi and watch its lungs attain the greatest distention."[9] Vesalius too describes ventilation by inserting a reed or cane into the trachea of animals.[10] In 1908 George Poe demonstrated his 'mechanical respirator' by asphyxiating dogs and seemingly bringing them back to life.[11]

Respiratory therapy grew considerably through the twentieth century. There was a time when respiratory therapists were on-the-job trained technicians, with little formal education. Their main function was to ensure safe oxygen use, to administer intermittent positive pressure breathing (IPPB) treatments, to perform cardiopulmonary resuscitation (CPR), and to operate negative pressure (iron lung) ventilators. They were initially titled inhalation therapists. With the invention of positive pressure mechanical ventilators, the commercial availability of pulmonary surfactant for neonates and the more widespread hospital provision of neonatal and pediatric care, more sophisticated pulmonary function testing (PFT), a need for thoroughly trained clinical practitioners presented itself. Over the years respiratory therapists have evolved to being college and university trained clinicians who work in a variety of settings.

In 2007 the American Association for Respiratory Care (AARC) began developing recommendations for the promotion of the field of respiratory care in the United States[7] in response to increased concern regarding licensure and credentialing issues as well as international recognition of those practicing in the United States.[6] The task force decided to recommend that by 2015 the minimum education requirement for licensure and certification as a respiratory therapist be a bachelor of science in respiratory therapy (BSRT).[12] The AARC task force also recommended the American Respiratory Care Foundation change its scholarship policies and only award assistance and grants to those working toward a bachelors degree. The Committee on Accreditation for Respiratory Care (CoARC) was asked by the AARC task force to change its accreditation standards and no longer accredit associates level respiratory care programs.[12] The CoARC replied by a press release rejecting the recommendation.[13] In 2011 legislation introduced by the AARC will help improve the use of respiratory therapists in clinical applications by allowing them to manage patients suffering from asthma and COPD seeing a clinic for routine checkups.[14] Similar bills have been introduced before and have died in committee.[4][5][15]

[edit] Treatment

See also: Pulmonary rehabilitation and Pulmonary hygiene

Medication — Medication is the most important treatment of most diseases of pulmonology, usually by inhalation (bronchodilators and steroids) or also by mouth or IV (antibiotics, leukotriene antagonists). A common example being the usage of inhalers in the treatment of inflammatory lung conditions such as Asthma or Chronic obstructive pulmonary disease (Emphysema. Oxygen therapy is often necessary in severe respiratory disease such as pulmonary fibrosis.

Intensive Care — Mechanical ventilation may be required in instances of rapidly advancing disease or difficulty after surgery. Different modes of mechanical ventilation are used for various instances depending on the patients need.

Pulmonary Rehabilitation — Pulmonary rehabilitation may be initiated as a treatment as a source for continuity of improvement after a hospital stay or as a therapeutic way to increase quality of life. Pulmonary rehabilitation is intended to educate the patient, the family, and improve the overall quality of life and prognosis for the patient. Pulmonary Rehabilitation involves therapies and evaluations by Respiratory Practitioners, Occupational Therapists and Physical Therapists.

[edit] Credentialing and licensure

In the United States and Canada, Respiratory Therapists are healthcare professionals who, after receiving a degree in cardiopulmonary science or respiratory science, complete a credentialing process. After satisfactorily completing the required examinations and added to a registry, the therapist is then eligible to apply for a license to practice in the region governed by their respective licensing body. In the United States, specialist respiratory therapists are clinicians who hold specialized credentials in a specific field of study, such as a Asthma Educator or a Neonatal & Pediatric Transport Specialist. In Canada, some similar credentialing exists, such as the Certified Respiratory Educator program.

Registered respiratory therapist patch.gif
International respiratory therapy

Internationally there is great variability among countries regarding the recognition status of respiratory therapy as a discrete healthcare profession. In many countries this recognition is in a transition stage; as an example, in 2011, hospitals in Beijing, China began a recruitment drive to acquire respiratory therapists for their intensive care units where previously nurses were the only clinician.[16]

[edit] Credentialing in the United States

In the United States there are two separate credentialing bodies. One is the State Board of Respiratory Care in the state in which a respiratory practitioner is licensed to practice and the other is the National Board for Respiratory Care (NBRC) a non-profit organization which regulates two levels of certification. The Certified Respiratory Therapist (CRT) and the Registered Respiratory Therapist (RRT). The CRT is the certification given after successfully passing the entry-level examination NBRC-ELE; The RRT certification is given after first becoming a CRT and then passing the NBRC-WRE and NBRC-CSE.

Most state boards of respiratory care require proof of the appropriate NBRC credential and award various license titles; including (but not limited to) Respiratory Care Practitioner, Licensed Registered Respiratory Therapist, and Licensed Certified Respiratory Therapist. There has been a substantial push to standardize the state licensure by the American Association for Respiratory Care.[7] The NBRC credential is renewed every 5 years for a fee in addition to fees assessed by the state boards of respiratory care.

Respiratory practitioners are eligible once licensed to take advanced provider courses offered by certification bodies, such as Pediatric Advanced Life Support, Advanced Cardiovascular Life Support, and Advanced Trauma Life Support as a member of the trauma management team.

[edit] Credentialing in Canada

Upon graduation from an accredited school of respiratory therapy, the graduate is then eligible to write the national exam administered by the Canadian Board for Respiratory Therapy. Success on this examination will then allow the respiratory practitioner to register with any licensing body in Canada. Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Ontario, Quebec and Saskatchewan are the Canadian provinces with provincial licensing bodies; in these provinces, it is illegal to practice the profession of Respiratory Care without first being licensed as a full or practicing member with the provincial licensing body. These provinces are so-called regulated provinces. In all other jurisdictions, the licensing body for the profession of Respiratory Care is the Canadian Society for Respiratory Therapy. Registration as a full member is optional for respiratory practitioners living in regulated provinces, however, for respiratory practitioners living in non-regulated provinces, registration as a full member with the CSRT is compulsory. Registration with the provincial regulatory body or the CSRT (in non-regulated provinces) confers upon the respiratory practitioner the title of Registered Respiratory Therapist (RRT).

Licensure is not strictly speaking necessary to take advanced provider courses such as PALS, NRP, or ACLS. Many students acquire these credentials as a part of their accredited respiratory care program.

[edit] Careers in respiratory care

[edit] Asthma Education

Asthma specialists work with clinics, hospitals and schools as an educator for teachers, parents, patients and practitioners on asthma and allergies. Respiratory practitioners in the role as an Asthma Educator additionally help diagnose and treat asthma and other respiratory illness.[17] Additionally, an Asthma Educator is the resource clinician in inpatient and outpatient environments for evaluating and advising physicians on treatment plans and helping facilitate patient understanding and compliance with the plan. In the United States, Certified Asthma Educators (AE-C) are credentialed by the National Asthma Educator Certification Board (NAECB).[18]

In Canada, the Canadian Network for Asthma Care (now known as the Canadian Network for Respiratory Care) administers two certifications to this end: the Certified Asthma Educator (CAE) (preferred by practitioners with a pediatric focus) and the Certified Respiratory Educator (CRE), which comprises the CAE program with additional training in COPD.[19]

[edit] Cystic fibrosis

Respiratory practitioners work with people suffering from cystic fibrosis in clinics and hospitals[20] by educating them about their disease and working with them on a treatment plan. While admitted to a hospital, patients with cystic fibrosis have their treatment schedule modified and maintained by respiratory Practitioners. Maintaining a healthy schedule for pharmokonetic and physical therapeutic airway clearance typically more frequent than home treatment plans because admissions are usually due to an increased need for therapy during the stay.

[edit] Cardiovascular perfusionist

Respiratory practitioners are able to fullfill the role of Perfusionist with appropriate training. The perfusionist is a highly trained member of the cardiothoracic surgical team which consists of cardiac surgeons, anesthesiologists, physician assistants, surgical technicians, other respiratory practitioners, and nurses. The perfusionist's main responsibility is to support the physiological and metabolic needs of the cardiac surgical patient so that the cardiac surgeon may operate on a still, unbeating heart. Perfusionist certifications are maintained and awarded by The American Academy of Cardiovascular Perfusion.[21]

[edit] Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass technique used for the treatment of life threatening cardiac or respiratory failure. An ECMO Clinical Specialist is a technical specialist trained to manage the ECMO system including blood pump, tubing, artificial oxygenator, and related equipment. The ECMO Specialist, under qualified medical direction and supervision, is also responsible for the clinical needs of the patient on ECMO which may include bedside management of oxygenation and carbon dioxide removal, maintenance of normal acid-base balance, administration of medications, blood and blood products, and maintenance of appropriate anticoagulation therapies for the blood.[22][23] This ECMO Clinical Specialist may be the bedside critical care nurse specifically trained in ECMO patient and circuit management,[24] or the ECMO system may be primarily managed by a registered respiratory therapist,[25] or physicians with training as ECMO clinical specialists.[24]

[edit] Intensive care

Intensive Care is one of the mainstays of respiratory therapy. Respiratory Practitioners are taking an increased clinical role in recent years related to intensive care. Ventilatory support is usually the largest criteria for being placed into an intensive care setting which is maintained entirely by Respiratory Practitioners and Cardiopulmonary specialists. Mechanical Ventilation is a rapidly expanding science and has been recognized as a complex technology by the respiratory therapy credentialing agency (NBRC) who in 2011 added the speciality credential called the "Adult Critical Care Specialist", available only to the registered respiratory therapist (RRT-ACCS).[26]

[edit] Neonatal & Pediatric Intensive Care

Much like adult intensivist Practitioners neonatal and pediatric specialists deal primarily with monitoring ventilation and perfusion.[27] The NPS practitioner is trained extensively in antenatal and intrapartum patients and family. Neonatal assessment and laboratory studies. The practitioner is also a specialist in ventilatory support and cardio-pulmonary therapy of neonatal and pediatric patients.[27] In the United States NPS credentialing is available to both the certified respiratory therapist (CRT-NPS) and the registered respiratory therapist (RRT-NPS) however the registered respiratory therapist (RRT-NPS) is preferred by most organizations.[27][28][29]

[edit] Sleep Disorder Specialist

See also: Polysomnography

The Sleep Disorder Specialist is a Registered Respiratory Therapist (RRT-SDS) whom performs sleep disorders testing and therapeutic intervention along with diagnosis of sleep related disease such as Obstructive Sleep Apnea or Central Apnea. The role is very similar to the Polysomnographic Technologist.

[edit] Case Management

See also: Certified Case Manager

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human services needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Eligibility and certification is maintained by the Commission for Case Management Certification, a body certifying healthcare professionals in the United States.[30]

[edit] Surface & Air Transport

See also: Air medical services

Respiratory Practitioners work with nurses, physicians, and paramedics in emergency flight and ground transport.[31] They are a vital practitioner delivering care inside helicopters, air ambulance or ground ambulance working to pick up a patient and move them to a facility that has what they need. In the United States certification for transport (C-NPT) is currently awarded by The National Certification Corporation.[32] The NREMT has included Respiratory Practitioners as qualifing for the advanced credentialing as a critical care paramedic CCEMT-P.

[edit] Pulmonary research and science

Respiratory scientists are specialists in pulmonary function.[33] Respiratory practitioners work with Pulmonologists in both clinical and general research of the respiratory system, ranging from the anatomy of the respiratory epithelium to the most effective treatment of pulmonary hypertension in pediatrics. Scientific research also takes place to look for causes and possible treatment in diseases such as asthma and lung cancer.[34]

[edit] See also

[edit] References

  1. ^ "PCC Notes: Respiratory students train". The Reflector. http://www.reflector.com/news/pcc-notes-respiratory-students-train-759223. Retrieved 6 November 2011. 
  2. ^ Harbrecht BG, Delgado E, Tuttle RP, Cohen-Melamed MH, Saul MI, Valenta CA (2009). "Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients.". Respiratory Care 54 (7): 861–7. PMID 19558737. 
  3. ^ O'Malley RJ, Rhee KJ (1993). "Contribution of air medical personnel to the airway management of injured patients.". Air Med J 12 (11-12): 425–8. doi:10.1016/S1067-991X(05)80138-5. PMID 10130326. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10130326. 
  4. ^ a b 112th Congress (2011) (Mar 8, 2011). "H.R. 941". Legislation. GovTrack.us. http://www.govtrack.us/congress/bill.xpd?bill=h112-941&tab=summary. Retrieved August 28, 2011. "Medicare Respiratory Therapy Initiative Act of 2011" 
  5. ^ a b 110th Congress (2007) (Oct 25, 2007). "H.R. 3968". Legislation. GovTrack.us. http://www.govtrack.us/congress/bill.xpd?bill=h110-3968. Retrieved August 28, 2011. "Medicare Respiratory Therapy Initiative Act of 2007" 
  6. ^ a b Shelledy DC, Wiezalis CP (2005). "Education and credentialing in respiratory care: where are we and where should we be headed?". Respiratory Care Clinics of North America (journal) 11 (3): 517–30. doi:10.1016/j.rcc.2005.04.003. PMID 16168918. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168918. 
  7. ^ a b c Kacmarek RM, Durbin CG, Barnes TA, Kageler WV, Walton JR, O'Neil EH (2009). "Creating a vision for respiratory care in 2015 and beyond.". Respiratory Care 54 (3): 375–89. PMID 19245732. 
  8. ^ "Hawaii Revised Statutes Chapter 466D-RespiratoryTherapists" http://hawaii.gov/dcca/pvl/hrs/HRS466D.pdf; July 2011
  9. ^ Colice, Gene L (2006). "Historical Perspective on the Development of Mechanical Ventilation". In Martin J Tobin. Principles & Practice of Mechanical Ventilation (2 ed.). New York: McGraw-Hill. ISBN 978-0071447676. 
  10. ^ Chamberlain D (2003) "Never quite there: A tale of resuscitation medicine" Clinical Medicine, Journal of the Royal College of Physicians' 3 6:573-577
  11. ^ "Smother Small Dog To See it Revived. Successful Demonstration of an Artificial Respiration Machine Cheered in Brooklyn. Women in the Audience, But Most of Those Present Were Physicians. The Dog, Gathered in from the Street, Wagged Its Tail.". New York Times. May 29, 1908, Friday. http://en.wikipedia.org/wiki/Image:Poe_1908May29.gif. Retrieved 2007-12-25. "An audience, composed of about thirty men and three or four women, most of the men being physicians, attended a demonstration of Prof. George Poe's machine for producing artificial respiration in the library of the Kings County Medical Society, at 1,313 Bedford Avenue, Brooklyn, last night, under the auspices of the First Legion of the Red Cross Society." 
  12. ^ a b Barnes TA, Kacmarek RM, Kageler WV, Morris MJ, Durbin CG (2011). "Transitioning the respiratory therapy workforce for 2015 and beyond.". Respiratory Care 56 (5): 681–90. doi:10.4187/respcare.01169. PMID 21276324. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21276324. 
  13. ^ CoARC Memorandum to Our Communities of Interest Regarding 2015 Recommendations http://www.coarc.com/13.html November 15, 2010
  14. ^ 112th Congress (2011) (Mar 8, 2011). "H.R. 941". Legislation. GovTrack.us. http://www.govtrack.us/congress/bill.xpd?bill=h112-941. Retrieved August 28, 2011. "Medicare Respiratory Therapy Initiative Act of 2011" 
  15. ^ 110th Congress (2008) (Mar 5, 2008). "S. 2704". Legislation. GovTrack.us. http://www.govtrack.us/congress/bill.xpd?bill=s110-2704. Retrieved August 28, 2011. "Medicare Respiratory Therapy Initiative Act of 2008" 
  16. ^ Li J, Zhan QY, Liang ZA, Tu ML, Sun B, Yao XL et al. (2011). "Respiratory Care Practices and Requirement for Respiratory Therapists in Beijing ICUs.". Respiratory Care. doi:10.4187/respcare.01093. PMID 22005194. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22005194. 
  17. ^ http://www.childrenshospital.vanderbilt.org/interior.php?mid=6587 Vanderbilt Children's Asthma Clinic
  18. ^ http://www.naecb.org National Asthma Educator Certification Board (NAECB)
  19. ^ http://www.cnrchome.net/whatitis.html Canadian Network for Respiratory Care Certification for Asthma and Respiratory Educators (CAEs and CREs)
  20. ^ http://www.childrenshospital.vanderbilt.org/interior.php?mid=6618 Vanderbilt Childrens Hospital Cystic Fibrosis Clinic
  21. ^ "Clinical Perfusionists Currently Certified by the American Board of Cardiovascular Perfusion through December 31, 2010". American Board of Cardiovascular Perfusion. http://www.abcp.org/cert_listing.htm. Retrieved 2010-02-15. 
  22. ^ Dalton HJ (2011). "Extracorporeal life support: moving at the speed of light.". Respiratory Care 56 (9): 1445-53; discuiion 1453-6. doi:10.4187/respcare.01369. PMID 21944690. 
  23. ^ http://www.wakehealth.edu/ecmo/ Wake Forrest Baptist Health
  24. ^ a b Extracorporeal Life Support Organization, ELSO. "ELSO Guidelines for ECMO Centers". University of Michigan Health System. http://www.elso.med.umich.edu/WordForms/ELSO%20Guidelines%20For%20ECMO%20Centers.pdf. Retrieved February 2010. 
  25. ^ American Association for Respiratory Care (07 07) [8/3/98], Respiratory Practitioners as Extracorporeal Membrane Oxygenation (ECMO) Specialists, http://www.aarc.org/resources/position_statements/ecmo.html 
  26. ^ http://www.nbrc.org/Examinations/ACCS/tabid/113/Default.aspx National Board of Respiratory Care, Adult Critical Care Specialist
  27. ^ a b c Kashani KB, Farmer JC (2006). "The support of severe respiratory failure beyond the hospital and during transportation.". Curr Opin Crit Care 12 (1): 43–9. PMID 16394783. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16394783. 
  28. ^ Beninati W, Meyer MT, Carter TE (2008). "The critical care air transport program.". Crit Care Med 36 (7 Suppl): S370-6. doi:10.1097/CCM.0b013e31817e3143. PMID 18594265. http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18594265. 
  29. ^ DiBlasi RM, Cheifetz IM (2011). "Neonatal and pediatric respiratory care: what does the future hold?". Respiratory Care 56 (9): 1466–80. doi:10.4187/respcare.01505. PMID 21944692. 
  30. ^ http://www.ccmcertification.org/secondary.php?section=About Commission for Case Management Certification
  31. ^ http://www.vanderbilthealth.com/lifeflight/16045
  32. ^ http://www.nccwebsite.org/catalogs/exam-npt/ The National Certification Corporation
  33. ^ Cheifetz IM (2011). "Management of acute lung injury: sharing data between adults and children.". Respiratory Care 56 (9): 1258-68; discussion 1268-72. doi:10.4187/respcare.01413. PMID 21944680. 
  34. ^ Curley MA (2011). "Respiratory research in the critically ill pediatric patient: why is it so difficult?". Respiratory Care 56 (9): 1247-54; discussion 1254-7. doi:10.4187/respcare.01255. PMID 21944679. 
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