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Page 1History of the Respiratory Care Profession Although all of medical history influences the present and future of respiratory care, those events primarily since 1943 are particularly of interest. This chapter focuses on those events, as well as the North American model of practice of respiratory care, which varies considerably from practice elsewhere in the world. Contemporary respiratory care was established as a discrete health care discipline shortly after World War II (WWII). Unlike other medical professions, no single event describes the definitive moment of the profession's birth. In the twentieth century, advances in medical science and technology shifted from Europe to North America. Significant Historic, Scientific, and Technologic Advances The two world wars that decimated Europe and to a lesser degree, the Far East, left North America relatively unscathed. By the midpoint of the century the United States and Canada, with stable economies, viable technologic infrastructures, and abundant resources, were positioned to serve as the major socioeconomic support for a large part of the world. This dominance explains in part the unique character of the North American model. Historic, scientific, and technologic advances before 1943 that paved the way for the birth of respiratory care are beyond the scope of this book. However, some such advances, along with other notable events from more recent years, are summarized briefly in Table 1
Table 1 Historic Moments in the Evolution of Respiratory Therapy
One of the most significant technologic advances was in response to the poliomyelitis epidemic in the 1930s. Poliomyelitis patients suffered from impaired or destroyed breathing capabilities and required mechanical ventilation. Such treatment was performed primarily through the use of negative-pressure tank ventilators later nicknamed "iron lungs." Click the pictures below for more information on the polio epidemic...
Several physicians and scientists experimented with negative pressure, but Alfred F. Jones developed one of the first full-body iron lungs in 1864 (Figure 1-1). This device evolved into the Emerson respirator, developed by John Haven Emerson (Figure 1-2). With the increasing availability of electricity in urban areas, the Emerson respirator supplied a simply designed electric motor that hospitals could afford to answer the demand for respirators caused by the poliomyelitis epidemic.
Figure 1-1 Alfred F. Jones' body-enclosing iron lung. (Modified from Emerson JH: The evolution of iron lungs. Cambridge, Mass: [private publication]; 1978.)
Figure 1-2 John Haven Emerson introduced the Emerson Respiratory, which made mechanical ventilation practical because of its design, simplicity, and electric motor. (Courtesy J.H. Emerson Company, Cambridge, Mass.)
Another important advance came in 1895 with Karl von Linde's fractional distillation of liquefied air, which resulted in large quantities of relatively inexpensive oxygen, essentially a byproduct of nitrogen production. The efficacy of oxygen therapy was not clearly established, however, until the 1920s, spurred in part by John Barcroft's classification of anoxia (hypoxia) and description of his treatment modalities. By the close of WWII, oxygen administration was available in virtually every hospital in the United States. The world wars contributed significantly to the transition from oxygen therapy to inhalation therapy. WWII itself brought about three fundamental advances-(1) antibiotics, (2) demand breathing valves for combat pilots, and (3) nonrebreathing valves and masks for aviators. Antibiotics reduced mortality associated with overwhelming infections and, in so doing, also greatly expanded thoracic surgical opportunities. The new therapies, such as antibiotics, vaccines, and insulin, coupled with war-proven technology in the civilian marketplace, placed growing demands on the health care community. A 1995 report noted that in 1900 the leading diseases were heart failure, shock, pneumonia and pleurisy, angina pectoris, and cerebrovascular disorders, all conditions necessitating respiratory care treatments. Oxygen demand valves, used by WWII combat aviators flying above 5000 meters, found a practical application in medicine by 1947. These valves were marketed as intermittent positive pressure breathing (IPPB) devices with sidearm nebulizers. These early breathing devices were powered by large cylinders of compressed gas and could deliver bland aerosols, antibiotics, mucolytic agents, and bronchodilators. At the same time, the turning and ambulating of postsurgical patients to prevent pneumonia and other complications was gaining increased attention and importance. This growth and development marked the next phase in the history of respiratory care, gradually expanding the duties of oxygen technicians. The availability of the famous B-L-B nonrebreathing mask used by WWII aviators that allowed for a simple, practical way to deliver a controlled percentage of oxygen further metamorphosed the respiratory therapist from an oxygen technician. The inventors wrote the following in their patent application: It is well known that a provision of inhalation apparatus which will be economical in the use of oxygen and which at the same time permits the administration of 100 per cent oxygen will open up a whole new field of oxygen therapy of great value in certain classes of cases ... Another contributing factor to the transition of inhalation therapy was the brief monograph, "Manual of Oxygen Therapy Techniques," written by Albert H. Andrews (Figure 1-3) in 1943. Andrews was a noted otolaryngologist from Chicago. He proposed that inhalation therapy departments should operate under the medical direction of an influential staff physician. The departmental architecture suggested in this monograph was copied across North America, contributing significantly to the beginnings of the profession.
Figure 1-3 Albert H. Andrews, a noted otolaryngologist from Chicago, described the purpose and structure of the hospital-based oxygen service in 1943. (Courtesy American College of Chest Physicians, Chicago.)
Edward R. Levine, a pioneer in pulmonary medicine, recounted the evolution of technology-driven respiratory care in his memoirs. As a young attending physician, Levine tried to involve resident physicians in his earliest efforts in caring for pulmonary patients, especially postsurgical ones. As he expressed it " ... the results were uneven in quality." He wrote that nurses were somewhat better trained than physicians in bedside care but that they simply did not have the time to handle all the pulmonary patients. Levine in turn organized an early inhalation therapy program as part of a department of chest diseases he started in Chicago's Michael Reese Hospital in 1943. On-the-job trained (OJT) technicians were employed to manage the bedside care of postsurgical patients. During the mid-1940s the oxygen therapy devices were heavy, bulky, and unwieldy, characteristics that created a significant problem. Hospital gas supply systems were multiyoked, high-pressure cylinders. Consequently, strong men working in central supply or orderly departments were pressed into service to ensure that oxygen therapy was available on demand. These generally unappreciated oxygen orderlies, or oxygen technicians, were the direct ancestors of the modem respiratory therapist. In less than a decade the somewhat more respected, better-trained inhalation therapist replaced the oxygen technician. The cause for this change was the realization that IPPB technology permitted practitioners to change various components of ventilation at will. The inhalation therapist could modify the administered pressure and the fraction (percent) of inspired oxygen, FIO2, thus altering the inspiratory phase of ventilation. In the following two decades a remarkable variety of mechanical respirators and ventilators became commercially available. The abundance of machines is testimony to the inventive skills of the engineers and their collaborating clinical practitioners. The marketing and distribution of the MA-1 adult ventilator (Bennett Respiration Products, Santa Monica, Calif.) in 1967 was an exciting advance. This ventilator represented a class of simple, electrically driven devices capable of ventilating acutely ill individuals over a prolonged period with reasonable expectations that they would survive. These machines introduced complex electronic microprocessing, circuit boards, relays, photoelectric controls potentiometers, and system monitoring cards. Another newly applied technology, arterial blood gas (ABG) analysis, permitted the rapid and accurate measurement of pH, PCO2 and PO2, allowing for the quantification of mechanical ventilation. Taken together, these were enormous advances that furthered fairly sophisticated control of respiration. Respiratory therapy now was being provided in contrast to the more primitive inhalation therapy. Fortunately, the unending pressure of technologic development continues. This continuum of change has forged the present era, in which respiration must be considered in its three components-ventilation, diffusion, and perfusion-not simply as external respiration. Students in Chicago-area schools of nurse anesthesia, along with OJT inhalation therapy technicians from Michael Reese and Alexian Brothers hospitals, formed the nuclear group that organized the Inhalation Therapy Association (ITA) on July 13, 1946, at the University of Chicago Hospital. By early 1947, budgetary needs related to medical sponsorship, development of credentials, and national educational endeavors dictated a more formal organizational structure. On March 7, articles of incorporation were filed with the Illinois secretary of state to form the ITA. On April 5, 1947, the ITA was chartered, and the following purposes were stated in the articles of incorporation:
The incorporates of the ITA were George A. Kneeland, Richard E. Goss, Vincent T. McCue, Brother Roland Maher (who served as its first president), and Brother Silverius Case. Professionally, Kneeland was a registered pharmacist; Maher and Case were nurse-anesthetists; McCue was an inhalation therapy department manager; and Goss was a manufacturer of vinyl oxygen tent canopies. The 59 members included nine physicians, a pharmacist, an attorney, seven nurse-anesthetists, and eight registered nurses. The Tri-State Hospital Assembly, comprising the state hospital associations of Illinois, Indiana, and Michigan, provided an early forum for the educational and political expression of the new organization. The assembly was important for its positive name recognition and as a venue to promote the specialty within the hospital community. Without significant support the ITA struggled during the first years of its existence. Two notable events in the mid-1950s helped the ITA overcome its perception as a mere regional association. First, the name was changed to the more global American Association of Inhalation Therapists (AAIT). Second, under the presidency of Sister Mary Borromea, OSF, CRNA, (Figure 1-4; OSF, Order of Saint Francis; CRNA, certified registered nurse anesthetist) and with the encouragement of the physician directors, a multiclient public relations firm, Carriere and Jobson, Inc. was hired to manage the business affairs of the AAIT. In May 1955, Albert Carriere, a principal in the firm, was named the AAIT executive director.
Figure 1-4 Sister Mary Borromea, OSF, CRNA, (deceased) was the fourth president of the Inhalation Therapy Association (1955-1956). During her terms of office the first paid executive director was hired; the first annual convention was held; and the Respiratory Care journal first was published. OSF, Order of Saint Francis; CRNA, certified registered nurse anesthetist. (Courtesy American Association for Respiratory Care, Dallas.) Carriere directed the business operations of the AAIT for the next 12 years. By 1967 the perception was that the AAIT's executive director held the association in virtual financial thrall. Although many of his organizational colleagues saw Carriere as a financial savior, Easton R. Smith, 1967 AAIT president, vigorously challenged that notion. He forced the executive director to resign in late 1967, effectively ushering in the present organizational strategy of financial control by the members. By the 1970s, nearly all the organization's infrastructure, as well as that of the profession, was in place, as follows:
The profession, however, had never examined the efficacy of the modes of therapy it was using. This extraordinarily important activity was essentially left to others. Modes of respiratory therapy were based primarily on clinical impressions, not rigorous clinical studies. A Conference on the Scientific Basis of Respiratory Therapy, supported jointly by the then-National Heart and Lung Institute (NHLI) and the American Thoracic Society (ATS), was convened in May 1974 at Temple University Conference Center at Sugarloaf in Philadelphia. Prominent scientists nationwide reviewed the efficacy of oxygen therapy, aerosol therapy, physical therapy, and IPPB therapy. The proceedings of that conference were published in December 1974, engendering considerable angst on the part of respiratory therapists. IPPB therapy, the major clinical task, was scrutinized with discouraging implications. The studies of Barach, Cournand, and especially Motley published as early as 1947, had served as the underpinning for the unparalleled use and misuse of IPPB therapy for more than a quarter century. The initial fears of the respiratory therapists after the proceedings proved unfounded simply because the pathologic processes that had been treated previously with IPPB still needed to be treated. Other modes of therapy with better efficacy replaced the pervasive use of IPPB. Just as important, if not more so, is that the organization, currently known as the American Association for Respiratory Care (AARC), has successfully used the Sugarloaf Conference example as a template for scientific examination of every form of clinical respiratory therapy since 1974. As late as 1970, AAIT then-president Robert A. Dittmar recalled that, in the context of public health issues, licensure was considered a substandard solution to subvert the national Registry credentialing programs. Then, in 1971 the U.S. Department of Health, Education, and Welfare (DHEW) imposed a voluntary 2-year moratorium on additional state licensing. In the spirit of cooperative citizenship the organization enthusiastically supported the moratorium. Furthermore, physician mentors of that era were against any form of licensure on the part of the affiliated organizations chartered by the AARC. A significant organizational milestone was reached in 1980. AARC president at the time, Sam P. Giordano, using persuasive arguments, challenged the conventional wisdom that state licensure was not in the best interests of respiratory therapists-an official position held by the AARC for more than 20 years. After the spring meeting of the board of directors in 1980, Giordano wrote the following: . .. the Board decided that the association needs to develop a plan to assist the chartered affiliates in their efforts to pursue meaningful, nonrestrictive licensure. A national organization is limited in what it can do on a state level by virtue of the fact that there is a great deal of inconsistency in how the legislative process works from state to state. However, it has been felt that the association can playa key role in educating and informing the membership on the common steps that must be taken to assure a successful licensure effort on the state level. With this public announcement, the AARC launched one of the most ambitious, sustained, and successful undertakings in its history. Giordano appointed Jeri E. Eiserman to the post of licensure coordinator, in which she served as the chief architect of this massive undertaking. Eiserman's zealous pursuit of state licensure in 1980 carried over to her own AARC presidency in 1986. As she characterized her administration, she stated the following: I attended 40 plus state society meetings as AARC president. Nearly everywhere I went one of the speeches that I gave addressed the critical nature of state licensure. Too, I did everything I could to marshal the AARC's resources to help states that were willing to pursue licensure. Our model credentialing act was one such resource, one that supported a whole compendium of like materials. Clearly the first purpose enunciated in the 1947 incorporation document, although still in continual evolution, has been faithfully met. The association continues to promote increasingly high standards of practice and the professional advancement of its constituents. By mid-1999, respiratory therapists were licensed in 39 states, the District of Columbia, and Puerto Rico. Four states have certification laws, and one state has a registration law. Education is the fundamental reason for the existence of the AARC and has been since its organizational inception. A key purpose listed in the Articles of Incorporation of the newly chartered ITA was, "To advance the knowledge of Inhalation Therapy through institutes, lectures, and other means ... " Modern amplification of that purpose is codified in the AARC bylaws that read in part as follows: The Association is formed to: a.) Encourage, develop, and provide educational programs for those persons interested in respiratory therapy and diagnostics ... In other words the AARC actively promotes the sequential functions of higher education-research, archiving, and dissemination of knowledge. The original ITA purpose emphasized that the institutes, lectures, and so forth were to be " ... given under the sponsorship of doctors of the Society of Anesthesia." The practical design of such sponsorship was the hope that these educational endeavors would find credibility and immediate legitimacy in the broad medical community. The AARC was formally recognized by the medical community as the preeminent organization for respiratory care education in the United States in 1954. Presently the AARC supports two related constituency groups-the education specialty section and the education committee-along with sponsorship of the Committee on Accreditation for Respiratory Care (CoARC). Furthermore, the AARC is prepared to act as an ombudsman in matters of education for those individuals and agencies not formally allied with it. The centerpiece of the organization's educational thrust is the annual convention and exhibition. In 1955, only 83 people met at the first convention in Chicago. Currently, approximately 7000 conventioneers gather annually. Attendees participate in programs approved for more than 20 contact hours of continuing respiratory care education (CRCE) units. Additionally, this convention is a vehicle used to expose original research by respiratory therapists and others to the scrutiny of the medical community. The AARC's continuing education program enjoys nearly universal recognition in the United States. The point accreditation system, designed and developed in 1968, has matured into the CRCE program. CRCE units are recognized by nearly all states requiring continuing education for license maintenance and retention. In 1972, researchers at Providence Hospital in Seattle and Parkland Memorial Hospital in Dallas independently approached the AARC Program Committee asking to present their findings at the convention. The committee quickly developed the scientific paper competition portion of the program. This segment of the convention was overwhelmingly successful. The competition was eventually restructured, and in 1973 it debuted as the enormously popular Open Forum segment. The AARC started an education forum in 1966, bringing together a handful of respiratory care educators to discuss issues of common interest. This forum slowly evolved into the popular meeting, the Summer Forum. The roots of formal accreditation of respiratory care educational programs trace back to 1950. That year the New York Academy of Medicine's Committee on Public Health Relations published a widely circulated report, "Standard of Effective Administration of Inhalation Therapy, " outlining a need for trained technical personnel in the care of both medical and surgical pulmonary patients. In collaboration with the New York State Society of Anesthesiologists, the Medical Society of the State of New York formed a Special Joint Committee on Inhalation Therapy (SJCIT) in 1954. One of its objectives was " ... to establish the essentials of acceptable schools of inhalation therapy (not to include administration of anesthetic agents) ... " By April 1956 this committee had finished its task, reporting the completed "essentials." Within 2 months the House of Delegates of the American Medical Association (AMA) adopted the resolution introduced by the Medical Society of the State of New York, with the delegates stating the following: Resolved, that the Council on Medical Education and Hospitals is hereby requested to endorse such or similar "Essentials" and to stimulate the creation of schools of inhalation in various parts of these United States of America. A report entitled "Essentials for an Approved School of Inhalation Therapy Technicians" was adopted by sponsors (AAIT, AMA, American College of Chest Physicians [ACCP], and ASA) at a conference in 1957. The validity of these essentials was tested during a subsequent 3-year trial, with the AMA Council on Medical Education and Hospitals recommending final adoption to the AMA's House of Delegates, which granted formal approval in December 1962.
The first official meeting of the Board of Schools of Inhalation Therapy Technicians was held at the AMA's Chicago headquarters in 1963. At that time the board was deemed officially functional. The Joint Review Committee for Inhalation Therapy Education (JRCITE), later renamed the Joint Review Committee for Respiratory Therapy Education (JRCRTE, which was later known as the Joint Review Committee for Respiratory Care Education [JRCRCE)), came into being in January 1970 as a Minnesota corporation under the guidance of the highly respected physician and aviation physiologist, H. Frederic Helmholz, Jr. (Figure 1-5).
Figure 1-5. Frederic Helmholz, Jr., a highly respected physician and aviation physiologist, guided the formation of the Joint Review Committee for Inhalation Therapy Education (JRCITE) on January 9, 1970, as a Minnesota corporation. The JRCITE was later renamed the Joint Review Committee for Respiratory Care Education (JRCRCE).
A maturing and increasingly assertive AARC leadership was poised to overcome perceived barriers to professional identity, self-determination, and responsibility. A core issue was the lack of therapist-physician parity on the Board of Schools. The prevailing sense among respiratory therapists was that issues concerning the profession, including education, were not adequately represented by the therapists, those individuals making up the profession. Consequently, the physicians could and did present a united front in the deliberations of the boards they controlled at the time-Board of Schools, Registry Board, and AAIT Medical Advisory Board. Over time the respiratory therapist's role in determining the direction of the profession grew. The JRCITE's corporate articles and bylaws addressed the therapists' points of contention. By early 1993, relations between the JRCRTE and the AARC were strained again, perhaps exacerbated by the AARC's effort to map out an educational direction for respiratory therapists into the next century.36 In 1994 the AARC immediately sponsored a newly formed Respiratory Care Accreditation Board (RCAB). From these events arose a new structure for accreditation of respiratory care training programs. In 1998 this responsibility was transferred from the JRCRTE and RCAB to CoARC. National and State Credentialing A core responsibility of the accreditation process is quality assurance. That is, accredited educational programs generally prepare their graduates to pass appropriate examinations at the level to which they were trained and earn appropriate credentials. At the dawn of the new millennium, the American Registry of Inhalation Therapists (ARIT), which later became the National Board for Respiratory Care (NBRC), had conferred nearly a quarter million credentials on health care professionals worldwide. These credentials are registered respiratory therapist (RRT), certified respiratory therapist (CRT), registered pulmonary function technologist (RPFT), certified pulmonary function technologist (CPFT), and perinatal/pediatric respiratory care specialist. The sources of these credentials are inextricably tied to those early actions and circumstances that ultimately resulted in the formation of the AARC and CoARC. The ITA Articles of Incorporation contain the impetus for the NBRC: 'To grant certificates of qualification to such as have successfully completed the prescribed requirements. To establish a central registry for members of the Association. " James E. Peo, AARC president in 1958, described the administrative mechanics of qualifying for listing in the "central registry," that is, for ITA membership, as follows: It was the custom at the time that after having completed a series of lectures given by the doctors, we would take a written examination covering the topics which the doctors had lectured on. Everyone received an attendance certificate. If we passed the test, we would receive the Registry certificate. These early experiences in examining and credentialing met with limited acceptance in the medical community. The association, however, persisted, and by mid-1960 Carriere was able to report the following: The final revisions in the Registered By-Laws (sic) have been duplicated by our attorney and sent to members of the Advisory Board .... we are awaiting final approval by the American Society of Anesthesiologists, whose committee on Inhalation Therapy is meeting during the first week in October. The Registry Board organized quickly, offering a twopart pilot examination in November 1960 in Minneapolis. The written and oral examinations were administered and proctored by physicians because no registered therapists yet existed to participate. To take the exam, the candidate must be an active member in good standing of the AAIT. In May 1961, 12 candidates taking the examination were designated registered inhalation therapists, along with 23 others who took the exam that month in Chicago (Figure 1-6). Written and oral examinations were conducted until 1979, when clinical simulation examinations (CSEs) replaced the oral forms.
Figure 1-6 Sister Mary Yvonne Jenn, a registered respiratory therapist shown here in 1998, was the first registered therapist in North America. She was the first registrar of the American Registry of Inhalation Therapists (ARIT), now the National Board for Respiratory Care (NBRC). (Courtesy NBRC, Lenexa, Kan.)
During its first decade the NBRC credentialed only 1594 practitioners, whereas in that same period the AARC's membership rolls grew from 750 to 5147 members, representing about 33% of all active practitioners. Increasingly apparent was that the profession was becoming conspicuous in the health care field because of its inordinately low number of credentialed practitioners-about 10%. To rectify the situation the AARC in 1969 launched a new credentials effort. Then-President John Julius succinctly described as follows the opening of what became an organizational success story: Louise Hemmel, the (AARC) secretary, outlined for me what should be done to recognize people who weren't registered, but represented the majority of workers in the field. Basically, her proposal was the Technician Certification Program. The technician certification program proved enormously successful. During the 5 years that the AARC managed it, more than 10,000 practitioners were recognized as certified respiratory therapy technicians (CRTT's), now known as CRT's. By 1972, having developed a viable, proven credential, AARC President James A. Liverett, Jr. made plans to hand the certification process over to the NBRC, as follows: I carried the message of our thinking to Kansas City where the NBRC met in 1972. I responded to the Board's invitation to address them on this topic. I must say that the trustees were a bit skeptical about this proposal. They didn't appear to be too sure about our motives in giving this program to them. All I could do was (to) openly discuss the logic of my reasoning-that credentialing should be with credentialing-planting seeds that flourished in 1974, when ARIT, Inc. and the AART Technician Certification Board merged to form the National Board for Respiratory Therapy. The NBRC enjoys unconditional membership in the National Commission for Health Certifying Agencies (NCHCA) because the NBRC is now a leader among health certification agencies. The validity of its examinations rests on a national job analysis conducted every 5 years. Criterion-referenced validation studies are conducted on each examination before it is given for the first time. In addition, use of the federally trademarked NBRC fulfills the vision of those individuals who founded the profession in the 1940s. Historically, the first regularly appearing publication of the profession was the Inhalation Therapy Association Bulletin. This quarterly periodical appeared between 1950 and mid-1954, after which a series of newsletter-type publications were distributed, essentially focusing on association news. Medical periodicals such as the journal of the American Medical Association (JAMA) and the New England journal of Medicine (NEJM) exert a significant social impact. They are highly regarded by the lay public and frequently quoted in the popular media. Stimulated by the presence of these powerful journals and other models, such as Chest, Anesthesiology, and the American Review of Respiratory Disease, the respiratory care profession sought to emulate them. By 1956, sufficient resources had been amassed to launch and sustain a quarterly journal. Respiratory Care is a monthly science journal established as the quarterly publication, Inhalation Therapy, under the editorship of longtime educator James F. Whitacre (Figure 1-8). Respiratory Care is published currently for the AARC by Daedalus Enterprises, Inc., and its contents include editorials; original, previously unpublished contributions; case reports; guidelines, recommendations, and statements; reviews of books, films, tapes, and software; classic reprints; and more. The section devoted to guidelines, recommendations, and statements reflects the historical influence of the AARC on the scientific basis for clinical practice. The material appearing in Respiratory Care, especially the special proceedings and consensus conferences, is tremendously valuable to the entire field of pulmonary medicine.
Figure 1-8 James F. Whitacre, a registered respiratory therapist, was among the first group of registered therapists in the United States. During his long career, he served on the boards of the American Association for Respiratory Care (AARC), the National Board of Respiratory Care (NBRC), and the Joint Review Committee for Respiratory Therapy Education (JRCRTE).
In 1969 William F. Miller (Figure 1-9), a pulmonary physiologist from Dallas, and his colleague, Dr. William W. Waring from New Orleans, along with publications Editor-in-Chief and RRT Allan Saposnick of Philadelphia, led a movement to restructure the contents of the journal. They set in motion the administrative actions that resulted in Inhalation Therapy/Respiratory Care becoming a science journal; its contents were to be free of all political influences that could be exerted by its owner, the association.
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