Respiratory therapist

Respiratory therapists work in many settings within medicine. In the hospital setting, respiratory therapists evaluate, diagnose and cardiopulmonary illness. In the clinic or outpatient setting respiratory therapists assist with diagnosis and serve as an educator for patients suffering from cardiac and respiratory illness.^[1] In the United States, respiratory therapists 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 therapists 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 therapists 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 therapists work with physicians in the diagnosis of sleep-related illnesses. Respiratory Therapists in the United States are migrating toward a role with autonomy similar to the nurse practitioner, or as an extension of the physician like the physician assistant.^[6] Respiratory Therapists are frequently utilized as complete cardiovascular specialists being utilized to place and manage arterial accesses along with peripherally-inserted central catheters.^[7]

Medication is the most important treatment of most diseases of pulmonology and cardiology, 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.

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. Respiratory Therapists are frequently required to intubate, initiate intravenous lines, place arterial lines as well as many other vascular accesses such as central venous catheters and pulmonary artery catheters (Swan-Ganz).^[7] Respiratory Therapists are specialists in life support initiation and management. All United States neonatal intensive care units with a level 2 or greater designation are required to have dedicated respiratory therapists to that intensive care unit in order to maintain accreditation from the American Academy of Pediatrics.

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 therapists, Occupational Therapists and Physical Therapists.

In the United States and Canada, respiratory therapists are healthcare professionals who, after receiving a degree in respiratory medicine or respiratory science complete a credentialing process. After satisfactorily completing the required examinations and added to a registry, the practitioner 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 an Asthma Educator or a Neonatal & Pediatric Transport Specialist. In Canada, some similar credentialing exists, such as the Certified Respiratory Educator program.

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.^[8]

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 Care. Success on this examination will then allow the respiratory therapist 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 therapists living in regulated provinces, however, for respiratory therapists 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 therapist the title of Registered Respiratory Therapist (RRT). While an active license is not required to take advanced provider courses such as PALS, NRP, or ACLS, the practice of skills taught must have an accompanied license. Many students acquire advanced provider certifications as a part of their accredited respiratory care program.

Registered respiratory therapists in Canada earned between $49,173 CDN to $120,386 CDN annually in 2010.^{[citation needed]}

In Philippines respiratory therapists are clinicians who have been awarded at minimum a Bachelor of Science in Respiratory Care degree.^[9] Licenses to practice respiratory care are regulated by the Professional Regulatory Board of Respiratory Therapy and Professional Regulation Commission which is established and legally maintained by the Philippine Respiratory Therapy Act (Republic Act No. 10024).^[10]

In United Arab Emirates respiratory therapists must have been awarded a Bachelor of Science in Respiratory Care. An additional two-years of experience is required for foreign applicants. Licenses are maintained and awarded by the Dubai Health Authority. The Dubai Health Authority restricts respiratory therapists to working only in physical medicine and rehabilitation Centers, in hospitals, in surgical clinics with cardio-thoracic surgeons and with physicians in family/general practice or pulmonology.^[11]

In the United States a respiratory therapist is a clinician who has at a minimum completed an Associate of Science in Respiratory Care degree along with a certification process. After satisfactorily completing required examinations either administered by the National Board for Respiratory Care or directly by the individual state licensing board (either the medical examiners board or a special state respiratory care board). There are two recognized governing bodies in the United States; the State Board of Respiratory Care in the state in which a respiratory therapist 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 along with some additional specialist certifications. 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.^[12] The NBRC credential is renewed every 5 years for a fee in addition to fees assessed by the state boards of respiratory care.

Respiratory Therapists 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.

Respiratory Therapists in the United States earned a median of $54,280 ($26.10/hour) USD in 2010.^[13]

The traditional role of the operating room respiratory therapist has included providing technical support to the anesthesiologist for the proper use and maintenance of the anesthetic gas machine, in addition to also providing airway management. This role in the operating room has evolved to include a more advanced and specialized role with increasing responsibilities to the respiratory therapist. Like nurse anesthetists, respiratory therapists are academically prepared to perform activities such as sedation by administration of anesthetic gases and medications, insertion and management of vascular (arterial and venous) access and assessment of the depth of anesthesia under the guidance of an anesthesiologist or nurse anesthetist and under the authority of medical directives.^[14] This role is similar to the more main-steam nurse anesthetist profession,^[15] and is defined as equivalent by the United States regulations for anesthesia service providers.^[16]

Note that, in the U.S., becoming an anethesia assistant is a two-year program of study at the master's level. Pre-requisites for entry into an AA program are similar to those for medical school including advanced chemistry, biology, physics and math.

Asthma specialists work with clinics, hospitals and schools as an educator for teachers, parents, patients and practitioners on asthma and allergies. Respiratory Therapists 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.^[18] In the United States, Certified Asthma Educators (AE-C) are credentialed by the National Asthma Education Certification Board (NAECB).^[19]

In Canada, the Canadian Network for Respiratory Care administers two certifications for the specialization as Respiratory Therapist Asthma Educator, 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.^[20]

Respiratory Therapists work with people suffering from cystic fibrosis in clinics and hospitals^[21] 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 therapists. 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.

Respiratory Therapists are able to fulfill 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 therapists, 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.^[22]

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.^[23][24] This ECMO Clinical Specialist may be the bedside critical care nurse specifically trained in ECMO patient and circuit management,^[25] or the ECMO system may be primarily managed by a registered respiratory therapist,^[26] or physicians with training as ECMO clinical specialists.^[25]

Much like adult intensivist respiratory therapists, neonatal and pediatric specialists deal primarily with managing life support for the pediatric or neonatal patient.^[27] Pediatric respiratory therapists are trained extensively in antenatal and intrapartum patients and family.^[27] In the United States a specialist certification exists and is awarded by the National Board for Respiratory Care. Available to respiratory therapists holding certification as a certified respiratory therapist or registered respiratory therapist however the registered respiratory therapist is preferred by most institutions.^[27][28][29]

Respiratory Therapists monitor, interpret and diagnose findings from a sleep study, as well as the medical history and physical exam to make the diagnosis and decide on treatment related to sleep-disorders. A sleep study can also help diagnose narcolepsy.^[30] In the United States a sleep disorder specialist can be a Registered Respiratory Therapist with the sleep disorder specialist certification (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.

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.^[31]

Respiratory Therapists work with nurses, physicians, and paramedics in emergency flight and ground transport.^[32] 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.^[33] The NREMT has included respiratory therapists as qualifying for the advanced credentialing as a critical care paramedic CCEMT-P.

Respiratory Therapists are sometimes referred to as Respiratory Scientists who are specialists in pulmonary function.^[34] respiratory therapists 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.^[35]

The profession of respiratory care was officially established over 60 years ago;^[12] and respiratory research has officially existed since the early 1900s.^[36] During the early years, respiratory therapists were referred to as "oxygen technicians", and most of their activities involved moving cylinders of compressed gas and administering oxygen via nasal catheter or oxygen tent.^[37] Most oxygen technicians were trained on the job, although brief training programs began to appear in the late 1940s and 1950s.^[38][39]

Today the profession hardly resembles what it was in the 1940s. Respiratory Therapists provide direct care, patient education, and care coordination. They are academically trained in respiratory nursing and respiratory medicine. They practice in acute care facilities, long-term acute care facilities, skilled nursing facilities, assisted-living centers, subacute care units, rehabilitation centers, diagnostics units, and in the home.^[40] respiratory therapist training has also dramatically changed. Current accreditation standards require respiratory therapists to have, at minimum, an Associate of Science in Respiratory Care degree from an accredited program.^[41] Legal requirements to practice respiratory therapy have also dramatically changed. 49 states now legally recognize respiratory therapists.^[42] Limited permits or state licenses are now required in all states except Alaska, which has no statutory authority over the practice of respiratory care. Most states that have a licensure requirement also require continuing education.

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^[12] 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).^[43] 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.^[43] The CoARC replied by a press release rejecting the recommendation.^[44] 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.^[45] Similar bills have been introduced before and have died in committee.^[4][5][46] 1111

• Respiratory Care Associations — A list of respiratory therapy organizations
• Registered Respiratory Therapist — Becoming more prominent is the advanced practice respiratory therapist.
• Certified Respiratory Therapist — Formerly called a technician, this is the entry level therapist credential.
• American Association of Respiratory Care — The AARC is the only professional association for Respiratory Therapists in the United States.
• National Board for Respiratory Care — The NBRC is a non-profit credentialing agency keeping a registry of therapists in the United States and Latin America.
• Canadian Society of Respiratory Therapists – The national professional association for respiratory therapists in Canada.
• Respiratory Pharmacology - A list of important drugs used in the respiratory therapy field.