Chapter 2 – The Profession of Respiratory Therapy

Learning Objectives

• Roles & functions of key professional bodies:

  • American Association for Respiratory Care (AARC)

  • National Board for Respiratory Care (NBRC)

  • Commission on Accreditation for Respiratory Care (CoARC)

• Contribution of professional/medical organizations to development & quality of medicine

• Scope of respiratory care practice: assessment, management, education, rehabilitation, etc.

• Practice settings in which RTs work (hospital to home)

• Administrative roles & responsibilities: Director, Education Coordinator, QA Coordinator, Supervisors/Lead Therapists, Researcher, Clinical Staff, Medical Director

• Accreditation, credentialing, medical direction & licensure dynamics

• Future-oriented roles each RT must embrace for profession’s growth

Historical Context & Growth

• Profession officially established in the $1930\text{s}$ (USA)

  • Early title: “oxygen technicians/orderlies” trained on the job

• Modern workforce ≈ $191,457$ RTs

• Currently one of the fastest-growing health-care professions, mirroring uptick in cardiopulmonary disease prevalence (COPD, asthma, post-COVID sequelae)

Contemporary Scope of Practice

Broad Responsibilities

• Patient assessment, diagnostic evaluation, disease management & education

• Provision of cardiopulmonary rehabilitation and long-term care across all sites

Diagnostic Activities

• Obtain/analyze physiologic specimens (ABG, sputum, capillary samples)

• Interpret physiologic data (ABG, PFTs, hemodynamics)

• Conduct cardiopulmonary & neurophysiological testing

• Perform sleep-disorder studies (polysomnography)

Therapeutic Activities

• Apply & monitor medical gases/environmental control

• Mechanical ventilation: invasive & non-invasive, transport, weaning protocols

• Insert/manage artificial airways (ETT, tracheostomy)

• Bronchopulmonary hygiene (CPT, PEP, HFCWO)

• Administer pharmacologic agents (aerosolized bronchodilators, inhaled vasodilators)

• Cardiopulmonary rehab & hemodynamic support (ECMO team collaboration)

• Sleep support: PAP titration, follow-up education

Practice Settings

• Acute-care hospitals (ICU, ED, NICU, PICU, OR, cath lab)

• Outpatient clinics & physician offices

• Home-care companies & durable medical equipment (DME) providers

• Interfacility transport (ground/air critical-care teams)

• Sleep laboratories

• Skilled nursing & long-term acute-care facilities

• Pulmonary rehabilitation programs

• Insurance & utilization-review organizations

Respiratory Therapy Department Structure

Goal

• Deliver high-quality, efficient, evidence-based cardiopulmonary care to multiple clients: patients, nursing units, physicians

Centralized Model

• Shared leadership, policies, protocols, equipment pool & QA metrics

Key Departmental Roles

Department Director

• Titles: Director, Technical Director, Chief, Manager

• Must be a highly skilled, forward-thinking RT focused on quality & professional growth

Educational Coordinator

• Performs individual competency assessments

• Designs orientation & continuing-competency curricula

• Implements rollouts for new technology/protocols

Quality Assurance (QA) Coordinator

• Measures efficiency: historically $\frac{\text{RVU}}{\text{Time}}$ vs. FTEs

• Modern approach: Value-based efficiency $= \frac{\text{Benefit}}{\text{FTE effort}}$

  • Benefit indices: cost savings, survival, patient-perceived benefit

• Identifies improvement opportunities (LEAN, Six-Sigma methods)

Researcher/Scientist

• Advanced-degree clinicians driving outcomes research, protocol validation & grant acquisition

Supervisors / Lead Therapists

• Experienced, higher-credentialed RTs (often RRT-ACCS, RRT-NPS)

• Daily operations: staffing, advanced-procedure support, first-level conflict management

Respiratory Therapists (Clinical Staff)

• Bedside front-line providers; may specialize (NICU, ECMO, PFT lab)

• Often work $12\text{-hour}$ shifts; require cross-training for surge capacity

Medical Director

• Pulmonary/critical-care physician or anesthesiologist

• Shares clinical quality responsibility with Director

• Available $24/7$, develops evidence-based protocols, mentors RT leadership

Credentialing Pathway

• Two general levels:

  1. Certified Respiratory Therapist (CRT)

  2. Registered Respiratory Therapist (RRT)

• Sequence:

  • Complete CoARC-accredited program (≥ associate degree)

  • Take Therapist Multiple-Choice (TMC) exam

  • Cut score $S_1$ ⇒ CRT

  • Higher cut score $S_2$ ⇒ eligibility for Clinical Simulation Exam (CSE)

  • Pass CSE ⇒ RRT

• Specialty credentials (via NBRC):

  • CPFT, RPFT, NPS, ACCS, SDS

Professional & Regulatory Organizations

American Association for Respiratory Care (AARC)

• Premier professional body; governance: Board of Directors, House of Delegates, Board of Medical Advisors, President’s Council

National Board for Respiratory Care (NBRC)

• Voluntary credentialing agency; mission: promote excellence via high competency standards

Commission on Accreditation for Respiratory Care (CoARC)

• Accredits associate, baccalaureate & master’s RT programs in USA & Puerto Rico

American Respiratory Care Foundation (ARCF)

• Philanthropic arm supporting research, education & journal conferences

Coalition for Baccalaureate & Graduate RT Education (CoBGRTE)

• Advocates baccalaureate/graduate entry-to-practice model

International Council for Respiratory Care (ICRC)

• $25$ member countries; addresses global RT trends & standards

Additional Influencers

• National Asthma Educator Certification Board (NAECB)

• The Joint Commission (TJC)

• Centers for Medicare & Medicaid Services (CMS) under HHS

• Association for the Advancement of Medical Instrumentation (AAMI)

Education & Degree Advancement

• Minimum entry: CoARC-accredited associate degree to sit for NBRC TMC

• AARC encourages baccalaureate entry; degree advancement & online BSRT/masters programs proliferate

State Licensure

• Protects public health; minimum competency typically CRT

• Trend toward RRT-required licensure:

  • Ohio first ( $2015$ ) → followed by CA, AZ, NJ, NM, OR, GA

  • COVID-19 slowed conversion due to workforce shortages

Professionalism & Ethics

• Complete accredited program & credentialing

• Engage in continuing education (e.g., AARC CRCE credits)

• Adhere to institutional/state codes of ethics & HIPAA privacy

• Active participation in professional societies; advocacy & mentorship

Future Directions

AARC “2015 and Beyond” Initiative

• Forecasts evolving patient-care models & RT roles

• Five key questions addressed:

  1. Future delivery methods for patient health-care services?

  2. How will respiratory care be provided?

  3. New knowledge/skills/attributes needed for safe, cost-effective care?

  4. Education/credentialing systems required to impart those competencies?

  5. Transition strategies that avoid negative impact on existing workforce?

Emerging Roles

• Pulmonary Disease Manager: empowers chronic-disease patients (COPD, ILD) toward self-management

• Advanced Practice Respiratory Therapist (APRT):

  • Addresses shortage of specialized non-physician providers for cardiopulmonary patients

  • CoARC standards finalized for master-level programs; at least $1$ program accredited to date

Practical/Philosophical Implications

• Value-based health care aligns RT protocols with Triple Aim: $\text{Better outcomes + Lower cost + Enhanced patient experience}$

• RTs pivotal in ventilator triage & pandemic response (ethics of allocation)

• Technological literacy (AI ventilator analytics, tele-monitoring) becoming core competency

• Advocacy for clean-air initiatives & smoking cessation extends RT influence beyond bedside