Monday, May 29, 2017

1940-1960: The RT Profession Matures

ITA Logo (6)
The respiratory profession as we know it today was born in the 1940s.  This is the decade nursing assistants and orderlies, mainly the strong, male variety, were recruited to transport, set up, monitor, and clean oxygen equipment. This was the beginning of the inhalation therapy profession.  Those individuals recruited were called oxygen orderlies or inhalation therapists. 

These first inhalation therapists were generally trained on the job (and were called OJTS) and usually poorly understood the task they were undertaking. For the most part they were referred to as button pushers, meaning that the physician gave them orders and they did what they were told.

Although this must have become frustrating for the inhalation therapists were were up on all the modern inhalation therapy wisdom.  They must have yearned to question many physician orders, and perhaps even the efficacy of what they were ordered to do.  They must have yearned for the autonomy to do things that might better benefit their patients. Some might have found physicians willing and eager to accept their ideas, although most were probably unwilling to heed the advice of uneducated therapists who were often considered mere ancillary staff.

Perhaps it was for this reason that, said  R. Weilacher...
...On July 13, 1946, a diverse group of 'oxygen orderlies,' physicians, nurses, and other interested people met at the University of Chicago to form the Inhalational Therapy Association. The profession was born on April 15, 1947, when the Inhalation Therapy Association (ITA) was legally chartered as a not-for-profit entity in the State of Illinois. (6) 
1960s: Sister Mary Yvonne Jenn 
becomes the FIRST registered inhalation therapist
in the U.S. (Registry No. 1!) (10)
The ultimate goal of this organization was to better educate inhalation therapists and further improve credentials and respect for the new profession. Considering there were no schools that taught inhalation therapy, all this training was performed by the present staff and managers of inhalation departments.

Because they were eager to further understand the equipment they were using, and the patients they were trying to help, many inhalation therapists read periodicals written for the nursing and medical profession.  What they didn't learn by reading they learned by training from their superiors or by their own experiences and observations.

Weilacher said:
Because formal training programs had not yet been defined, the teaching of subordinates was an obligatory part of management. Essentially this form of instruction was usually limited to passing on information gleaned from a limited number of resources and isolated experiences. Though this obligation served as a chrysalis for perpetuating the clinical profession, unfortunately it preserved the biases, prejudices, and misconceptions of instructors who had no experience in scientific methodology. These misconceptions were easily adopted by upwardly mobile subordinates and readily perpetuated elsewhere. (6)
This theory may help explain many of the problems that continue to plague the profession to this day.  Yet there were now a group of professionals that ranged from inhalation therapists and managers to physicians who were pent on improving the profession.

In 1947, Dr. Albert Andrews of Chicago wrote a short book, "Manual of Oxygen Therapy Techniques," that "documented the purpose and structure of the hospital-based inhalation therapy department," said Weilacher. (6)

This book was studied and the methods described were used by managers throughout the country to organize their inhalation therapy departments.

Dr. Anderson was an "ardent proponent" that IT departments should be operated under the direction of a physician on staff.  But this system was short lived due to changes forced upon hospitals by a decrease in staff during WWII.  (6)

Shortly after the war, in 1948, Alvin Barach wrote the first book specifically aimed at the inhalation therapy profession (ITA).

Then, in 1950, Barach, Edwin Emma, and Vincent Collins published...
...formalized minimum standards for training programs in the 1950s.  They received support from the Committee on Public Health Relations of the New York Academy of Medicine.  In the document, they specified a curriculum and conditions of training.  They noted that in most medical schools inhalation therapy was rarely part of the curriculum. (9, page 1163)
The italics there were added by this blogger for emphasis.  This was one of the things that inhalation therapists started realizing as they gained experience and education.  Yet trying to convince the medical profession that a group of therapists and technicians with little formal education that they knew more about inhalation therapy than physicians was a daunting task, one that continues to plague the profession to this day.

A little less than a decade later, in 1956, the ITA started publication of the first magazine specifically targeted to the inhalation therapist, and it was called "Inhaltion Tharapy." (This magazine is now referred to as "Respiratory Care.")

During the 1930s oxygen was beginning to be piped into hospitals, although this mainly occurred only in larger hospitals.  During the 1940s this trend continued, and by the end of the 1940s many hospitals had piped in oxygen systems with large oxygen tanks placed outside their doors.  When a person required oxygen, all the therapist had to do was plug in the equipment to the specific adapter on the wall.

While such systems made life easier for the inhalation therapist, it also created the first threat that the profession might no longer be needed.  Thankfully, however, a new role for the inhalation therapist soon developed, and this arose out of a revolution that was taking place in operating rooms around Europe and the United States.

By the 1950s new anaesthetics had been developed, along with newer methods of anesthetizing patients.  This made it easier for surgeons to perform abdominal surgeries without having to worry that a patient might die during the operation due to anesthesia.  This resulted in a spike in abdominal surgeries.

Of course this spike in abdominal surgeries resulted in a spike in post operative complications, which included postoperative atelectasis and pneumonia.

After a series of studies it was determined that these complications were the result of inactivity due to pain and medications used to control pain.  Such patients were not taking in deep breaths necessary to keep alveoli open, and this was causing atelectasis.

This, coupled with lack of a good cough to clear secretions, made the lungs a breeding ground for germs, resulting in pulmonary infections such as pneumonia.

So a new role for the inhalation therapist and nurses was to work with these patients to encourage them to take deep breaths and to move around, even at the expense of pushing these patients to the pain threshold.

In 1952 the first intermittent positive breathing (IPPB) machines were introduced to the market.  These machines were initially used to ventilate patients during operations.  Rubber tubing from the machines was connected to a rubber mask that was held over the patient's face.  During longer operations the tubing was connected to endotracheal tube.

These machines eventually made their way to patient rooms where they were either connected to rubber masks or a cannula inserted into a tracheostomy.

A variety of companies tapped into this new market, resulting in a variety of IPPB machines.  The most common were the Bennet PR 1 and 2, and by 1955 the Bird Mark 7.

These machines, along with iron lungs, were used as ventilators during the 1950s, although the IPPB machines soon became more common.  It was the role of the inhalation therapist to manage both IPPB machines and the iron lungs.

With the advent of positive pressure breathing, various companies rushed to tap into this market to create machines that would eventually replace both IPPB machines and iron lungs.

These new machines were called volume ventilators. The Emerson Volume Ventilator was introduced to the market in 1964, and the MA1 Volume Ventilator that hit the market in 1967.

The Emerson ventilator was often referred to as a big green washing machine.  It had parts that were similar to parts inside a Volkswagon Beetle, and for this reason, when the machine stopped working, say a belt broke, a belt might be removed from the Beetle and replaced into the ventilator.  The machine provided humidification by means of a simple hot plate that could be repaired by parts bought at a local shop.

The MA1 was such a sturdy and compact unit that had simple knobs on the front where the therapist could dial in tidal volume and rate.  Alarms were added to these machines over time, and were usually more complicated to operate than the machines themselves, which were actually quite simple.  An MAI was actually still in service at the community hospital I started working for in 1997.  I used it only once before it was replaced with the Servo 300A.

Monitoring, maintaining and cleaning these machines was a complicated task, and it required the services of the inhalation therapist.  This, along with the routine use of IPPB machines to provide intermittent bronchodilator therapy to post operative patients and lung patients hospital wide brought added security to the profession of inhalation therapy.

So it was during the 1950s that IPPB therapy became routinely prescribed in hospitals worldwide.  Physicians would often order them to be used three to four times per day and as needed to force the lungs open in order to create better distribution of medicine in lung patients.

This type of therapy was although thought to force collapsed areas of the lungs open in order to prevent and treat post operative atelectasis and prevent post operative pneumonia.  So it became quite common for inhalation therapists to perform IPPB treatments to patients, and this was the beginning of the IPPB revolution.

The best part about this was that at this time there was a fee for each of these treatments performed, so inhalation therapy departments were quite lucrative for hospitals, further justifying the need to keep inhalation therapy departments intact.
Also during this time oxygen was being used routinely for hypoxia that resulted from diseases such as pneumonia, heart failure, chronic bronchitis, and emphysema.  Inhalation therapists, nurses and physicians were observing that some of their chronic bronchitis and emphysema patients were becoming lethargic, and sometimes dying, when exposed to high amounts of oxygen.

This observation gave birth to the fear that high levels of oxygen might knock out the drive to breathe in such patients who had a chronically elevated carbon dioxide (CO2) levels, and this gave birth to the hypoxic drive theory that would cause physicians to underoxygenate chronic obstructive pulmonary disease (COPD) patients for the next 40 plus years.

The hypoxic drive theory was proven by Dr. E.J.M. Campbell in the 1950s based on a study of only four COPD patients.  In a report to the physicians in 1960 he reported his findings, and ever since then medical students have had the hypoxic drive theiry pounded into their heads.

The nice thing about the hypoxic drive theory is it provided yet another reason for the importance of inhalation therapists.

It was about this time that it was observed that as ITs obtained more responsibility and were taking care of a greater number of disorders with oxygen therapy and IPPB therapy, that the scope of knowledge needed far exceeded their training. This was particularly apparent on weekends and night shifts when the least experienced therapists were working alone. (5)

Partially as a result of this, beginning in 1950 members of the ITA started teaching classes.  Initially there were 16 classes in total, and upon completion of an exam participants earned a certificate and became the first certified inhalation therapists.

Another thing that was new during the 1950s was cardiopulmonary resuscitation, or CPR.  Various studies were performed that proved that most adults who stopped breathing were having cardiac issues, and that the most effective means of oxygenating these individuals was by performing chest compressions.
bOther studies proved that mouth to mouth breathing was not only safe, but it was the best way to breathe for unconscious patients.  So chest compressions and mouth to mouth breathing became routine elements of CPR.

Another revolutionary breakthrough occurred in 1953 when the AMBU-bag was invented, allowing caregivers an easy and safe means for breathing for patients who were unable to do it on their own.  Performing CPR, and managing the airways by using AMBU-bags, became the routine task of inhalation therapists.

In 1954 the ITA was renamed the American Association of Inhalation Therapists (AAIT). Then, in 1957, members of the American Medical Association, American College of Chest Physicians, and the American Society of Anaesthesiologists adapted a resolution called "Essentials for an Improved School of Inhalation Therapy Technicians."   (8)

Completion of the program resulted in certification.  In October of 1960 the American Registry of Inhalation Therapists (ARIT) was formed to oversee examinations for formal credentialing for people in the field, and a multiple choice test was created with a requirement to complete an oral exam that tested the IT student's ability to use critical thinking skills in real life settings. (8) (9, page 1163)

The first person to fulfill all the requirements of these classes was Sister Mary Yvonne Jenn, who, in 1961, became the first Registered Inhalation Therapist (RIT). (9, page 1164)

References:
  1.  "Questions and Answers," The Modesto Bee, Thursday, Dec. 2, 1948
  2. Glover, Dennis W., "The History of Respiratory Therapy," 2010, page 40
  3. Branson, Richard D, "Jack Emerson:  Notes on his life and contributions to Respiratory Care," Respiratory Care, July 1998, vol. 43, no. 7, pages 567-
  4. Glover, ibid, page 48
  5. Wyka, Kenneth A, Paul Joseph Mathews, William F. Clark, "Fundamentals of Respiratory Care," 2001, page 10, "The Late 1950s and 1960s: Organizational and Clinical Maturation."
  6. Weilacher, Robert R, BHA, RRT, "The History of the AARC," aarc.org, http://www.aarc.org/member_services/history.html, accessed 10/26/12
  7. Whitnack, Jeff, "The History of Respiratory Therapy," AARCTimes, - Volume 26, Issues 1-6 - Page 66
  8. "AARC Timeline," https://www.aarc.org/member_services/timeline/, accessed 10/11/14
  9. Hess, R. Dean,  Neil R. MacIntyre, Shelley C. Mishoe, William F. Galvin, Alexander B. Adams, editors, "Respiratory Care: Principles and Practice," 2nd edition, 2012, Jones and Bartlett Learning, LLC, U.S.
  10. AARC Facebook page, https://www.facebook.com/aarc.org/?fref=ts, accessed March 3, 2016

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