Unit 1: History of Respiratory Care

(6 hours)

Introduction

The history of science and medicine is a fascinating subject that spans from antiquity to the twenty-
first century. Respiratory care is a relatively modern discipline, yet its roots may be traced all the
way back to the start of civilization. Positive pressure breathing with mouth-to-mouth resuscitation
is likely to have been documented for the first time more than 28 centuries ago. This unit describes
the history and development of the field of respiratory care and possible future directions for the
profession.

Learning Outcomes
At the end of this unit, you are expected to:
1. summarize some of the major events in the history of science and medicine;
2. explain how the respiratory care profession began;
3. describe the historical development of the major clinical areas of respiratory care;
4. name some of the important historical figures in respiratory care;
5. describe the major respiratory care educational, credentialing, and professional
associations;
6. explain how the respiratory care organizations began; and
7. describe the development of respiratory care education.

Presentation of Contents

I. DEFINITIONS
Respiratory care, often known as respiratory therapy, is a health care discipline that focuses on
improving cardiopulmonary function and overall health.

Respiratory therapists (RTs) use scientific concepts to prevent, identify, and treat acute and
chronic cardiopulmonary system dysfunction.
The examination, treatment, management, control, diagnostic evaluation, education, and care of
individuals with cardiopulmonary system defects and anomalies is referred to as respiratory care.

Respiratory therapists (RTs), also known as respiratory care practitioners, are health-care
professionals who have been educated and trained to offer patients with respiratory treatment. All
direct patient care services offered by RTs, regardless of practice setting, must be done under the
supervision of a competent physician.

II. THE HISTORY OF RESPIRATORY CARE

• 1943: Edwin R. Levine, MD, establishes a primitive inhalation therapy program using on-the-
job trained technicians to manage post-surgical patients at Michael Reese Hospital in Chicago.

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• July 13, 1946: Dr. Levine’s students and other interested doctors, nurses, and oxygen orderlies
meet at the University of Chicago Hospital to form the Inhalation Therapy Association (ITA).
• April 15, 1947: The ITA is formally chartered as a not-for-profit entity in the state of Illinois.
The new Association boasts 59 members, 17 of whom are from various religious orders.
• 1947: Albert Andrews, MD, outlines the structure and purpose of a hospital-based inhalation
therapy department in his book, Manual of Oxygen Therapy Techniques.
• 1950: The New York Academy of Medicine publishes a report, “Standard of Effective
Administration of Inhalation Therapy,” setting the stage for formal education for people in the
field
• March 16, 1954: The ITA is renamed the American Association of Inhalation Therapists
(AAIT). In February 1966, it was again renamed the American Association for Inhalation
Therapy (still, AAIT).
• May 11, 1954: The New York State Society of Anesthesiologists and the Medical Society of
the State of New York form a Special Joint Committee in Inhalation Therapy to establish “the
essentials of acceptable schools of inhalation therapy.”
• November 7-11, 1955: The AAIT holds its first annual meeting (now the AARC International
Respiratory Congress) at the Hotel St. Clair in Chicago.
• June 1956: The American Medical Association (AMA) House of Delegates adopts a
resolution calling for the use of the New York Essentials in the creation of schools of inhalation
therapy.
• 1956: The AAIT begins publishing a science journal, Inhalation Therapy (now
RESPIRATORY CARE).
• October 1957: The AAIT, AMA, American College of Chest Physicians, and American
Society of Anesthesiologists jointly adopt the Essentials for an Approved School of Inhalation
Therapy Technicians; the Essentials begin a three-year trial period.
• 1960: The American Registry of Inhalation Therapists (ARIT) is formed to oversee a new
examination leading to a formal credential for people in the field.
• November 18, 1960: The ARIT administers the first Registry exams in Minneapolis.
• December 1962: The AMA House of Delegates grants formal approval for the “Essentials for
an Approved School of Inhalation Therapy Technicians.”
• October 8, 1963: The Board of Schools of Inhalation Therapy Technicians is formed in
Chicago.
• 1969: The AAIT launches the Technician Certification Program to offer a credential to people
working in the field who do not qualify to take the Registry exams.
• January 9, 1970: The Board of Schools of Inhalation Therapy Technicians becomes the Joint
Review Committee for Respiratory Therapy Education (JRCRTE).
• 1973: The AAIT becomes the American Association for Respiratory Therapy (AART).
• 1974: The profession’s two credentialing programs merge into the National Board for
Respiratory Therapy (NBRT); the AAIT forms the American Respiratory Therapy Foundation
(ARTF) to support research, education, and charitable activities in the profession.
• 1982: California passes the first modern licensure law governing the profession of respiratory
care; President Ronald Reagan proclaims the first National Respiratory Care Week.
• 1986: The AART becomes the American Association for Respiratory Care (AARC); the ARTF
becomes the American Respiratory Care Foundation (ARCF); the NBRT becomes the National
Board for Respiratory Care (NBRC).

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• 1990: The AARC begins developing Clinical Practice Guidelines (CPGs) for treatments and
modalities common in the field; the ARCF launches an International Fellowship Program to
bring health care professionals from around the world to the U.S. every year to tour health care
facilities in two cites and then attend the AARC International Respiratory Congress.

III. HISTORY OF RESPIRATORY MEDICINE AND SCIENCE

Ancient Times
• Early cultures developed herbal remedies for many diseases.
• The foundation of modern medicine is attributed to the “father of medicine,” Hippocrates,
a Greek physician who lived during the 5th and 4th centuries BC.

Other great scientists of this time period

• Aristotle (342−322 BC) – first great biologist
• Erasistratus (330−240 BC) – regarded by some as the founder of the science of physiology;
developed a pneumatic theory of respiration in Egypt.
• Galen (130−199 AD) – anatomist who believed the air has a substance, vital to life
• Hippocratic medicine was based on four essential fluids: phlegm, blood, yellow bile, and
black bile.
• Hippocrates believed that the air contained an essential substance that was distributed to
the body by the heart.
• The Hippocratic oath, which calls for physicians to follow certain ethical

Middle Ages
• The fall of the Roman empire in 476 AD resulted in a period of slow scientific progress.
• An intellectual rebirth in Europe began in the 12th century.
• Leonardo da Vinci (1453−1519) determined that subatmospheric intrapleural pressures
inflated the lungs.
• Andreas Vesalius (1514−1564) considered to be the founder of the modern filed of human
anatomy; performed human dissections and experimented with resuscitation principles, is
given to most medical students at graduation.

Enlightenment Period
• In 1754, Joseph Black described the properties of CO2.
• In 1774, Joseph Priestley described his discovery of oxygen, which he described as
“dephlogisticated air.”
• Lazzaro Spallazani described tissue respiration.
• In 1787, Jacques Charles described the relationship between gas temperature and volume,
which became “Charles law.”
• In 1778, Thomas Beddoes began using oxygen to treat various conditions at his Pneumatic
Institute

Nineteenth and Early Twentieth Centuries

• John Dalton described his law of partial pressures in 1801.
• In 1808, Joseph Louis Gay-Lussac described the relationship between gas temperature and
pressure.
• In 1831, Thomas Graham described his law of diffusion for gases (Graham’s law).
• In 1865, Louis Pasteur advanced his “germ theory” of disease and suggested that some
diseases were the result of microorganisms.
• In 1846, the spirometer and ether anesthesia were invented.

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 • In 1896, William Roentgen discovered the x-ray, which opened the door for the modern
field of radiology.
• Thomas Guedel (1934) developed a technique for ether anesthesia

IV. DEVELOPMENT OF THE RESPIRATORY CARE PROFESSION

Clinical Advances in Respiratory Care
In many respects, innovations in various therapeutic modalities that evolved in the twentieth
century influenced the evolution of the respiratory care profession. The requirement for a health
care practitioner to offer oxygen treatment, mechanical ventilatory support, and administration of
medical aerosols became obvious as the scientific basis for these services became well established.
Parallel to this need was the ongoing development of specialized cardiopulmonary diagnostic tests
and monitoring procedures, both of which required the expertise of health care professionals.

• An oxygen mask was developed in 1938 by 3 physicians from the Mayo Clinic for use by
Army pilots flying at high altitude.

• The first health care specialists in the field were oxygen technicians in the 1940s.

• In the 1940s, technicians were used to haul O2 cylinders and apply O2 delivery devices.

• In the 1950s, positive-pressure breathing devices were applied to patients.

• Formal education programs for inhalation therapists began in the 1960s.

• The development of sophisticated mechanical ventilators in the 1960s expanded the role of
the respiratory therapist (RT).
• RTs were soon responsible for arterial blood gas and pulmonary function laboratories.
• In 1974, the designation “respiratory therapist” became standard.
• In 1983 the state of California passed the first licensure bill for Respiratory Care
Practitioners (RCP’s). Minimum entry level was set at completion of a one-year technician
level training program.
Oxygen Therapy
• Large-scale production of O2 was developed in 1907 by Karl von Linde.
• The use of a nasal catheter for oxygen administration was introduced by Lane in the same
year.
• Oxygen tents were first used in 1910, and O2 masks, in 1918.
• In 1920, Hill developed an oxygen tent to treat leg ulcers.
• In 1926 Barach introduced a sophisticated oxygen tent for clinical use.
• O2 therapy was widely prescribed in the 1940s.
• The Clark electrode was first developed in the 1960s and allow measurement of arterial
PO2.
• The ear oximeter was invented in 1974, and pulse oximeter, in the 1980s.
• The Venti mask to deliver a specific FIO2 was introduced in 1960.
• Portable liquid O2 systems were introduced in the1970s.

Aerosol Medications
Aerosol therapy is defined as the administration of liquid or powdered aerosol particles via
inhalation to achieve a desired therapeutic effect. Bland aerosols (sterile water, saline solutions)
or solutions containing pharmacologically active drugs may be administered.

• In 1910, aerosolized epinephrine was introduced as a treatment for asthma.

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 • Later, isoproterenol (1940) and isoetharine (1951), metaproterenol (1961), albuterol sulfate
(1980), and levalbuterol (2000) were introduced, primarily for the emergency treatment of
acute asthma attacks.
• In the late 1990s, long-acting bronchodilators – administered twice daily – were introduced
for the maintenance treatment of COPD.

Mechanical Ventilation
It refers to the use of a mechanical device to provide ventilatory support for patients.

• The iron lung was introduced in 1928 by Philip Drinker.

• Jack Emerson developed an improved version of the iron lung that was used for polio
victims in the 1940s and 1950s.
• A negative-pressure “wrap” ventilator was introduced in the 1950s.
• Originally, positive-pressure ventilation was used during anesthesia.
• The Drager Pulmotor (1911), the Spiropulsator (1934), the Bennett TV-2P (1948) and Bird
Mark 7 (1958) were positive-pressure ventilators.
• The Bennett MA-1, Ohio 560, and Engstrom 300 were introduced in the 1960s as volume-
cycled ventilators.
• More advanced volume ventilators became available in the 1970s: Servo 900, Bourns Bear
I and II, and MA II.
• The first microprocessor-controlled ventilators were developed in the 1980s (Bennett
7200).
• Ventilators with the capability of applying advanced modes of ventilation became available
in the 21st century.

Airway Management
It refers to the use of various techniques and devices to establish or maintain a functional air
passageway.

• William MacEwen in 1880 applied the first endotracheal tube to a patient successfully.
• By 1887, Fell had developed a bellows–endotracheal tube system for mechanical
ventilation, and this system was used in 1900 to deliver anesthesia.
• In 1913, the laryngoscope was introduced.
• The double-lumen Carlen tube for independent lung ventilation was introduced in 1940
• The first suction catheter was described in 1941.
• In 1962 a double-lumen tube was developed by Robertshaw.
• Low-pressure cuffs for endotracheal tubes were introduced in the 1970s.

Cardiopulmonary Diagnostics
• Measurement of the lung’s residual volume was first done in 1800.
• In 1846, the first water-sealed spirometer was developed by John Hutchinson.
• In 1948, forced expiratory volume in 1 second (FEV1) was suggested as a measure of
obstructive lung disease by Tiffeneau.
• In 1967, rapid arterial blood gas analysis became available.
• Pulse oximeter was introduced in 1980s.
• Polysomnography became a routine in the 1980s.

V. PROFESSIONAL ORGANIZATIONS AND EVENTS

• The Inhalation Therapy Association was founded in 1947.
• The ITA became the American Association for Inhalation Therapists in 1954.
• The AAIT became the American Association for Respiratory Therapy in 1973.
• The AART became the American Association for Respiratory Care in 1982.

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American Association of Respiratory Care (AARC)
• Publishes Respiratory Care Journal Monthly
• Issues Clinical Practice Guidelines as Guide to Patient Procedures
• Serves as Advocate for The Profession to Legislative Bodies, Regulatory Agencies,
Insurance Companies, And the General Public
• During the 1980s, state licensure for RTs started.
• State licensure is based on RTs passing the entry level exam offered by the National Board
for Respiratory Care.
• The NBRC offers a certification and registry examination for RTs.

Committee on Accreditation for Respiratory Care (COARC)

• Maintain respiratory therapy program standardization and quality.
• Every program graduating RT students is regulated by COARC.

Summary of RT organizations
• AARC: national organization, sets national standards for the profession, primary advocacy
group
• NBRC: Credentialing body, must pass this national test to become licensed. They are
responsible for all credentialing (CRT, RRT, NPS…)
• COARC: agency responsible for maintaining RT educational programs

Scope of Practice
• List of The Functions Performed by Respiratory Therapists:
o Recognized by The AARC
o CLINICAL PRACTICE GUIDELINES
• Must operate within the scope of practice; performing functions outside the scope of
practice may result in malpractice lawsuits and loss of licensure

Respiratory Care Education

• The first formal RT program was offered in Chicago in 1950.
• RT schools grew in the 1960s; many programs were hospital based.
• Today, RT programs are offered mostly at colleges and universities.
o In 2006, about 350 formal RT education programs exist in the United States

Future of Respiratory Care

• Expanded Scope of Practice (e.g., Polysomnography)
• Greater Use of Therapist Driven Protocols
• Increased Role as Pulmonary Physician Extender (Physician Assistant)

Hospital Structure
• Chief Executive Officer (CEO) – Administrator
• Medical Director of Hospital
• Medical Staff
• Hospital Departments
• Administration (CEO, directors…)
• Admissions (admit patients)
• Support Staff (includes healthcare providers)

Support Staff
• Dietary (licensed practitioners, some patients are on strict diets)
• Housekeeping (very important role in preventing disease transmission)

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 • Purchasing (buys supplies for the hospital)
• Maintenance (fixes non-medical equipment in hospital)
• Medical Records (keep track of all patient records)
• Medical Billing
• Quality Assurance/Utilization Review
• Education (typically nursing)
• Social Services (helps with financial issues and family issues, grieving)
• Discharge Planning
• Clinical Departments

Clinical Departments
• Nursing (largest in all hospitals)
• Imaging (includes X-ray, CT Scan, MRI, cath labs, nuclear medicine, ultrasound etc)
• Laboratory (perform blood, urine, sputum analysis for diagnosis)
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Pharmacy
• Respiratory Therapy

Respiratory Therapy Department Structure

• Department Manager
• Receptionist/Administrative Assistant
• Equipment Specialist
• Clinical Educator
• Supervisor/Lead Therapist
• Staff Therapists
• Oxygen Technicians

Functions of the Respiratory Therapy Department

• Administration of Therapy
o Physician’s Orders
o Protocols
• Administration of Therapy
o Triage of Work Load
▪ Cardiac Arrest
▪ Emergency Department
▪ Mechanical Ventilation
▪ Routine Therapy
▪ Diagnostic Testing
• Documentation
• Patient Assessment/Consultation
• Quality Assurance
• Patient education
• Cost Containment

VI. FUTURE OF RESPIRATORY CARE

A notable pulmonary physician and one of the numerous physician proponents of RTs, David
Pierson, MD, set out to depict the future of respiratory care in 2001. Pierson expected a far
higher use of patient assessment and protocols in chronic illness state management in all
clinical settings, among other things. He also envisioned RTs playing a bigger role in palliative
and end-of-life care.

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 Feedback
1. Define the respiratory care profession in your own words. Include at least three main concepts.
How did the profession get started? Why are we here?

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2. Describe how RT schools got started. What kinds of programs do they have now? How do these
programs differ from those in the early days?
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3. Describe at least four careers that would become possible for you as a result of baccalaureate or
graduate education.
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4. Heroes are found in history. Name three important historical figures in respiratory care. Pick
one and briefly explain how this person might inspire you in your career.
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5. Explain how important respiratory care organizations and how it began.
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6. Describe the development of respiratory care education

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7. Explain briefly the major respiratory care educational, credentialing, and professional
associations.

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Summary of the Unit
In this unit, you learned about the history of respiratory care. It should be noted that:

• RTs apply scientific principles to prevent, identify, and treat acute or chronic dysfunction
of the cardiopulmonary system.
• Respiratory care includes the assessment, treatment, management, control, diagnostic
evaluation, education, and care of patients with deficiencies and abnormalities of the
cardiopulmonary system.
• The AARC is the professional association for the profession.
• RTs work under the direction of a physician who is specially trained in pulmonary
medicine, anesthesiology, and critical care medicine.
• The NBRC, the credentialing board for RTs, was founded in 1974. The American Registry
of Inhalation Therapists was founded in 1960.
• The CoARC accredits respiratory care educational programs. The first Board of Schools
was established in 1963.
• As the physiologic basis for oxygen therapy became understood, use of oxygen to treat
respiratory disease became established by the 1920s, and oxygen was used routinely in
hospitals by the 1940s.
• Use of aerosolized medications for the treatment of asthma began in 1910, with numerous
new drugs being developed in the twentieth century and continuing up to the present.
• Mechanical ventilation was explored in the 1800s. In 1928, Drinker developed his iron
lung; this was followed by the Emerson iron lung in the 1930s, which was used extensively
during the polio epidemics of the 1940s and 1950s, and the modern critical care ventilator,
which became available in the 1960s.
• The ITA was founded in 1947, becoming the AAIT in 1954, the AART in 1973, and the
AARC in 1982.
• The AARC now has 10 Specialty Sections to provide resources to members based on
where they are employed and practice.
• Respiratory Care Week is a yearly event to promote the profession and raise awareness of
the importance of good lung health.
• In the future, there will be an increase in demand for respiratory care because of advances
in treatment and technology; increases in and aging of the population; and increases in the
number of patients with asthma, COPD, and other cardiopulmonary diseases.

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 Reflection

Now that you have reached this far, it is time to reflect and make a move by answering the
following questions.
• What is the most important thing you learned from this unit? Why do you think so?
• How did you gain learning?
• What can/should you do with what you know?

References:
Kackmareck, R. M. et. al. (2017). Egan’s Fundamentals of Respiratory Care. Eleventh Edition.
Canada: Elsevier

Eubanks, D. & Bone R. (1990), Comprehensive Respiratory Care. Second Edition. USA:
Curvelwell Publisher

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