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Physicians Roundtable

RTs in the ICU

The complexity of critical care emphasizes the increasing value of respiratory therapists.

Respiratory therapists have long played an important in the intensive care unit, but perhaps never before has the RT in the ICU had a more direct impact on a hospital's bottom line. From the monitoring of complex ventilators to helping reduce readmissions, implementing care strategies and complying with infection control and other protocols and processes, RTs have become integral members of multidisciplinary ICU care teams.  

Recently, Kevin O'Neil, MD, FACP, FCCP, chair of the American College of Chest Physicians CHEST Respiratory Care Network, and the organization's vice-chair, Dr. David Bowton, MD, shared their thoughts on the increasing roles and responsibilities of RTs.

Have RTs always had a presence in the ICU? How has their role changed and evolved in recent years?
Bowton: RTs have always been an important care provider in the ICU.  Their role has changed, however, over the last 50 years from a focus on providing inhalation therapy to the management of sophisticated microprocessor mechanical ventilators.
O'Neil: This has been coupled with an increase in the rigor of their education, certification and licensing. RTs have also assumed some new roles in the ICU. In many hospitals, for example, RTs have assumed responsibility for both care delivery and management of ECMO programs.

Have recent advances in technology changed the role of the RT in the ICU?
O'Neil: We're not sure that advances in technology have changed the role of the RT but they certainly have emphasized the RT's value, particularly in regard to ventilator management. Technology has dramatically changed the knowledge base required of RTs in the ICU.  Ventilator graphics are now ubiquitous and RTs must be skilled in their interpretation.  In some smaller hospitals, the RT is the expert on complex ventilator care. As our understanding of cardiopulmonary interactions has increased, so has the role of RTs in ensuring hemodynamic stability in our critically ill patients.  Both the number of inhaled drugs and the available technologies to administer them have increased dramatically in the last two decades.  Thus, the required RT knowledge base has increased concordantly. They are often the only provider in the ICU who truly understands the use of many inhaled drugs and the options available to administer them.

Is sedation management a big part of the RT's role in the ICU?
Bowton: Sedation management is largely an issue within ICUs/stepdown units and not in general care areas.  With the widespread use of protocolized "wake up and breathe" strategies there is a huge premium placed on integrating the functions of the bedside nurse with the RT to ensure that mechanically ventilated patients are weaned as quickly as possible.  In most hospital settings RTs do not administer sedative drugs nor titrate them; this is usually the responsibility of the bedside nurse.  However, they must work together to ascertain if the patient's level of sedation is at goal, and to decide when they will lift sedation and assess the patient for weaning.  Sedation management is also one of the tools for the RT in addressing patient- ventilator asynchrony and they need to have in-depth knowledge of the medications and sedation protocols in use in their unit.

How does the RT fit into the infection control strategy of an ICU or hospital?
O'Neil: Tracking and minimization of hospital-acquired infections has been a national patient safety goal for many years.  RTs have the same responsibilities as all health care providers to follow universal precautions, practice hand washing, adhere to established isolation practices and to set an example for other providers in the unit. RTs play a critical role in preventing ventilator-associated pneumonia and hospital acquired pneumonia. This extends from rigorous hand hygiene, to careful handling and prevention of contamination of respiratory equipment, to maintaining bronchial hygiene in the patient through early ambulation, appropriate positioning, rapid weaning from mechanical ventilation, coughing and deep breathing, the appropriate application of assistive devices and suctioning and monitoring compliance with ventilator bundles. , RTs are also often the providers tasked with monitoring and reporting VAEs using the new CDC criteria, developed with input from the AARC and other critical care organizations

Does the RT in the ICU have a role to play in reducing readmissions?
Bowton: The RT plays a significant role in reducing readmissions to the ICU and the hospital as many of these are related to respiratory compromise.  RTs input on the care team ensures that the patient's respiratory regimen is optimal (both from a medication perspective and the use of adjuncts for bronchial hygiene). They are also the healthcare provider most able at assess secretion management. RTs are critical to ensure that the patient is able to use inhaler devices appropriately, provide education to the patient to effect this, and to make recommendations for change based upon patient factors and cost.  RTs have also taken on leadership roles in COPD readmission programs in many facilities and are involved in community outreach programs.

Have Affordable Care Act reforms and the increase on patient satisfaction impacted the role of RTs, including those working in the ICU?

O'Neil: There are clear changes, but we seem to be just at the starting line. The emphasis on reducing readmissions, particularly for COPD, has highlighted the value of the RT as a COPD navigator, educator and health care provider and focused attention on the role of pulmonary rehabilitation. Protocol directed therapy that allows RTs and other HCPs to work at the top of their licenses is important for cost effective care under Value Based Purchasing. These protocols are especially important in the ICU. Certainly, from a patient satisfaction perspective, there is a huge role for RT to educate patients about their respiratory regimen, ensuring that they can apply it properly, and that it meets the patient's needs.  The need for, and development of, the interpersonal skills of RTs to facilitate patient education and working within an interprofessional team have become increasingly important.

Are there special areas of study, advanced degrees and/or professional certifications that can benefit an RT interested in working in an ICU?  
Bowton: Across the country, more and more hospitals are requiring RTs working in the ICU to be Registered Respiratory Therapists (RRTS) rather than Certified Respiratory Therapists (CRTs), and all RT educational programs across the country are now required to educate their students to the level of RRT prior to graduation.  While most states still only require the CRT for licensure to practice, a few are now requiring the RRT.  The National Board of Respiratory Care (NBRC) Adult Critical Care certification, established in 2012, demonstrates enhanced skill in critical care and differentiates the holder as having special expertise in adult critical care. We encourage all of our RTs working in our ICUs to pursue this credential. Respiratory Therapy education is in transition and there are increasing numbers of Respiratory Therapy Bachelor's and Master's programs as well as degree completion programs. While most hospitals don't currently require an advanced degree for ICU positions, the additional training and skills acquired can be very helpful.

What is the job outlook for RTs interested in working in intensive care?
Bowton: The job outlook for RTs is generally good, but differs considerably depending on the region. In those areas with numerous RT programs, especially in Sunbelt states, the job market can be pretty tight. Hospital margins are tighter than ever and there has been a reduction in workforce in many areas. But the aging of our RT workforce (in addition to the rest of the population) will ensure that there will be an ongoing need for new RTs.  Further, new roles for RTs are being developed that will increase the opportunities for challenging and rewarding job opportunities.

Is there anything you would like to add about the Role of the RT in the ICU?
O'Neil: The RT is a critically important member of the healthcare team and the increasing complexity of care driven by technology and severity of illness, have only emphasized their value. Going forward, additional skills and knowledge will be required of all healthcare providers, including RTs. Changes in the healthcare landscape, including reimbursement models, quality reporting and technology pose significant challenges for RTs. They also offer unique opportunities if Respiratory Therapy is prepared to accept the challenge.

Kevin O'Neil, MD, FACP, FCCP practices pulmonary, critical care and sleep medicine in Wilmington, NC where he is the medical director for Pulmonary Rehabilitation and Respiratory Care at New Hanover Regional Medical Center. He is the current chair of CHEST's Respiratory Care Network and a commissioner for the Commission on Accreditation for Respiratory Care (CoARC).







David Bowton, MD, is a Professor in the Section on Critical Care in the Department of Anesthesiology at Wake Forest School of Medicine.  He was previously medical director of Respiratory Care at Wake Forest Baptist Medical Center, and is a past president of the Commission on Accreditation for Respiratory Care. He is the current vice-chair of the CHEST Respiratory Care Network.





  • The opinions expressed here are of the interviewees and do not necessarily reflect those of the American College of Chest Physicians or other organizations.

Chuck Holt is on staff at ADVANCE. Contact him at cholt@advanceweb.com

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