In 2024, pulmonary rehabilitation turned 50.1 Yet even after being around for half a century and documenting consistent improvements in patient outcomes, pulmonary rehabilitation “remains underused and underresourced,” according to the 2023 American Thoracic Society (ATS) clinical guidelines for pulmonary rehabilitation.2
Pulmonary rehabilitation “reduces dyspnea; increases exercise capacity; improves health-related quality of life (HRQoL) and emotional function; confers social support; and, for those with chronic obstructive pulmonary disease (COPD), reduces hospital admissions and mortality risk after hospitalization,” according to the ATS guidelines.2
“Pulmonary rehabilitation (PR) is an essential component of the integrated care of people with chronic respiratory disease,” said ATS guideline authors, who went on to offer recommendations on when pulmonary rehabilitation should be used, based on evidence showing that PR led to improved patient outcomes. The guidelines recommend offering2:
- pulmonary rehabilitation for adults with stable chronic obstructive pulmonary disease (COPD) and for adults following hospitalization for COPD exacerbation (strong recommendations);
- center-based pulmonary rehabilitation or telerehabilitation for chronic respiratory disease (strong recommendation);
- pulmonary rehabilitation for patients with interstitial lung disease (strong recommendation);
- either supervised maintenance pulmonary rehabilitation or usual care after initial pulmonary rehabilitation for adults with COPD (conditional recommendation); and
- pulmonary rehabilitation for patients with pulmonary hypertension (conditional recommendation).
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You can’t do pulmonology and ICU medicine without RTs…It’s good to be hand in hand with RTs, especially when you’re dealing with respiratory problems. In the ICU world, that might mean assisting with ventilator management, oxygen delivery, bilevel positive airway pressure, and treatments like that.
Respiratory therapists (RTs) are among the health care providers who offer pulmonary rehabilitation to patients. These specially trained health care providers can bridge gaps between patients and pulmonologists and improve care in a health care system that’s stretched beyond its limits.
How can RTs and pulmonary/critical care physicians best work together? An example of the kind of effective teamwork that makes for better patient outcomes can be found at Temple Lung Center in Philadelphia, where such teamwork is encouraged. To gain insight into the role and value of RTs in improving patients care, we spoke with Temple Health pulmonologist Lijo C. Illipparambil, MD, who is also an assistant professor of clinical thoracic medicine and surgery at Temple’s Lewis Katz School of Medicine, and Temple respiratory therapist Noel Rice-Ham.
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RT/Physician Collaboration at Temple Lung Center
All patients with pulmonary problems can benefit from RT, said Dr Illipparambil. Patients that benefit the most are those with chronic ventilator needs or chronic or advanced lung diseases, who require additional assistance due to their respiratory status, he added.
“Success stories are most often with chronic ventilator patients who an RT has worked with before or knows them very well. When you come on as a new attending or new team taking care of that patient, and you try to make changes or adjustments, the RT already knows the lung physiology and the mechanics of what works for that patient, so it can be very helpful to discuss [this] with the RT before you make any changes,” he shared.
At Temple Lung Center, pulmonologists and RTs work together in a system that fosters referrals and collaboration. From the physician point of view, RTs are generally very accessible, said Dr Illipparambil. “They’re very much integrated with us, and we work with them almost every day, both on the pulmonology and ICU side.”
“You can’t do pulmonology and ICU medicine without RTs,” said Dr Illipparambil. “It’s good to be hand in hand with RTs, especially when you’re dealing with respiratory problems. In the ICU world, that might mean assisting with ventilator management, oxygen delivery, bilevel positive airway pressure , and treatments like that.”
Pulmonologists at Temple meet with RTs every morning to discuss which patients will be extubated and to review the results of spontaneous breathing trials. “An RT is always there to help out with getting patients on other devices like HiFlo or BiPAP or even helping with clearance,” Dr Illipparambil noted. In pulmonology, RTs help with testing to identify diseases and get patients on the appropriate devices or pressure settings.
RTs also have a lot of experience with different settings and different machines like cough assist, which can help the patient clear mucus and feel better, noted Dr Illipparambil.
Rice-Ham said she works with a lot of patients undergoing lung transplantation at Temple. “I came from working inpatient, where I’d see patients right after transplants or in the ICU setting. Now, I see patients who come in regularly for testing prior to or after the transplant.”
How RTs Benefit the Patient Care Team
As a respiratory therapist, Rice-Ham knows from experience that RTs often remember patients from past visits and may spend substantial time watching how patients react to different treatments in critical and noncritical settings. “I get to know the patients from the inside out and observe how they’re progressing. Physicians rely on us to see the things they don’t always see,” she said.
In her current position, Rice-Ham estimated that she spends an equal amount of time doing testing and speaking to patients. “We find ourselves having personal talks with patients and families, especially in the outpatient setting. Education can be as simple as discussing how someone wears their oxygen tank or cleans their equipment. We’re always prepared for whatever question comes up. Many patients want to know about using inhalers properly,” she explained.
Although 75% of RTs are employed by a hospital, studies highlight the advantages of RTs in community settings as well.3 As part of a multidisciplinary team, RTs can help identify the early stages of diseases like COPD by reviewing lung function and other risk factors, like social determinants of health. Earlier interventions and care can shift the health care system into a more preventative versus reactive mode, ultimately resulting in cost savings and improvements in patients’ quality of life.
While physicians like Dr Illipparambil consider RTs to be a vital part of the patient care team, Rice-Ham said that some collaborative barriers remain, particularly in the inpatient setting. “At the lung center, we see a lot of patients. In the inpatient setting, it’s not as often. I don’t know if the inpatient physicians include us as much as they could. It depends on the physician’s experience with RTs,” she explained.
Why Is Pulmonary Rehabilitation Underutilized?
Although PR was originally developed for patients with COPD, its scope has expanded to address the needs of patients with other chronic respiratory diseases as well as those with cancer and undergoing lung transplantation.2
Yet, as the ATS pulmonary rehabilitation guidelines acknowledge, PR is underutilized. “Less than 5% of people with COPD who may benefit from PR receive it,” the ATS guideline authors noted.2
The availability of these services is not the only problem, said the guideline authors; another reason for underuse of PR is “insufficient HCP [health care provider] and patient knowledge and awareness of the process and benefits of PR” and the fact that “HCPs’ referral of patients to PR is suboptimal.”2
“There needs to be more recognition of what a respiratory therapist is,” said Rice-Ham. “A lot of times, we don’t get that respect because other providers don’t know about our qualifications and training. There’s a barrier of the unknown about who we are.”
In some places, there are “respiratory-therapist-driven protocols” for patient care, she noted. Where such protocols exist, they help facilitate better relationships between RTs and physicians.
Another barrier to collaboration between physicians and RTs can be inadequate communication among busy health care professionals. Because RTs see so many patients, they need to know the plan for the day, especially if there are changes to a patient’s settings or recommendations. Physicians, nurses, and RTs must communicate and ensure everyone is on the same page.
The RT’s Evolving Role
Traditionally, respiratory therapists were thought of as technicians rather than practitioners, but their role has since evolved, said Rice-Ham, who has a bachelor of science degree in respiratory therapy as well as a master’s degree in health care administration.
RTs who conduct pulmonary rehabilitation are trained clinicians who can support patients with a range of pulmonary issues. Typical duties of an RT include analyzing blood and sputum in the lab, helping physicians diagnose lung and breathing disorders, assisting with the development of treatment plans, managing breathing equipment and devices, and providing education to patients and families.
Over the past several years, the RT’s role has evolved to meet the growing demands of patients beyond the critical care setting.3 In addition to specializing in critical care and pulmonary rehabilitation, RTs may also specialize in polysomnography, geriatrics, home care, pediatrics, or neonatal care.
RTs can start working with an associate’s degree, although many programs expect therapists to have a bachelor’s degree. RTs take boards similar to nursing, and many obtain specialty certifications in a particular area of expertise, said Rice-Ham. Every state besides Alaska also requires RTs to have a license to practice,4 and RTs must also undergo continuing education and renew their certification every 5 years.5
Some physicians, particularly in smaller community settings, may be unaware of the education and training required to become an RT, said Rice-Ham. Notably, this is not the case at Temple Lung Center, she added, where physicians have a high level of experience working with RTs and can see their capabilities firsthand.
The Future of Respiratory Therapy
The occupation of respiratory therapy is projected to grow by 13% to 23% over the next decade, outpacing many other professions.4,5 This increase is timely, as the Association of American Medical Colleges predicts the US physician shortage will reach 140,000 unfilled roles by 2033.6
In addition, respiratory therapy is among the many allied health professions that are expanding their advanced practice certifications to support rising patient demands. An Advanced Practice Respiratory Therapist (APRT) accreditation became available in June 2022. To complete the program, registered RTs must complete a graduate-level education and training program approved by the Commission on Accreditation for Respiratory Care.7
APRTs will practice as part of a physician-led team to document medical histories and progress noted and examine, treat, and educate patients. They’ll also order and interpret labs and diagnostic tests, reducing administrative work for physicians and enabling more efficient and hands-on care. As RTs and physicians continue joining forces, patients will undoubtedly benefit.
