As the COVID-19 pandemic hits North America with full force, front-line medical personnel are waging desperate fights against a dangerous, deadly viral enemy. The doctors and nurses are rightly being hailed as heroes, but a modern medical team is also made up of various other professionals, all of whom have a role to play. In focus today: the respiratory therapist. TVO.org spoke with Carolyn McCoy, director of professional practice at the Canadian Society of Respiratory Therapists, to learn more about the RT's role in this pandemic.
Matt Gurney: Let me start with a super-basic question here. What does a respiratory therapist do?
Carolyn McCoy: The job of a respiratory therapist is to support the cardiopulmonary health and well-being of patients from the moment they're born until the moment they take their last breath. So respiratory therapists work with newborn babies, they work with children, they work with adults, and they work with the elderly. They work across the continuum of care. So right now respiratory, therapists working in hospitals are getting a lot of attention, but they do work in the community as well, where they provide primary care and chronic-disease management. They're also working as researchers. In a hospital setting, which is obviously getting a lot of attention right now, a respiratory therapist works with acutely ill patients, providing oxygen therapy, airway management, diagnostic tests, and management of ventilators, among other things.
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Gurney: Again, sticking with the super-basic questions: In terms of your education and your "fit" within the broader medical team, what are you guys? Doctors, nurses, technicians?
McCoy: We're our own profession. You can come in right out of high school, but, mostly, people come to the training with some university. Nationally, the entry-to-practice requirement is a three-year diploma, and there are degrees in respiratory therapy and degree-completion options for respiratory therapy. But we are our own profession.
Gurney: Obviously, I want to talk to you about the pandemic, but let's establish a bit more of a foundation first. You'd mentioned before that you can do work in communities. What kind of work would that be?
McCoy: Community-based respiratory therapy often goes right to the patient's place of residence. So whether that be their home, whether it be a nursing home, a long-term-care home or institution, they will go and provide care. That care will vary, but it would always involve a cardiorespiratory assessment. It may involve assessing oxygen or ventilation needs — we're hearing a lot about ventilators, and ventilation can happen in the home for some chronic conditions. They also develop care plans along with the medical team. Respiratory therapists don't work in silos; they work as part of a larger team. And that inter-professional relationship really shines in the community environment. They also do diagnostic tests in the home, as well as pulmonary-function tests. They can procure arterial samples, which give us an indication of how well the lungs are doing their job in terms of oxygenating the blood and removing carbon dioxide. A big part of the job is day-to-day management of diseases and chronic conditions. But, also, if there's a change in a patient's status, they help develop collaborative care plans, so that the patient is empowered to recognize and respond appropriately.
Gurney: Okay, again, in a general sense — not pandemic specific — what does a respiratory therapist do in a hospital setting?
McCoy: No two days look the same. It's not uncommon for an RT to be working in a pediatric unit one day and then potentially working in an adult critical-care unit the next day. So there's a lot of variability, and a respiratory therapist will see anywhere from 20 to 40 patients a day, throughout the hospital or throughout a unit. And that day would typically involve a number of assessments of those patients — determining appropriate oxygen therapy and adjusting throughout the day based on their needs. RTs assess the need for respiratory medications, like puffers, do diagnostic tests, and work in outpatient clinics or with inpatients. We do a lot of patient education and interdisciplinary meetings to develop care plans for patients. They monitor patients throughout the day and intervene as necessary if a patient deteriorates. Typically, respiratory therapists are part of a rapid-response team. If there's a cardiopulmonary arrest, a "code blue," the respiratory therapist helps with the resuscitation of that patient. Specifically in critical care units, the RT would be doing all those same tasks but also managing some very sophisticated equipment relating to keeping airways open and keeping the patient ventilated. There's a lot of airway management.
Gurney: In any of these settings — in the community, an institution, or a critical-care ward — how much autonomy does an RT have?
McCoy: That varies a bit from jurisdiction to jurisdiction. But, typically, once a care plan is established, there are protocols and medical directives in place that allow the respiratory therapist to make suggestions based on their clinical knowledge and expertise. So, for example, it wouldn't be uncommon for respiratory therapists to administer oxygen to a patient who is short of breath at a hospital, without having to contact the physician. It all depends on the care plan.
Gurney: Let's talk about the pandemic. How does a respiratory therapist slot into our overall response to a public-health crisis like this? Are you more in demand now than you would have been a month or two ago?
McCoy: Respiratory therapists look after the sickest patients even when there isn't a pandemic. What has changed is the workload and the volume of patients. We still see our usual patients. We still have trauma and asthma patients, and now we're also seeing a rise in COVID-19 patients with breathing difficulties. So we're doing the same work, but now there's more of it.
Gurney: Tell me about that work. If someone is in a hospital, and they're in an acute crisis, and there's a big group of medical personnel swirling around them, all trying to save that person's life, is there an RT there? If so, what are they doing?
McCoy: Have you heard about ABCs? From a CPR course? Airways-Breathing-Circulation?
McCoy: An RT is doing the A and the B. They're making sure the airway is open and making sure the patient is breathing. That may mean administering respiratory meds in the case of an asthma attack. Or it may mean inserting an artificial airway to keep that patient breathing. It means monitoring oxygen and making sure they're getting the appropriate level — giving too much can be as dangerous as not enough. When a patient needs support from a ventilator, the respiratory therapist is involved in that. Maybe it's with a mask, tightly sealed over the face. We do that. We can also set them up for full invasive mechanical ventilation, using a breathing tube.
Gurney: The COVID-19 virus attacks the lungs. The people who have a bad case of it have respiratory problems. The most severely ill need ventilators. You might have answered this already above, but is there any particular and unique demand being placed upon respiratory therapists dealing with COVID-19 that's notably different from the role you just described?
McCoy: Well, the thing to understand is that hospitals are seeing COVID-19 patients before they reach that critical-care stage. People with COVID-19 will typically present at a hospital because they're not oxygenating properly. They aren't getting enough oxygen into their blood and then into their organs. So, immediately, an RT or a nurse is going to determine their need and how to best address that. As fast as possible. They can do a lot immediately with oxygen and medications to get that patient more oxygen. The RT will then monitor that patient closely to see if more intervention is necessary. Once a patient crosses a particular threshold, they're taken to critical or intensive care. The RT would then be part of a team that would assess the need for an artificial airway. Inserting an artificial airway is invasive. So the current guideline is the most experienced person available does that. That can be the RT or someone else. Once the patient is intubated, the next focus is managing the ventilator itself. These patients are very, very sick, and there isn't one "recipe" for how their ventilator should be configured. Let's say you and I both developed COVID-19 and needed to be ventilated. Chances are high that we'd have different ventilator settings. The RT needs to assess and evaluate each patient and choose the appropriate style of ventilation and the parameters. This is part of an RT's typical duties.
But it gets more complicated when a patient gets sicker — and that's true for everyone: nurses, doctors, the whole team. COVID-19 patients are very sick and complicated. But these teams are already used to dealing with the sickest patients. Something we're seeing very strongly from the emerging literature is a recommendation for prone positioning — flipping the patient over onto their stomach. This isn't a quick flip! These patients are often attached to many leads and sensors, some of them quite invasive, including urinary catheters and airway intubation. All sorts of lines and leads and wires. Rolling them over is a very well-choreographed process.
Gurney: [laughs] I think every man out there who has ever had a urinary catheter joins me in hoping it would be a well-choreographed process. A lot of coverage is talking about shortages of the PPE — personal protective equipment — that's needed to keep front-line medical personnel safe. And something we learned during SARS, and again during COVID-19, is that the kind of intensive intervention required by patients in an ICU can itself contribute to spreading the virus. And that puts health-care professionals at risk. Right now, thank God, it looks like Canada will have enough ventilators. But we could have a billion ventilators, and that wouldn’t matter if all the professionals who knew how to use them were sick or dead. So what kind of risks are your staff facing now?
McCoy: Yes. Some of these procedures that we have to do are what we call "aerosol-generating" procedures. We're doing these fairly frequently, even when we're not in a pandemic. Intubation is an example — and extubation. There are others. We perform or assist in these, and they put personnel at risk of exposure. What's different now compared to, say, six months ago — because of the surge in patients and because of the nature of the virus — we are starting to see unprecedented demand for protective equipment and shortages that we haven't experienced. So, while that risk has always existed, typically, there's never been a problem with getting the appropriate protective equipment. And that, in the case of an aerosol-generating procedure, would be gloves, an isolation gown, an N95 mask, and a face shield. Six months ago, we'd never have questioned our supplies of those. Now there's a global surge in demand for this protective equipment, and some staff aren't being asked to do a procedure without one, but they're reusing them. This goes against the evidence and guidelines. But we are hearing about a looming shortage, and we are concerned. This virus is highly transmissible.
Gurney: You're in communication, obviously, with colleagues and fellow professionals, probably now more than ever. How's morale? What are you hearing?
McCoy: The media has really helped with morale. You're helping the public understand the role of respiratory therapists. We're seeing ourselves represented as front-line health-care workers. But, because of the context of this pandemic and the possible shortages of PPE, they're concerned. They're concerned about their own safety but also about their families and communities. Even if they have PPE, we're hearing from our RTs, how do I know I won't be exposed at work in some other way? We have guidelines and protocols, but nothing is foolproof, even when followed. We're also worried about the risk of burnout. They're working longer hours, and they're busier during those hours. We've received some tremendous support from the Canadian Psychological Association. They've mobilized 200 volunteer members who are offering pro bono counselling within 24 hours for front-line health-care workers, including RTs, to help with the mental-health-care pressures of the pandemic.
Gurney: Is there anything I should have asked but didn't?
McCoy: I'd just add one thing. It's about ventilator management. I think we all know, or have come to appreciate, how important ventilators are in this pandemic. On a typical day, on average, an RT might manage five ventilated patients. In a busy period, they're capable of managing more. If the patients are particularly sick, though, they'd normally manage fewer. So we are watching that. But respiratory therapists are ready for this challenge. They are well educated. Well trained. We know what the enemy is, and we're ready to fight it. We are experts, and we are prepared. If we have enough ventilators and PPE, we can get through this.
This interview has condensed and edited for length and clarity.