History of Respiratory Care
After reading this chapter you will be able to:
Summarize some of the major events in the history of science and medicine.
Explain how the respiratory care profession got started.
Describe the historical development of the major clinical areas of respiratory care.
Name some of the important historical figures in respiratory care.
Describe the major respiratory care educational, credentialing, and professional associations.
Explain how the important respiratory care organizations got started.
The history of science and medicine is a fascinating topic, which begins in ancient times and progresses to the twenty-first century. Although respiratory care is a newer discipline, its roots go back to the dawn of civilization. The first written account of positive pressure ventilation using mouth-to-mouth resuscitation is thought to have been recorded more than 28 centuries ago.1 Air was thought to be one of the four basic elements by the ancients, and the practice of medicine dates back to ancient Babylonia and Egypt. The progression of science and medicine continued through the centuries, and development of the modern disciplines of anesthesiology, pulmonary medicine, and respiratory care during the twentieth century was dependent on the work of many earlier scientists and physicians. This chapter describes the history and development of the field of respiratory care and possible future directions for the profession.
Definitions
Respiratory care, also known as respiratory therapy, has been defined as the health care discipline that specializes in the promotion of optimal cardiopulmonary function and health.2 Respiratory therapists (RTs) apply scientific principles to prevent, identify, and treat acute or chronic dysfunction of the cardiopulmonary system.2 Respiratory care includes the assessment, treatment, management, control, diagnostic evaluation, education, and care of patients with deficiencies and abnormalities of the cardiopulmonary system.2 Respiratory care is increasingly involved in the prevention of respiratory disease, the management of patients with chronic respiratory disease, and the promotion of health and wellness.2
Respiratory therapists, also known as respiratory care practitioners, are health care professionals who are educated and trained to provide respiratory care to patients. About 75% of all respiratory therapists work in hospitals or other acute care settings.3 However, many respiratory therapists are employed in clinics, physicians’ offices, skilled nursing facilities, cardiopulmonary diagnostic laboratories, and public schools. Others work in research, disease management programs, home care, and industry. Some respiratory therapists work in colleges and universities, teaching students the skills they need to become respiratory therapists. Regardless of practice setting, all direct patient care services provided by respiratory therapists must be done under the direction of a qualified physician. Medical directors are usually physicians who are specialists in pulmonary or critical care medicine.
A human resources survey conducted in 2009 revealed that there were approximately 145,000 respiratory therapists practicing in the United States3; this represented a 9.3% increase over a similar study conducted 4 years earlier in 2005. As the incidence of chronic respiratory diseases continues to increase, the demand for respiratory therapists is expected to be even greater in the years ahead. Although the respiratory therapist as a distinct health care provider was originally a uniquely North American phenomenon, since the 1990s there has been a steady increase in interest of other countries in having specially trained professionals provide respiratory care. This trend is referred to as the “globalization of respiratory care.”
History of Respiratory Medicine and Science
Several excellent reviews of the history of respiratory care have been written, and the reader is encouraged to review these publications.1,4–6 Summaries of notable historical events in science, medicine, and respiratory care are provided in Tables 1-1 and 1-2. A brief description of the history of science and medicine follows.
TABLE 1-1
| Dates | Historical Event |
| Ancient Period | |
| 1550 bc | What may be the world’s oldest medical document, known as Ebers Papyrus, describes an ancient Egyptian inhalational treatment for asthma |
| 800 bc | Biblical reference to what may be the first recorded episode of mouth-to-mouth resuscitation |
| 500-300 bc | Hippocrates (460-370 bc; Greece) describes diseases as “humoral disorders” and speculates that an essential substance in air enters the heart and is distributed throughout the body |
| 304 bc | Erasistratus of Alexandria describes the pneumatic theory of respiration, in which air travels through the lungs to the heart and then through the air-filled arteries to the tissues of the body |
| 100-200 ad | Galen (130-199 ad) in Asia Minor identifies “pneuma” as the vital substance in inspired air that enters the heart and then the blood |
| Middle Ages (500-1500 ad) and Renaissance (1450-1600) | |
| 500-1500 ad | The Middle Ages brings a period of little scientific progress in the West; however, this period coincides with the Golden Age of Arabian medicine (850-1050 ad) |
| 1400s-1500s | da Vinci (1452-1519; Italy) performs human dissections and physiologic experiments on animals, learning that subatmospheric intrapleural pressures inflate the lungs and that there is a vital substance in air that supports combustion |
| 1542 | Vesalius (1514-1564; Belgium), one of the great early pioneers in human anatomy, performs a thoracotomy on a pig, placing a reed tracheotomy tube for ventilation of the animal, and resuscitates an apparently dead person |
| Seventeenth Century (1600s) | |
| 1628 | Harvey (1578-1657; England) describes the arterial and venous circulatory systems |
| 1643 | Torricelli (1608-1647; Italy) builds the world’s first barometer for measurement of atmospheric pressure |
| 1648 | Pascal (1623-1662) describes the relationship between altitude and barometric pressure |
| 1662; 1666 | Boyle (1627-1691; England) explains the inverse relationship between gas pressure and volume (Boyle’s law: pressure [P] × volume [V] = k or [P1V1] = [P2V2]). Boyle also describes a mysterious substance in air that supports combustion |
| 1683 | van Leewenhoek (1632-1723; Holland) improves the microscope and begins the science of microbiology |
| Eighteenth Century (1700s) | |
| 1738 | Bernoulli (1700-1782; Switzerland) determines that as the velocity of a liquid or gas increases, the pressure decreases (Bernoulli principle). Bernoulli also proposed that gases are composed of tiny particles in rapid, random motion. This idea became the basis of the modern kinetic theory of gases, which was developed further by Maxwell (1831-1879; Scotland) in 1860 |
| 1744 | Fothergill (1712-1780; England) reports successful resuscitation methods |
| 1754 | Black (1728-1799; Scotland) rediscovers carbon dioxide, which he calls “fixed air” (prior work had been done by van Helmot in the 1600s) |
| 1771 | Scheele (1742-1786; Sweden) makes “fire air” (oxygen) by heating magnesium oxide; Scheele’s findings are published in June 1774 |
| 1774 | Priestley (1733-1804; England), usually credited with the discovery of oxygen, publishes his work on “dephlogisticated air” (oxygen) 3 months after Scheele’s report |
| 1775 | Lavosier (1743-1794; France) renames “dephlogisticated air” “oxygen,” or “acid maker” and shows that oxygen is absorbed by the lungs and consumed by the body, producing carbon dioxide and water vapor, which are exhaled |
| 1776 | Hunter (1728-1793; England) recommends use of a fireplace bellows for artificial ventilation |
| 1787 | Charles (1746-1823; France) describes the relationship between gas temperature and volume; Charles’ law: volume (V)/temperature (T) = constant; or (V1/T1) = (V2/T2) |
| 1794 | Lavosier (1743-1794; France) describes oxygen absorption by the lungs and carbon dioxide production |
| 1798 | Beddoes (1760-1808; England) establishes the Pneumatic Institute in Bristol and uses oxygen to treat various disorders |
| Nineteenth Century (1800s) | |
| 1800 | Henry (1774-1836; England) determines that the amount of gas dissolved in a liquid is directly proportioned to its partial pressure (Henry’s law) |
| 1800s | Fick (1829-1911) describes a method to calculate cardiac output based on oxygen consumption and arterial and venous oxygen content:  |
| 1801-1808 | Dalton (1766-1844; England) describes his atomic theory and the relationship between the partial pressures and total pressure of a gas mixture; Dalton’s law: P1 + P2 + P3 … PN = PTotal, where P = pressure |
| 1806 | de LaPlace (1749-1827; France) describes the relationship between pressure and surface tension in fluid droplets |
| 1808 | Gay-Lussac (1778-1850; France) describes the relationship between gas pressure and temperature; Gay-Lussac’s law: pressure (P)/temperature (T) = constant; or (P1/T1) = (P2/T2) |
| 1811 | Avogadro (1776-1856; Italy) describes “Avogadro principle,” where equal volumes of all gases (at the same temperature and pressure) contain the same number of molecules |
| 1816 | Laennec (1781-1826; France) invents the stethoscope for chest auscultation and lays the foundation for modern pulmonology with his book Diseases of the Chest |
| 1831 | Graham (1805-1869; Scotland) describes diffusion of gases (Graham’s law) |
| 1837 | Magnus (1802-1870; Germany) measures arterial and venous blood oxygen and carbon dioxide content |
| 1846 | Hutchinson (1811-1861; England) develops the spirometer and measures the vital capacity of more than 2000 human subjects |
| 1864 | Jones (United States) patents a negative pressure device to support ventilation |
| 1865 | Pasteur (1822-1895; France) describes his “germ theory” of disease |
| 1876 | Woillez develops the spirophore negative pressure ventilator |
| 1878 | Bert (1833-1886; France) shows that low inspired oxygen levels cause hyperventilation |
| 1880 | MacEwen reports success with oral endotracheal intubation |
| 1885 | Miescher-Rusch demonstrates that carbon dioxide is the major stimulus for breathing |
| 1886; 1904 | Bohr (1855-1911; Danish) describes the oxyhemoglobin dissociation curve |
| 1888 | The Fell-O’Dwyer device combines a foot-operated bellows with a laryngeal tube for ventilatory support |
| 1895 | Roentgen (1845-1923; Germany) discovers the “x-ray.” A direct vision laryngoscope is introduced by Jackson in the United States and Kirstein in Germany |
Data from references 1, 3–13, and 16.
TABLE 1-2
| Twentieth Century | |
| Early 1900s | Bohr (1855-1911; Denmark), Hasselbach (1874-1962; Denmark), Krogh (1874-1940; Denmark), Haldane (1860-1936; Scotland), Barcroft (1872-1947; Ireland), Priestly (1880-1941; Britain), Y. Henderson (1873-1944; United States), L.J. Henderson (1878-1942; United States), Fenn (1893-1971; United States), Rahn (1912-1990; United States), and others make great strides in respiratory physiology and the understanding of oxygenation, ventilation, and acid-base balance |
| 1904 | Bohr, Hasselbach, and Krogh (1874-1940) describe the relationships between oxygen and carbon dioxide transport. Sauerbruch (1875-1951; Germany) uses a negative pressure operating chamber for surgery in Europe |
| 1907 | von Linde (1842-1934; Germany) begins large-scale commercial preparation of oxygen |
| 1909 | Melltzer (1851-1920; United States) introduces oral endotracheal intubation |
| 1910 | Oxygen tents are in use, and the clinical use of aerosolized epinephrine is introduced |
| 1911 | Drager (1847-1917; Germany) develops the Pulmotor ventilator for use in resuscitation |
| 1913 | Jackson develops a laryngoscope to insert endotracheal tubes |
| 1918 | Oxygen mask is used to treat combat-induced pulmonary edema |
| 1919 | Strohl (1887-1977; France) suggests the use of FVC as a measure of pulmonary function |
| 1920 | Hill develops an oxygen tent to treat leg ulcers |
| 1926 | Barach develops an oxygen tent with cooling and carbon dioxide removal |
| 1928 | Drinker develops his “iron lung” negative pressure ventilator |
| 1938 | Barach develops the meter mask for administering dilute oxygen. Boothby, Lovelace, and Bulbulian devise the BLB mask at the Mayo Clinic for delivering high concentrations of oxygen |
| 1940 | Isoproterenol, a potent beta-1 and beta-2 bronchodilator administered via aerosol, is introduced. Most common side effects are cardiac (beta-1) |
| 1945 | Motley, Cournand, and Werko use IPPB to treat various respiratory disorders |
| 1947 | The ITA is formed in Chicago, Illinois. The ITA later becomes the AARC |
| 1948 | Bennett introduces the TV-2P positive pressure ventilator |
| 1948 | FEV1 is introduced as a pulmonary function measure of obstructive lung disease |
| 1951 | Isoetherine (Bronkosol), a preferential beta-2 aerosol bronchodilator with fewer cardiac side effects, is introduced |
| 1952 | Mørch introduces the piston ventilator |
| 1954 | The ITA becomes the AAIT |
| 1958 | Bird introduces the Bird Mark 7 positive pressure ventilator |
| 1960 | The Campbell Ventimask for delivering dilute concentrations of oxygen is introduced |
| 1961 | Jenn becomes the first registered respiratory therapist. Also, metaproterenol, a preferential beta-2 bronchodilator, is introduced |
| 1963 | Board of Schools is formed to accredit inhalation therapy educational programs |
| 1964 | The Emerson Postoperative Ventilator (3-PV) positive pressure volume ventilator is introduced |
| 1967 | The Bennett MA-1 volume ventilator is introduced, ushering in the modern age of mechanical ventilatory support for routine use in critical care units |
| 1967 | Combined pH-Clark-Severinghaus electrode is developed for rapid blood gas analysis |
| 1968 | Fiberoptic bronchoscope becomes available for clinical use. The Engström 300 and Ohio 560 positive pressure volume ventilators are introduced |
| 1969 | ARDS and PEEP are described by Petty, Ashblaugh, and Bigelow |
| 1970 | Swan-Ganz catheter developed for measurement of pulmonary artery pressures. The ARCF is incorporated. The JRCITE is incorporated to accredit respiratory therapy educational programs |
| 1971 | Continuous positive airway pressure is introduced by Gregory. Respiratory Care journal is named |
| 1972 | Siemens Servo 900 ventilator is introduced |
| 1973 | IMV is described by Kirby and Downs. The AAIT becomes the AART |
| 1974 | IMV Emerson ventilator is introduced |
| 1974 | NBRT is formed |
| 1975 | Bourns Bear I ventilator is introduced |
| 1977 | The JRCITE becomes the JRCRTE |
| 1978 | Puritan Bennett introduces the MA-2 volume ventilator. The AAR Times magazine is introduced |
| 1979 | AIDS is recognized by the Centers for Disease Control (CDC [later, Centers for Disease Control and Prevention]) |
| 1982 | Siemens Servo 900C and Bourns Bear II ventilators are introduced |
| 1983 | The NBRT becomes the NBRC |
| 1983 | President Reagan signs proclamation declaring National Respiratory Care Week |
| 1984 | Bennett 7200 microprocessor controlled ventilator is introduced |
| 1984 | The AART is renamed the AARC |
| 1991 | Servo 300 ventilator is introduced |
| 1992, 1993 | The AARC holds national respiratory care education consensus conferences |
| 1994 | The CDC publishes the first guidelines for the prevention of VAP |
| 1998 | The CoARC is formed, replacing the JRCRTE |
| Twenty-First Century | |
| 2002 | The NBRC adopts a continuing competency program for respiratory therapists to maintain their credentials |
| 2002 | The Tripartite Statements of Support are adopted by the AARC, NBRC, and CoARC to advance respiratory care education and credentialing |
| 2003 | The AARC publishes its white paper on the development of baccalaureate and graduate education in respiratory care. Asian bird flu appears in South Korea |
| 2004 | The Fiftieth AARC International Congress is held in New Orleans |
| 2005 | Number of working respiratory therapists in the United States reaches 132,651 |
| 2006 | The National Heart, Lung and Blood Institute (NHLBI) of the U.S. Department of Health and Human Services begins national awareness and education campaign for COPD. The AARC works with government officials to recruit and train respiratory therapists for disaster response |
| 2007 | The first AARC president to serve a 2-year term begins term of office |
| 2008 | First of three conferences held for 2015 and Beyond strategic initiative of the AARC |
Data from references 1, 3–13, and 16.
Ancient Times
Humans have been concerned about the common problems of sickness, disease, old age, and death since primitive times. Early cultures developed herbal treatments for many diseases, and surgery may have been performed in Neolithic times. Physicians practiced medicine in ancient Mesopotamia, Egypt, India, and China.1,4,7 However, the foundation of modern Western medicine was laid in ancient Greece with the development of the Hippocratic Corpus.1,4,7,8 This ancient collection of medical treatises is attributed to the “father of medicine,” Hippocrates, a Greek physician who lived during the fifth and fourth centuries bc.1,7,8 Hippocratic medicine was based on four essential fluids, or “humors”—phlegm, blood, yellow bile, and black bile—and the four elements—earth (cold, dry), fire (hot, dry), water (cold, moist), and air (hot, moist). Diseases were thought to be humoral disorders caused by imbalances in these essential substances. Hippocrates believed there was an essential substance in air that was distributed to the body by the heart.1 The Hippocratic Oath, which admonishes physicians to follow certain ethical principles, is given in a modern form to many medical students at graduation.1,8
Aristotle (384-322 bc), a Greek philosopher and perhaps the first great biologist, believed that knowledge could be gained through careful observation.1,8 Aristotle made many scientific observations, including observations obtained by performing experiments on animals. Erasistratus (about 330-240 bc), regarded by some as the founder of the science of physiology, developed a pneumatic theory of respiration in Alexandria, Egypt, in which air (“pneuma”) entered the lungs and was transferred to the heart.1,7 Galen (130-199 ad) was an anatomist in Asia Minor whose comprehensive work dominated medical thinking for centuries.1,6,7 Galen also believed that inspired air contained a vital substance that somehow charged the blood through the heart.1
Middle Ages, the Renaissance, and the Enlightenment Period
The Romans carried on the Greek traditions in philosophy, science, and medicine. With the fall of the Western Roman Empire in 476 ad, many Greek and Roman texts were lost and Europe entered a period during which there were few advances in science or medicine. In the seventh century ad, the Arabians conquered Persia, where they found and preserved many of the works of the ancient Greeks, including the works of Hippocrates, Aristotle, and Galen.1,7 A Golden Age of Arabian medicine (850-1050 ad) followed.
An intellectual rebirth in Europe began in the twelfth century.1,7 Medieval universities were formed, and contact with the Arabs in Spain and Sicily reintroduced ancient Greek and Roman texts. Magnus (1192-1280) studied the works of Aristotle and made many observations related to astronomy, botany, chemistry, zoology, and physiology. The Renaissance (1450-1600) ushered in a period of scientific, artistic, and medical advances. da Vinci (1452-1519) studied human anatomy, determined that subatmospheric interpleural pressures inflated the lungs, and observed that fire consumed a vital substance in air without which animals could not live.1,4 Vesalius (1514-1564), considered to be the founder of the modern field of human anatomy, performed human dissections and experimented with resuscitation.1
