On her first night as a visiting respiratory therapist in the Bronx, Shera McClelland, RRT, was overwhelmed by the number of COVID-19 patients she saw in critical care.
"I walked in and I immediately was struck with emotion," said McClelland, who traveled from Kansas to help out in New York City. "Everyone here, they're all stricken by this virus and they're all fighting for their life."
While McClelland, 38, has practiced respiratory care for more than 10 years, she said the virus has created unprecedented challenges for her profession. When COVID-19 patients go on ventilator support, for instance, low blood oxygen levels and fluid buildup in the lungs make it difficult for these patients to respond to treatment.
"We are maxing out these ventilator settings to try to really get them oxygenating," McClelland said. "When you've maxed everything out, where do you go from there?"
Respiratory therapists like McClelland have often been overlooked during the COVID-19 epidemic, even though they've played a crucial role. Their expertise in assessing blood gases, assisting with intubations and bronchoscopies, and specializing in ventilator management has exposed them to the sickest patients and to dangerous aerosolizing procedures.
Amanda Proctor, RRT, who previously practiced respiratory care in Orlando, Florida, said because the need for ventilation is so high for critical COVID-19 patients, running ventilators has been the main function of many therapists.
The majority of procedures that therapists perform occur at the head of the patient's bed, Proctor said, putting therapists at a high risk for infection. "Everything we do aerosolizes [the virus]," Proctor said in an interview.
One of the main challenges of managing ventilators during the COVID-19 crisis is that a number of patients are not responding.
"It's breathing a different way than we would normally breathe," Proctor said. When we take a breath in, our diaphragm contracts and creates a negative pressure -- or suction -- inside the chest cavity, drawing oxygen into the lungs. Instead, ventilators push air into the lungs. Not only does this have the potential to cause lung damage if a ventilator is operated incorrectly, Proctor also said that patients might take a long time to react to oxygenation efforts.
Beth Heltzel, RRT, a visiting respiratory therapist at NYU Winthrop in Long Island, said that she has seen patients with hypoxia take a long time to respond to ventilation.
"They have almost no oxygen reserve in their body," said Heltzel, who normally practices in Phoenix, Arizona.
COVID-19 patients require different ventilator settings to assist with oxygenation, Heltzel said. She has used pressure control or airway pressure release ventilation (APRV), as opposed to more conventional modes.
Heltzel added that COVID-19 patients are on ventilators far longer than average. "The majority of my patients that have been on the ventilator have been on it for at least 20-plus days," she said. In her nearly 2 weeks working at NYU Winthrop, Heltzel said she has yet to extubate a patient.
The demand for ventilator management has increased the workload for many respiratory therapists. McClelland said that each therapist at Lincoln Hospital treats around 15 patients. During a normal flu season at McClelland's employer hospitals in the Midwest, therapists are each assigned a maximum of eight patients.
Cydney Vanness, RRT, who usually works in New Jersey but is now working at NYU Langone in Brooklyn, said that her hospital is running around 13 to 15 therapists a shift, but would normally staff half that number.
"You could be seeing maybe 30 to 40 vents on a shift, easily," Vanness told 鶹ý.
Increased demand for therapists during the pandemic has highlighted a shortage that has persisted over the past few years, according to Lori Tinkler, the chief executive officer of the National Board for Respiratory Care (NBRC).
"The shortage has been growing, and I think it's going to be an even bigger shortage after this is over," Tinkler said in an interview.
The respiratory therapist shortage exists in part due to a low awareness of the profession, Tinkler said. In addition, therapists are not considered healthcare providers under the federal government, but rather hospital or laboratory personnel.
The NBRC has adjusted regulations to allow more therapists to enter the workforce during the crisis, including waiving credential verification fees, extending license expiration dates, and reinstating credentials for therapists who retired in the past 5 years. Tinkler said that the organization reinstated between 10,000 and 11,000 retiree credentials, and expects around 6,000 new graduates this spring.
As therapists continue to run the ventilators that are keeping many COVID-19 patients alive, many have recognized an increasing public awareness of their profession. Vanness said that the specialized training of respiratory therapists requires knowledge of more than just ventilators, and she hopes that the awareness of this fairly new field will continue to increase.
"We have to know the whole patient, and these diseases and their processes," she said. "We are essential workers. Without us, hospitals couldn't really manage."