Maurizio Cereda in the CPAP helmet which helps prevent the need to intubate patients.

The knowledge and skills in treating cardiopulmonary conditions puts them on the front line of care, from helping a premature baby in the neonatal intensive care unit breathe to saving the life of a patient suffering cardiac arrest. When COVID-19 arrived — imperiling the sickest patients’ ability to breathe — the role of the respiratory therapist took on a new urgency.

Working side by side on the front lines, RTs helped to rapidly adapt treatments to the frequent changes and challenges of this disease. “Respiratory therapists not only offered respiratory support for patients but also provided insights on care from their experience —adjusting ventilation strategy or providing advice if things don’t go as expected,” said Zaffer Qasim, MBBS, of Emergency Medicine and Critical Care at Penn Presbyterian Medical Center. “They helped us learn about evolving processes and technology and how to safely and practically implement them.”

Brainstorming Ventilator Options

Initially, COVID-positive patients in severe respiratory distress were immediately connected to mechanical ventilation via an endotracheal tube, leaving ventilators in some hospitals in short supply. A collaboration between Jorge Mora, MD, of the Center For Sleep & Respiratory Neurobiology, and Jason Ackrivo, MD, of Pulmonary, Allergy & Critical Care, led to a possible solution: using home ventilators as back up. Although not as sophisticated as hospital ventilators, they could do the trick if needed. Once a specific model was chosen, Colleen Cain, RRT, COPD educator, and Laura Marchiano, RRT, tracheostomy coordinator and home ventilation specialist, created a video educating staff on how to use it (after studying the manuals themselves!). “As we were making the video, Princeton already needed to use it. So we sent them a rough cut of the video and made ourselves available to talk them through any problems.”

While invasive mechanical ventilation saves lives, long-term use could permanently damage lungs and be a source of infection. So physicians and respiratory therapists brainstormed alternative, feasible strategies, such as BIPAP (Bilevel Positive Airway Pressure) which pushes air into a patient’s lungs through a mask or nasal plug, and the CPAP helmet.

More commonly used in Europe, the CPAP helmet can prevent the need for intubation and also help patients breathe on their own after extubation (removing the tube). “It also encloses the patient’s entire face,” Qasim said. “Any viral particles that are breathed out are contained within the helmet.” Maurizio Cereda, MD, of HUP’s Surgical ICU, who used the CPAP helmet during his training in Italy, worked with Michael Frazer, BS, RRT, associate director of HUP Respiratory Care, and Emily Gordon, MD, of Anesthesiology, to create educational videos on the use of the device, which was ultimately used throughout the Health System. “It was brand new to us, but they distilled the information down into a brief, easy format,” Qasim said.

Bringing in Reinforcements

As the COVID surge continued, it became clear that additional respiratory therapists would be needed on the units. This resulted in two strategies: bringing in respiratory therapists who worked on the outpatient side of patient care and adding RTs to Penn E-lert to monitor patients remotely.

For many of the outpatient RTs, the experience on the floor was eye opening. For example, for Chad Bonsall, MPH, RRT, who normally works in HUP Pulmonary Rehabilitation, the challenge was initially catching up on all the advances in life-saving equipment. I worked for many years on the inpatient side of HUP,” Bonsall said, “but this has been an entirely new ball game.”

Jennifer Coyle, RRT, who works in an outpatient pulmonary function lab at the Perelman Center, worried about “meeting the challenge of a new respiratory disease.” But she eventually found that her skills helped in ventilator management. “With each passing shift, I felt more secure in my abilities and the doubt and fear slowly began to pass.”

Respiratory therapist Amanda Shuttleworth at her E-lert station

“They came without complaint and quickly gained confidence,” said Margarete Pierce, MS, RRT, director of Respiratory Care and Pulmonary Diagnostics at HUP. “They did what they had to do to help the cause.”

Adding respiratory therapists to Penn E-lert — the remote monitoring system that provides an additional layer of support for critically ill patients at HUP, PPMC, and PAH — proved to benefit both patients and RTs on the units. After a brief pilot with three specially trained respiratory therapists proved successful, more were brought on board. One was Karsten Roberts, MSc, RRT.

An E-lert respiratory therapist is another pair of eyes, assisting RTs on the unit. In one instance, when a patient’s oxygen level was dropping, the care team on the unit was about to intubate when the E-lert respiratory therapist noticed — and notified the team — that the oxygen had become disconnected. Another patient was trying to pull out their endotracheal tube and the E-lert therapist notified his counterpart on the unit.

Thanks to E-lert’s high-definition cameras in patient rooms, “I can look at the ventilator up close, even reading the numbers of the endotracheal tube that marks the depths and comparing them to what I see on a chest x-ray to make sure it’s in a safe position,” Roberts said. In another case, one of Roberts’ colleagues discovered that a patient’s tracheostomy was malpositioned and the patient couldn’t breathe properly. “Thanks to the audio/visual capabilities of E-lert, and good team work, the respiratory therapist on the unit was able to help save the patient’s life.”

In addition to helping keep patients safe, “our routine ventilator checks eliminate the need for respiratory therapists to don PPE and go into patients’ room as often,” Roberts said. “Two months into the program, our 24-hour coverage has resulted in over 2,000 patient-ventilator assessments. That’s 2,000 times that the respiratory therapists in the ICU did not have to be exposed to a viral load.”

Roberts still does shifts in the medical ICU at HUP and, thanks to his experience in E-lert, sees things “from a different perspective,” which has already saved lives. On his first shift back to the unit, he noticed a patient whose heart rate was 40 (normal heart rate is 60 to 80). Although the nurse told Roberts that the patient had just received medication which could slow the heart rate, “my experience combined with just having been on E-lert told me that things weren’t adding up,” he said. He called the nurse but before she even arrived, the patient arrested and Roberts was already manually ventilating him. “E-lert has helped me think about things differently than before."

A New Reliance on RTs

COVID brought an increased reliance — and deserved recognition — to respiratory therapists. “A respiratory therapist is not about just turning knobs on a ventilator,” said Queenzle Rica, RRT, of Lancaster General Hospital. “It’s about vent management and critical thinking. This has been a big learning curve for everyone but it highlights our profession, which is great.”

During the pandemic, Rica found herself advocating more for patients. In one case of a patient who had been intubated for two weeks, she convinced other team members to give the patient more time to “wake” from sedation before removing the tube. “This was a hard case from the beginning. but I wanted to wait a little longer before extubating,” she said, adding that “if they pulled it too soon, there was no going back. The patient would be DNR.” As it turned out, the decision to hold off a bit was right. Not only was the patient able to breathe on her own but she was ultimately discharged. “It was a miracle,” Rica said.

Like others on the front line, RTs often took on more shifts to accommodate need. Ryan Ortega, MBA, RRT, who generally works with preemies in HUP’s neonatal ICU, often worked four 12-hour shifts each week. “Some days I was exhausted. Other days I felt motivated,” he said. “Some times it takes a crisis to get motivated.”

There was also an emotional toll of caring for these patients. “I’m used to setting up ventilators but to see so many people critically ill with same disease was unlike anything I’ve ever seen in my [23 years of] experience,” said RT Angela Reifsnyder, MPH, RRT, of Chester County Hospital. “We try to make breathing easy, but, for some patients, it is very difficult, and at times impossible to get the breathing comfortable."

She recalled seeing one patient brought in to CCH who had just been walking her dog when she suddenly collapsed. “She was so fearful, and struggling to breathe,” Reifsnyder said. Ten days later, she passed away. But Reifsnyder has also seen many COVID patients discharged to home. “We try to focus on our successes but also know that you did your best for the ones who don’t make it.”

resp therapist

For Ortega, the patient who stands out most was a pregnant woman with “oxygen levels so low that it seemed nothing we could change on the ventilator would fix it.” The team decided to initiate prone therapy, in which patients are turned to lie on their stomach for an extended period of time and then flipped onto their back. The team were extremely careful in turning the patient, making sure to protect her abdomen. A few days later the baby was successfully delivered in the OR. The baby flourished and the mom continued to improve. “Finally we were able to wean her off the ventilator,” Ortega said. “It was amazing to see someone so close to death and then just a few weeks later doing so well. I think for me, scenarios like that one gives me to the drive to continue being a respiratory therapist.”

As HUP’s COVID-positive patient volume continues to decline and the Health System is beginning to see more volume of non-COVID patients “some of the respiratory therapists who were deployed to  inpatient care are returning back to their jobs in the outpatient pulmonary function labs,” Pierce said. 

“The collaboration we had built pre-COVID was strengthened and reinforced,” Qasim said. “Respiratory therapists are an integral part of team. We can’t do our job without them to support us and mQuezadage patients.”

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