AARC--50 Years of Service
by Robert R. Weilacher, BHA, RRT
AARC Historian

A Fond Look Back at the Beginnings of Our Profession
Professional continuity is a manifestation of the capacity to change. Choices are made based on knowledge and shared concepts from the past about how things are to be done. Behavioral shifts to fit new circumstances are not so much constrained by the past as compelled by it.

AAIT LOGO The quintessential hallmark of any profession is its professional society. On July 13, 1946, a diverse group of "oxygen orderlies," physicians, nurses, and other interested people met at the University of Chicago to form the Inhalational Therapy Association. The profession was born on April 15, 1947, when the Inhalation Therapy Association (ITA) was legally chartered as a not-for-profit entity in the State of Illinois. In its sixth iteration as the American Association for Respiratory Care, the ITA continues to this day.

Lighting the fire
Carl Sagan once described the birth of the first star following the titanic occurrence known as the "big bang." Professor Sagan's rhapsodic, even poetic, star-folk allegory recounts the passing of billions of years of primordial darkness before tiny, mostly accidental events involving hydrogen atoms reached a critical mass and the nuclear fires of the first star were ignited. Similarly, the hundreds of observations, experiments, and discoveries reported by Smith, Masferrer, and others reached critical mass in 1947. The fires of a new profession were lit, and a new addition in a continually expanding universe of health care professions emerged.

In the profession's earliest years, it was much more homogeneous than it is today. An inhalation therapy department manager was expected to be able to perform every department-level job in the acute care hospital setting, from repairing equipment to formulating a budget, with skill and dispatch. Because formal training programs had not yet been defined, the teaching of subordinates was an obligatory part of management. Essentially this form of instruction was usually limited to passing on information gleaned from a limited number of resources and isolated experiences.

Though this obligation served as a chrysalis for perpetuating the clinical profession, unfortunately it preserved the biases, prejudices, and misconceptions of instructors who had no experience in scientific methodology. These misconceptions were easily adopted by upwardly mobile subordinates and readily perpetuated elsewhere.

Respiratory care is now a broad category that includes highly skilled clinical specialists in a mutually supportive montage of administrators, managers, educators, scientists, and various support people. Even so, there is a remarkable persistence in some cases related to the assignment of patient-care tasks. The modern RCP assumes as much responsibility for appropriate oxygen therapy as did the oxygen orderly of two generations ago. For the most part, the functions of these practitioners have diverged, merged, and separated along different fault lines, eventually converging in the form of new aggregates over the years.

There is no neat continuity in any of this. As new therapeutic modalities suddenly showed up, seemingly without antecedents, others disappeared just as rapidly. The burden of paying for health care shifted from the individual to the employer; then the government's methods of paying for health care shifted, too.

The processes involved in these changes remain an analytical challenge, especially as they relate to the role and function of the professional society. Underlying what sometimes appears to be chaos, a special kind of order persists. This order depends upon the continuity of interpersonal ties (primarily between interested physicians and RCPs) in shared self-definition and in a perception of reciprocal respect and obligations with other health care practitioners.

Much of this order has relied on the continuation of respiratory care's professional organization, the AARC. The sense of membership in a common body provides a ready-made network for the maintenance of individual obligations, preferences, and affiliations.

The capacity for change, as demonstrated by the AARC over the years, reflects strategies that are compatible with the abilities of its members to make a living. In the highly complex, even competitive milieu of modern health care delivery and distribution, members turn to their Association for help in exploring a variety of occupational niches. Members clearly benefit from an organization that can orchestrate a rapid-response marketplace opportunity for occupational survival.

With purpose and structure...
AART LOGO The homogeneity of early inhalation therapy derived from two key elements. First was the fact that oxygen and other therapeutic gases were dispensed from heavy, high-pressure cylinders. Early on, the specialty was dominated by strong young men out of necessity. Secondly, by 1947 Albert Andrews, an otolaryngologist from Chicago, had documented the purpose and structure of the hospital-based inhalation therapy department. He described a prototypical functioning service in five pages of his book Manual of Oxygen Therapy Techniques. This remarkably brief description was intensely studied, and its suggested departmental architecture was copied all across North America.

Dr. Andrews was an ardent proponent of the idea that inhalation therapy departments should operate under the medical direction of an influential physician staff member. His idea finds contemporary expression in the AARC's highly visible and active Board of Medical Advisors.

Yet this early uniformity was short-lived. Almost immediately the fruits of a burgeoning World War II-driven technology were reaching a civilian marketplace. Novel ideas and situations had to be considered. Department managers were eager to explore any venue that would hone their skills, increase productivity, enhance department revenues, and augment their influence in the workplace.

An example of expanding an envelope of opportunity to its limits was recently described by a highly respected RCP and past AARC president, Houston R. Anderson, who joined the staff of Duke University Medical Center in Durham, NC, in 1965. He explained that he went from "... just managing inhalation therapy to directing any number of departments: rehabilitation, pulmonary function laboratory, biomedical technology service, and, of course, respiratory care. This certainly implies, in my estimation, a multiskilled approach by 'putting a harness on technology,' if you will, in the name of health care."

As individuals reacted to or exploited local circumstances, so too did the AARC in a more global sense. Frequently department managers looked to their hospital administrative superiors for instruction, tutoring, and mentoring in acquiring management skills. These managers filled the leadership ranks of AARC, not hesitating to impose their newly learned skills on Association operations. For instance, the AARC vigorously embarked on a program of structuring nationally recognized practitioner credentials decades before it shifted the emphasis to state licensure.

The beginning years of the organization were decidedly reactionary. By contrast, today the Association expends considerable resources in assuming a much more proactive posture.

Looking to others for guidance
ITA BULLETIN The AARC is modeled from the template of much older health-related societies. Its Executive Committee, Board of Directors, and House of Delegates have their counterparts in groups like the renowned American Medical Association. Clearly, however, the AARC's unique bond with its medical sponsors sets the Association apart from the other allied health organizations.

In the AARC's infancy, a small body of highly motivated medical directors helped ensure the viability of the fledgling Association. Most likely, the AARC would have floundered had it not been for caring physicians like Edwin R. Levine -- the only physician who ever served as president of the AARC -- and other supportive medical directors who saw promise in inhalation therapists and their profession.

Perhaps the most noble legacy handed down from those early physicians was the understanding that sharing information was a professional imperative. Medical periodicals like the Journal of the American Medical Association and the New England Journal of Medicine, have had an immeasurable social impact. They are highly regarded by the lay public and are frequently quoted in the popular media.

Continually stimulated by the presence of these powerful journals, each health care profession strives to emulate them -- respiratory care being no exception. By 1956, the Association had amassed sufficient resources to launch and sustain a science journal titled Inhalation Therapy. This journal has since become Respiratory Care, the preeminent, monthly peer-reviewed, refereed science journal of the respiratory care profession.

Historical Moments in the Organization
AARTIMES On October 9, 1972 former AARC president (1959) Don E. Gilbert dictated his reflections on the history of the Association. He opened these reflections with

The AARC was an organization that had to be created. There were people who saw this need. With a great deal of courage and personal sacrifice, and with small knowledge of how to do it, the organization was started sometime during the late 1940s.

In his memoirs, Edwin R. Levine discussed the formation of the AARC in detail. His commentary on the birth of clinical respiratory therapy served as a preamble to this discussion. He remembered

I found that post-operative patients needed to be moved to prevent bronchial obstruction. Because of our previous physiologic work with retained secretions, I realized that patients could not remain on their backs during the post-operative period, although nurses insisted on this. I stayed with every patient making sure that the operative side stayed dependent most of the time, but still moving the patient around. We discovered that the important part of thoracic surgery was not so much what was done on the operating table, but what was done to prevent post-operative pneumonia by controlling secretions and breathing.
When I became an attending physician, I insisted that the residents follow cases. We were able to handle some of the patients much better. In general, though, I was still dissatisfied. It was necessary that when these patients received respiratory therapy they simply had to be supervised. I was able to have the residents supervise some of this; the nurses were trained a little better; but, the residents were uneven in quality, and the nurses didn't have time to handle all of the situations.

Levine moved from New York City to Chicago in 1943 where he started a department of chest diseases at Michael Reese Hospital. As a part of this new service, he organized a primitive inhalation therapy program to manage post-surgical patients, using onthe-job (OJT) trained technicians. He taught regularly scheduled weekly classes in human anatomy, chemistry, pulmonary physiology, and clinical applications. These classes were open to virtually anyone interested in them including service and industrial support people. They were mandatory for Michael Reese employees working in his service. Area schools of nurse-anesthesia were eager to augment their didactic curricula with this theoretical and practical training.

Levine's students coalesced into the nuclear group that informally organized an "Inhalational Therapy Association" on July 13, 1946 at the University of Chicago Hospital.

The Start of Something Big
OXYGEN TENT By early 1947, pecuniary demands related to medical sponsorship, development of credentials, and national educational endeavors dictated a more formal organizational structure. On March 7, Articles of Incorporation were filed with the Secretary of the State of Illinois for formation of the Inhalation Therapy Association (ITA). The purposes were

The incorporators were George A. Kneeland, Richard E. Goss, Vincent T. McCue, Brother Roland Maher, and Brother Silverius Case. Professionally, Kneeland was a registered pharmacist; Maher and Case were nurse-anesthetists; McCue was an inhalation therapy department manager; and Goss was a manufacturer of vinyl oxygen tent canopies in Chicago.

The ITA was chartered as "a corporation not for profit organized under the General Not For Profit Corporation Act of the State of Illinois on April 15, 1947." Its chartered members included nine physicians, a pharmacist, an attorney, seven nurse anesthetists, and eight registered nurses. Nearly half of the 59 charter members held identifiable professional credentials, and 17 were members of various religious orders.

The Tri-State Hospital Assembly, headquartered in Chicago, provided an early forum for the educational and political expression of the new organisation. Too, the assembly was exploited for its positive name recognition, and as a venue for promoting the specialty within the hospital community.

Nevertheless, without the financial support of a national constituency during the first years of its existence, the ITA struggled. At one point the only option appeared to simply declare the group bankrupt. As the story was related, a bankruptcy petition required a $50 filing fee. No one was willing to contribute to this fee so the organization lived on.

The onus of being perceived as nothing more than a regional association was overcome in the mid 1950s by two singular events. First, the name was changed to the more global American Association of Inhalation Therapists (AAIT) on March 16, 1954. Then, encouraged by the physician component of the group, a multi-client public relations firm, Carriere and Jobson, Inc., was hired to manage the business affairs of the Association. On May 4, 1955, Albert Carriere, a principal in that firm, was named the AAIT executive director.

While many of his organizational colleagues looked upon the executive director as a financial savior, Easton R. Smith, 1967 AAIT president, vigorously challenged that notion, which forced Carriere's resignation in late 1967, effectively returning control of the AAIT to its member-elected leaders.

Without question, Smith ushered in a new era, a new organizational strategy of member control, and in so doing, he become the first modern president of the Association.

1970s Begin an Era of AARC Growth
By the early 1970s, nearly everything in the Association's infrastructure, as well as that of the profession, was in place. Practitioner roles and functions had been defined, the House of Delegates was functioning, education essentials were well established, practitioner credentials enjoyed national recognition, and positive membership and practitioner growth was clearly evident. But the profession had never examined the efficacy of the modes of therapy that it was using, essentially leaving this extraordinarily important activity to others. Modes of respiratory therapy were based primarily on clinical impressions, not on rigorous clinical studies.

A conference on the scientific basis of respiratory therapy, supported jointly by the National Heart and Lung Institute (NHLI) and the American Thoracic Society (ATS), was convened May 2-4, 1974, at Temple University Conference Center at Sugarloaf in Philadelphia, PA. Prominent scientists from around the nation met and reviewed the efficacy of oxygen therapy, aerosol therapy, physical therapy, and intermittent positive pressure breathing (IPPB) therapy.

The proceedings of what many now call the Sugarloaf Conference were published in December 1974, making for considerable angst on the part of RCPs. IPPB therapy, the major clinical task of RCPs, was scrutinized with discouraging implications. The studies of Barach, Cournand, and especially Motley published as early as 1947 served as the underpinning for the unparalleled use and misuse of IPPB therapy for well over a quarter of a century.

The initial fears of the RCPs were proven to be unfounded simply because the pathology that had, heretofore, been treated with IPPB therapy still needed to be treated. Other modes of therapy of proven efficacy replaced the nearly ubiquitous use of IPPB therapy.

Just as important, if not more so, is the fact that the AARC has successfully used the Sugarloaf conference as a template for scientifically examining nearly every form of clinical respiratory therapy since 1974.

A Question of Licensure
A significant organizational milestone was reached in 1980. AARC president, Sam P. Giordano, using very persuasive arguments, challenged the conventional wisdom that state licensure was not in the best interests of RCPs--a position embraced by the Association for more than 20 years.

As late as 1970, AAIT president Robert A. Dittmar recalled

We began to concern ourselves more with public health issues. Licensure by states was again being discussed -- not in a positive fashion at that time. We felt that licensure would serve to subvert the national registry programs in favor of substandard solutions at best.

In 1971, the U.S. Department of Health, Education and Welfare (DHEW) imposed a voluntary two-year moratorium on additional state licensing. In a spirit of cooperative citizenship, the AAIT eagerly supported the moratorium. Additionally, physician mentors of that era militated strongly against any form of licensure activity on the part of the chartered affiliate organizations.

Following the Spring meeting of the Board of Directors (April 23-25, 1980), Giordano wrote

...the Board decided that the association needs to develop a plan to assist the chartered affiliates in their efforts to pursue meaningful, nonrestrictive licensure. A national organization is limited in what it can do on a state level by virtue of the fact that there is a great deal of inconsistency in how the legislative process works from state to state. However, it has been felt that the association can play a key role in educating and informing the membership on the common steps that must be taken to assure a successful licensure effort on the state level.

With this public announcement, the AARC launched one of the most ambitious, sustained, and successful undertakings in its history. Giordano appointed Jeri E. Eiserman to the post of Licensure Coordinator. Eiserman was, in effect, a committee-of-one, and in this position, served as the chief architect of this massive program.

Eiserman's zealous pursuit of state licensure in 1980 carried over to her own AARC presidency in 1986. As she characterized her administration she stated that

...legal recognition of the profession is critical. In 1986 we were facing some rightto-practice challenges. In protecting ourselves, we developed a scope of practice that lent legitimacy to it. With this in mind, a key objective when I entered the presidency was to push forward state credentialing as the top agenda item.
I vigorously advanced this item in all of my travels over the country. I attended 40plus state society meetings as AARC president. Nearly everywhere I went, one of the speeches that I gave addressed the critical nature of state licensure. Too, I did everything I could to marshal the AARC's resources to help states that were willing to pursue licensure. Our model credentialing act was one such resource that supported a whole compendium of like materials.

As of this writing, 38 states have state credentialing in the form of licensure or certification, or registration.

Historical Moments in Education
Education is the raison d'etre for the existence of the AARC, and has been since its organizational inception in 1946. A key purpose listed in the Articles of Incorporation of the newly chartered ITA was "To advance the knowledge of Inhalation Therapy through institutes, lectures, and other means ..." Contemporary amplification of that purpose is codified in Article II, Section 1 of the AARC Bylaws that reads, in part, "The Association is formed to: a. Encourage, develop, and provide educational programs for those persons interested in respiratory therapy and diagnostics ..."

The original ITA purpose continued by emphasizing that the institutes, lectures, and so forth were to be "... given under the sponsorship of doctors of the Society of Anesthesia." The practical design of such sponsorship was the hope that these educational endeavors would find credibility and immediate legitimacy in the medical community.

The AARC was formally recognized as the pre-eminent organization for respiratory care education in the United States in 1954. Currently, the AARC supports two related constituency groups: the Education Specialty Section and the Joint Review Committee for Respiratory Therapy Education (JRCRTE). Additionally, the Association is prepared to act in an ombudsman role in matters related to education for those persons and agencies not formally allied with it.

An Education Forum was started by the AARC in 1966, bringing together a handful of respiratory care educators to discuss items and issues of common interest. This forum slowly evolved into the popular meeting, the Summer Forum, during which educators are still highly visible. Moreover, its continuing education program enjoys nearly universal recognition in the U.S. The Point Accreditation System, designed and developed in 1968, has matured into the Continuing Respiratory Care Education (CRCE) program. CRCE units are recognized by nearly all of the states that require continuing education for license maintenance and retention.

The centerpiece of the organization's educational thrust is the annual convention and exhibition. In 1955, only 83 people met together during the first convention held in Chicago. Today, more than 7,000 conventioneers meet at the AARC's International Respiratory Congress.

The roots of formal accreditation of respiratory care educational programs can be traced back to 1950. That year the New York Academy of Medicine's Committee on Public Health Relations published a widely circulated report, "Standard of Effective Administration of Inhalation Therapy." This report outlined a need for trained technical personnel in the care of both medical and surgical pulmonary patients.

In collaboration with the New York State Society of Anesthesiologists, the Medical Society of the State of New York formed a Special Joint Committee in Inhalation Therapy on May 11, 1954. One of its purposes was "... to establish the essentials of acceptable schools of inhalation therapy (not to include administration of anesthetic agents) ..." By April 15, 1956 this Special Joint Committee had finished its task, reporting out the completed "Essentials." The next month, June 1956, the House of Delegates of the AMA adopted its Resolution No. 12, introduced by the Medical Society of the State of New York. The delegates "Resolved, that the Council on Medical Education and Hospitals is hereby requested to endorse such or similar 'Essentials' and to stimulate the creation of schools of inhalation therapy in various parts of these United States of America."

A report entitled, "Essentials for an Approved School of Inhalation Therapy Technicians," was adopted by sponsor participants (AAIT, ACCP, AMA, and ASA) at an exploratory conference in October 1957. The validity of these "Essentials," as well as the mechanics of accreditation, were tested during a subsequent 3-year trial period with the Council on Medical Education finally recommending adoption the AMA's House of Delegates. The House granted formal approval in December 1962.

The first official meeting of the Board of Schools of Inhalation Therapy Technicians was held at AMA's Chicago headquarters on October 8, 1963. At that time, the Board was deemed to be officially functional.

The Joint Review Committee for Respiratory Therapy Education, the successor group to the Board of Schools came into being on January 9, 1970 as a Minnesota corporation. This reorganization came about during a period extending from 1968 through 1971 when the accreditation administrative functions were in a state of disarray.

During that time, a maturing and an increasingly assertive AARC leadership was poised to attack perceived barriers to organizational self-determination. A tiny handful of physicians, exercising strong paternalism on the Board of Schools, was the center of growing resentment. An era of struggle for power between the therapist and physician constituents ensued.

In 1968, AAIT president John Julius had corresponded with his counterparts in the ACCP and ASA citing growing dissatisfaction and frustrations with the Board of Schools. On behalf of the membership and Board of Directors, he demanded the removal of the current chairman of that Board. Implicit in that stand was the notion that the AAIT would withdraw its sponsorship of the Board of Schools if substantive change was not forthcoming.

On that date, AAIT president Robert H. Miller addressed a communication to Collins in response to the news that the Board of Schools was pursuing corporate status, a long cherished desire of the AAIT. Miller insisted, on behalf of the AAIT membership, that proposed articles of incorporation and bylaws be shared with the sponsoring bodies prior to filing.

Shortly thereafter, Collins, Levine, and Kew incorporated a Board of Schools in Illinois. Nearly simultaneously, ASA president Wasmuth moved, on February 4, 1969, to incorporate a Board of Schools in Ohio with the concurrence of the AAIT. Thus, for a brief period, there were two legal entities entitled, "Board of Schools of Inhalation Therapy Technicians." The Ohio Board of Schools served as an accrediting agency for less than a year. The joint review committee structure was emerging under the auspices of the AMA. On January 9, 1970 the Joint Review Committee for Inhalation Therapy Education (JRC) was chartered in Minnesota. The JRC's corporate articles and bylaws addressed every point raised in Miller's letter of November 15, 1968.

The newly structured JRC, under the leadership of Dr. H. Frederick Helmholz of the Mayo Clinic, had a brief respite during the term of AAIT president Robert Dittmar in 1970. In 1971, however, AAIT president Robert Weilacher commissioned Robert A. Cornelius to visit educational programs around the country to record their dissatisfactions, if any, with the operations of the JRC. This was an innocuous undertaking as part of an affiliate society survey. At the time, it did stir a passionate response from beleaguered and sensitive JRC representatives.

It is interesting that more recent history has produced an almost parallel scenario between the AARC and the educational accreditation agency. In 1994, AARC withdrew its sponsorship from the JRCRTE after the group unilaterally amended its bylaws without the approval of its sponsors. After withdrawing its sponsorship of JRCRTE, the AARC formed a new accreditation agency, the Respiratory Care Accreditation Board, which subsequently set about configuring a new accreditation agency with revised Essentials.

A reconciliation of the AARC and JRCRTE led to the dissolution of the Respiratory Care Accreditation Board at the end of 1996. Today, the respiratory care profession looks forward to the establishment of a new accreditation agency, the Committee on Accreditation for Respiratory Care, which is scheduled to begin operations in 1998.

Historical Moments in Credentialing
With the advent of its thirty-fifth year of operations in 1995, the American Registry of Inhalation Therapists, which in due course became the National Board for Respiratory Care, has conferred more than 210,000 credentials on healthcare professionals around the world. These credentials are registered respiratory therapist (RRT), certified respiratory therapy technician (CRTT), registered pulmonary function technologist (RPFT), certified pulmonary function technologist (CPFT), and perinatal/ pediatric respiratory care specialist. The sources of these credentials are inextricably tied to those actions and circumstances that made for the ITA and the JRC.

The germinating seed for the NBRC is found in so much of the ITA Articles of Incorporation as reads

To grant certificates of qualification to such as have successfully completed the prescribed requirements. To establish a central registry for members of the Association.

James E. Peo, AARC president in 1958, described the administrative mechanics of qualifying for listing in the "central registry," that is, for ITA membership:

It was the custom at the time that after having completed a series of lectures given by the doctors, we would take a written examination covering the topics which the doctors had lectured on. Everyone received an attendance certificate. If we passed the test, we would receive the Registry certificate.

Gilbert, reflecting on that same era, championed the caliber of the examinations:

There were examinations given very similar to the Registry (NBRC) written examinations as a criterion of membership in the AAIT...they were just as difficult and comprehensive as the first Registry exams were.

These early experiences in examining and credentialing individuals met with limited acceptance in the medical community. Be that as it may, the Association persisted in this effort, and by mid-1960 the executive director, Albert Carriere, was able to report

The final revisions in the Registry By-Laws have been duplicated by our attorney and sent to members of the Advisory Board...we are awaiting final approval by the American Society of Anesthesiologists, whose committee on Inhalation Therapy is meeting during the first week in October.

The Registry board very quickly organized. They were able to offer their two-part pilot examination on November 18, 1960 in Minneapolis. The written and oral examinations were administered and proctored by physicians since there were no "registered" therapists to participate yet in the examining process. Written and oral examinations were conducted until 1979 when the Clinical Simulation Examination (CSE) replaced the orals. In May 1961, 12 candidates taking the pilot examinations were deemed to hold the coveted Registered Respiratory Therapist designation along with 23 others who were examined that month in Chicago.

During the first decade of its existence, the NBRC credentialed only 1,594 practitioners. During these same years, the AARC's membership rolls had grown from 750 to 5,147 members, representing about 33% of the total number of active practitioners. It was increasingly apparent that the profession was becoming conspicuous in the healthcare milieu because of its inordinately low number of credentialed practitioners--about 10% at the time. To rectify the situation, the AARC launched a major new effort in the credentials arena in 1969.

President John Julius succinctly described the opening rounds of what turned out to be an organizational crisis:

Louise Hemmel, the (AARC) secretary, outlined for me what should be done to recognize people who weren't registered, but represented the majority of the workers in the field. Basically, her proposal was the Technician Certification Program.

"I appointed a committee, with Louise chairing it, to look into the feasibility of certification," Julius explained. "This special committee worked on the feasibility issue for the remainder of my term in office. As my term closed, the final proposal was presented to the Board of Directors for approval, and to the Registry Board asking for their input on the idea."

Registry Board members were adamant in their thinking that only the Registry credential was adequate for the profession. At that meeting, two of the Registry trustees stomped out of the room to show their opposition to the certification of technicians.

The technician certification program proved to be enormously successful. During the five-year period that the AARC managed it, over 10,000 practitioners were recognized as Certified Respiratory Therapy Technicians (CRTT). By 1972, having developed a viable, proven credential, AARC president James Liverett made it one of his objectives to give the technician certification process over to the Registry.

I carried the message of our thinking to Kansas City where the NBRC met in 1972. I responded to the Registry Board's invitation to address them on this topic. I must say that the Registry trustees were a bit skeptical about this proposal. They didn't appear to be too sure about our motives in giving this program to them. All I could do was (to) openly discuss the logic of my reasoning--that credentialing should be with credentialing--planting seeds that flourished in 1974 when the ARIT, Inc. and the AART Technician Certification Board merged to form the National Board for Respiratory Therapy (NBRT).

Today, the NBRC enjoys unconditional membership in the National Commission for Health Certifying Agencies (NCHCA). This recognition has been earned because the NBRC is now a leader among allied health certification agencies. Its examinations are valid beyond question, such validation resting on a national job analysis conducted every five years. A policy of criterion referenced validation studies is conducted on each examination before it is given for the first time. And, as previously stated, the controversial oral examinations have long-since been replaced by the clinical simulation examination.

1. Smith, G.A. (ed.). (1989) Respiratory care: evolution of a profession. Lenexa, KS: Applied Measurement Professionals, Inc.
2. Masferrer, R., Dolan, G.K., & Ward, J.J. (1991). History of the respiratory care profession. In G.G. Burton, J.E. Hodgkin, & J.J. Ward (Eds.), Respiratory care: a guide to clinical practice (3rd ed., pp. 3-17). Philadelphia: J.B. Lippencott.