Perioperative respiratory therapy: New challenges and new opportunities

Background and rationale

The operating room (OR) is often imagined as a place of precision and control, yet it is also a place where fragile physiology collides with surgical necessity. Today’s surgical patients arrive with heavier burdens of respiratory illness than ever before: obesity, sleep apnea, tracheostomies, pulmonary hypertension, and interstitial lung disease. These conditions make perioperative respiratory care more complex and more precarious.^1,2

Respiratory therapists (RTs) have long been essential in intensive care units (ICUs), but they have been notably absent in U.S. operating rooms and recovery units. The absence is not due to lack of need, but to tradition. In the American model, anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) have carried most of the responsibility, while in Canada, RTs and anesthesia assistants already play established perioperative roles. The question is not whether RTs are capable of contributing in the OR, but whether the U.S. healthcare is willing to imagine a new model.

The impacts of COVID-19 forced us to think differently about respiratory support in the OR. For example, the pandemic enforced the necessity of proper usage and perioperative management of inhaled therapeutics, tracheostomy care, optimized ventilation according to pathophysiological principles (e.g., obesity), and initiation of noninvasive support, all tasks within the expertise of RTs. ³ Expanding the perioperative role of RTs may not solve every problem, but it offers a path toward safer, more efficient care.

At Massachusetts General Hospital (MGH), the RT department has a long-standing practice of integrating and evaluating innovative local initiatives to expand the scope of respiratory therapy.^4–6 We identified the perioperative environment as a natural setting for our next initiative.^4,5,7

Implementation at MGH

In February 2025, MGH launched a structured initiative embedding a dedicated RT in the perioperative environment during peak hours (7 a.m. to 7 p.m., weekdays). This RT is embedded, not consultative, and accessible in real time via a dedicated communication line.

The implementation process unfolded in stages. Clinicians in the OR recognized a clinical gap in which high-risk patients (e.g., severe obesity and neuromuscular disorders) were receiving variable, delayed, and often suboptimal ventilation strategies in their perioperative journey and wanted to include RTs in their workflow to improve respiratory support.

Next came a multidisciplinary planning process that brought together anesthesia, respiratory therapy, nursing, clinical operations, and quality improvement. The goal was to define needs, feasibility, and metrics for success. Pilot observations helped identify high-risk patient groups who would benefit most from RT involvement.

Finally, alignment with institutional priorities was critical. Leadership endorsement and flexibility in staffing models have been approved before implementation, and mechanisms for feedback and monitoring are now in place.

Today, the perioperative RT’s responsibilities include management of inhaled therapies (e.g., inhaled nitric oxide), ventilator support in PACU, noninvasive ventilatory support for patients with neuromuscular disease, tracheostomy management, immediate post-extubation support for patients with obesity and sleep apnea, and safe transport of critically ill patients to the ICU. A summary of the RT’s perioperative responsibilities is presented in Table 1.

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Table 1.

Respiratory therapist role in the operating room.

Location	Task	Clinical focus
OR	Delivery of inhaled therapies (e.g., nitric oxide)	Patients requiring pulmonary vasodilation or specialized respiratory management
OR	Ventilator management and troubleshooting	Obese patients, patients at risk for acute respiratory distress syndrome (ARDS), lung transplantation
OR	Recruitment maneuvers and individualized ventilatory strategies	Obesity, restrictive lung disease
PACU	Noninvasive ventilation (NIV) setup and management	Neuromuscular disease (e.g., amyotrophic lateral sclerosis (ALS)), obesity, obstructive sleep apnea (OSA)
PACU	Tracheostomy care and management	Tracheostomized surgical patients, oncologic patients
PACU	Post-extubation respiratory support and monitoring	High-risk extubations (e.g., severe obesity, ALS, OSA)
OR→ ICU	Transportation of unstable patients	Strict control of gas exchange and ventilator management
OR (overnight coverage)	Emergent ventilatory support	Emergency intraoperative respiratory events

Challenges and opportunities

Bringing RTs into the OR was not without its hurdles. The first was defining the scope of a role that had no precedent in the United States. Did this overlap with CRNAs? Would it mirror the Canadian model of anesthesia assistants? These were not minor questions; they went to the heart of professional identity.

Workforce concerns loomed just as large. With RT shortages straining ICUs across the country, ⁸ could we justify dedicating one to the OR? The solution was careful piloting, with ongoing monitoring of consult volumes, quality indicators, and value delivered. Instead of assuming impact, we began documenting it, and this work is still ongoing.

And then there was culture: what exactly would the RT do in the OR or PACU? Culture shifts slowly, but experience has a way of rewriting doubts. An obese patient’s extubation went more smoothly with the RT helping on transition to noninvasive ventilation; a tracheostomized patient in PACU was managed without delay and with confidence. Skepticism gave way to recognition. While the process is still evolving, we are already experiencing the tangible benefits of having an RT integrated into the perioperative team.

Future directions

This initiative opens more questions than it answers. Should perioperative RT training be formalized, with pathways similar to critical care specialization? Could embedding RTs help reduce surgical delays by streamlining transitions and avoiding complications? And how do we measure value, not only in avoided adverse events but in efficiency, satisfaction, and sustainability? Our hypothesis is that, given that perioperative RT training is a standard in Canada, formalizing RT training through defined pathways, similar to those establish in critical care, may represent a natural progression in the evolution of the profession.

Summary

Integrating RTs into the perioperative environment appears feasible and responsive to the needs of complex surgical patients. Embedding RTs in the OR and PACU may strengthen decision-making, enhance safety, and help address system-wide challenges such as surgical backlogs and perioperative complexity. While the model is novel in the United States, it draws on international precedents and may offer a pathway for broader role expansion in respiratory care.