Airway management and invasive ventilation protocols in critical care: a systematic review of clinical practices and workflows led by ICU respiratory therapists

Background: Invasive mechanical ventilation is vital in critical care, although inconsistent practices expose patients to ventilator-induced lung injury, oxygen toxicity, delayed liberation, airway complications, and infection. Respiratory therapists are positioned at the ventilator and lead protocolized assessment, adjustment, spontaneous breathing trials, airway surveillance, and interdisciplinary communication. Method: This review analyze studies on practices and workflows led by intensive care unit respiratory therapists for airway management and invasive ventilation. PubMed, Scopus, Web of Science Core Collection, and the Cochrane Library were targeted from inception to Jun 2026. Original studies enrolled invasively ventilated critical care patients and evaluated a respiratory therapist driven protocol. Outcomes included ventilation duration, weaning time, extubation success, reintubation, intensive care length of stay, protocol adherence, ventilator-associated pneumonia, acute respiratory distress syndrome, mortality, and workflow performance. Result: Eleven original studies were analyzed. Therapist-led daily screening, spontaneous breathing trials, standardized weaning, and protocolized ventilator adjustment generally shortened ventilation or weaning duration without higher reintubation or mortality. Implementation studies demonstrated high screening completion and interpretation accuracy, while extubation pathways improved autonomy and standardization. Lung-protective ventilation protocols increased adherence and were associated with lower acute respiratory distress syndrome incidence. Evidence for direct therapist-led intubation workflows remained limited. Conclusion: Respiratory therapist–led protocols strengthen consistency, timely liberation, and lung-protective care. Effectiveness depends on authority, physician collaboration, competency assessment, audit, education, and reliable interdisciplinary governance systems.