The scientific basis for protocol-directed respiratory care.

As defined by the American Association for Respiratory Care, respiratory care protocols are "guidelines, usually written in algorithmic form, for providing respiratory therapy services." The need for protocols has been framed by the frequent occurrence of misallocation of respiratory care, consisting both of over-ordering (ie, prescribing respiratory care that is unlikely to confer benefit) and under-ordering services (ie, failing to prescribe services that would be expected to offer benefit). In this context, the current paper reviews available studies regarding the effectiveness of respiratory care protocols. Such studies can be organized into those assessing respiratory care treatments in the ICU, and those addressing non-ICU respiratory care. In the ICU, studies have addressed sampling both ABGs and liberating patients from mechanical ventilation; in the latter activity, multiple concordant randomized controlled trials have shown that weaning protocols implemented by respiratory therapists and/or nurses can accelerate patients' liberation from mechanical ventilation, with shorter stay and lower cost. Outside of the ICU, studies have addressed the effectiveness of respiratory care protocols in guiding the use of supplemental oxygen, bronchopulmonary hygiene, bronchodilator use, and of assessing patient for step-down unit placement. All such studies have shown that respiratory care protocols are effective. Furthermore, 2 concordant randomized controlled trials have shown that comprehensive respiratory care protocol programs can enhance the allocation of respiratory care services, with concomitant savings and no excess adverse outcomes. Overall, while the overwhelming weight of available evidence supports the effectiveness of respiratory care protocols, gaps in current understanding remain, especially regarding settings outside the acute care hospital (eg, geriatric care, palliative care, and extended care facilities). In the same spirit that engendered the Sugarloaf Conference to assess the effectiveness of respiratory care, further assessment of the effectiveness of respiratory care protocols is encouraged and expected.