Background: Acute respiratory failure (ARF) is a life-threatening condition encountered in critical care settings. Non-pharmacologic interventions patient positioning and airway suctioning are essential components of ARF management. Respiratory therapists had a key role in delivering these strategies prone positioning and suctioning techniques. Methods: This systematic review followed PRISMA guidelines to evaluate studies on respiratory therapist-led suctioning and positioning strategies in ARF management. Literature was searched in PubMed, Scopus, and Web of Science for studies published between 2003 and 2024. Inclusion criteria focused on original research of adult patients with ARF or ARDS where suctioning or positioning was implemented by respiratory therapists. Results: Seven studies met the inclusion criteria. Four studies evaluated awake prone positioning (APP) in non-intubated patients, and three studies focused on suctioning techniques. APP show reduced intubation rates in selected populations in COVID-19 patients managed with high-flow nasal cannula therapy. Adherence to prone protocols was a critical factor influencing outcomes. Closed suction systems (CSS) were superior to open suction systems (OSS),preserving end-expiratory lung volume and minimizing physiological disturbances. CSS was associated with improved cardiopulmonary stability and fewer complications compared to OSS. Conclusion: Respiratory therapist-led suctioning and positioning strategies, APP and closed suctioning, were beneficial in ARF management. These interventions improve oxygenation, reduce intubation rates, and preserve lung mechanics. Optimal results depend on protocol adherence, patient selection, and therapist expertise. Further high-quality studies are needed to standardize these interventions and expand their applicability across varied clinical settings.