Airway Pressure Release Ventilation Versus Conventional Ventilation in Adults With or at Risk for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis of Randomized Trials
In brief
APRV improves oxygen levels but shows no survival benefit in nine trials
Across nine randomized trials involving 585 adults, airway pressure release ventilation did not demonstrate lower mortality or clear gains in ventilator-free days or ventilation duration compared with conventional ventilation. Oxygen levels improved and ICU stays were shorter, but varied protocols, study limitations, and low to very low certainty leave those findings uncertain; the evidence does not establish equivalence or superiority to modern lung-protective ventilation.
- Journal
- Lung (Q1)
- Published
- 31 October 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Muhammad Sajawal, Rabia Kamal, Syed Muhammad Moizuddin, Sana Ashfaq, Abdul Aziz, Abdur Rehman, et al.
- PMID
- 42965657
- DOI
- 10.1007/s00408-026-00957-0
Why clinicians should know about it
- Picked for Critical Care and Intensive Care Medicine (paper of the day, 1 November 2026): Randomized-trial synthesis evaluates APRV for ARDS and ventilation outcomes
Abstract
PURPOSE: To assess whether airway pressure release ventilation (APRV) reduces mortality compared with conventional invasive ventilation in adults with established acute respiratory distress syndrome (ARDS), acute lung injury, or conditions considered to confer a high risk of ARDS. METHODS: We searched PubMed, Embase, and the Cochrane Library from inception through August 15, 2026. We analyzed parallel-group randomized trials using random-effects models. Mortality at trial-defined follow-up was the primary outcome. We used Cochrane RoB 2 to assess risk of bias and GRADE to assess certainty of evidence. PROSPERO: CRD420251170819. RESULTS: Nine trials involving 585 participants were included. No mortality benefit was demonstrated (risk ratio 0.95, 95% CI 0.72-1.26). Ventilator-free days showed no clear difference (mean difference [MD] 3.83 days, 95% CI - 1.69 to 9.34; I²=83%). APRV was associated with a higher PaO₂/FiO₂ ratio (MD 56.21 mm Hg, 95% CI 24.63-87.79; I²=84%) and shorter ICU stay (MD - 2.53 days, 95% CI - 4.43 to - 0.64; I²=71%). Ventilation duration showed no clear difference (five trials, 413 participants; MD - 2.44 days, 95% CI - 4.96 to 0.09; I²=78%). Peak airway pressure was lower and mean airway pressure was higher with APRV. CONCLUSION: This synthesis does not establish that APRV improves survival, ventilator-free days, or ventilation duration. Oxygenation and ICU-stay findings require caution because populations, protocols, outcome timing, and risk of bias varied. Certainty of evidence was low to very low. These data do not establish mortality equivalence or superiority over contemporary lung-protective ventilation. TRIAL REGISTRATION: CRD420251170819; registered 17 October 2025.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.