Driving pressure-limited ventilation strategies versus conventional lung protective ventilation strategies for patients with ARDS/ARF: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Although driving pressure (DP) has been consistently demonstrated to be an independent predictor of mortality in mechanically ventilated patients, the clinical benefits of DP-limited ventilation strategies compared with conventional lung protective ventilation (CLPV) for patients with acute respiratory distress syndrome/acute respiratory failure (ARDS/ARF) remain controversial. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) that compared DP-limited ventilation strategies with CLPV in patients with ARDS/ARF. The Cochrane Central Register of Controlled Trials, EMBASE, PubMed, Web of Science and Scopus databases were systematically searched from inception to June 2025. The primary outcome was short-term mortality. RESULTS: A total of 1417 records were identified, with 4 studies (n = 465) meeting the inclusion criteria. No significant differences in mortality outcomes, including 28-day mortality (4 RCTs, 465 patients; Odds ratio = 1.01; 95% Confidence interval [0.49, 2.10]; P = 0.98; I2 = 56%), intensive care unit (ICU) mortality (3 RCTs, 355 patients; Odds ratio = 1.24; 95% Confidence interval [0.81, 1.89]; P = 0.33; I2 = 36%), or in-hospital mortality (3 RCTs, 355 patients; Odds ratio = 1.21; 95% Confidence interval [0.79, 1.84]; P = 0.38; I2 = 0%), were observed between the groups. DP-limited ventilation was associated with a shorter length of ICU stay (4 RCTs, 465 patients; Mean difference =-2.95 days, 95% CI [-5.17, -0.74], P = 0.009; I2 = 7%). Analysis revealed no difference in ventilator-free days within 28 days (P = 0.86) and the length of hospital stay (P = 0.52) between the two ventilation strategies. Additionally, no significant difference in the incidence of barotrauma (P = 0.31) or acidosis (P = 0.43) was observed. The DP and tidal volume (Vt) were comparable between the groups. CONCLUSIONS: Based on current limited evidence, DP-limited ventilation showed no clear benefit over CLPV in patients with ARDS/ARF, with no survival benefit and a shorter length of ICU stay, warranting large RCTs to determine its clinical value, identify responsive clinical phenotypes, and establish standardized clinical application procedures. TRIAL REGISTRATION: The research plan was registered at PROSPERO, and the registration number is CRD420251069853.