Evaluating sedation strategies in acute respiratory distress syndrome: A meta-analysis of inhaled versus intravenous agents.

INTRODUCTION

Acute respiratory distress syndrome (ARDS), often requires deep sedation to facilitate lung-protective ventilation. While intravenous sedatives (e.g., propofol, midazolam) are standard, inhaled agents (e.g., sevoflurane, isoflurane) have emerged as potential alternatives and may offer advantages in titratability and lung protection. This meta-analysis compares their efficacy in ARDS management.

METHODS

Following PRISMA guidelines, we systematically searched multiple databases (inception-May 2025) for randomized and observational studies comparing inhaled versus intravenous sedation in ARDS. Outcomes included ICU length of stay, ventilator-free days (VFDs), mortality, and respiratory parameters. Risk of bias was assessed using ROB-2 and Newcastle-Ottawa tools. Random-effects meta-analyses were conducted for pooled estimates.

RESULTS

Seven studies (1349 patients) were included. Inhaled sedation significantly reduced ICU stay (mean difference [MD]: -2.07 days; 95 % CI: -3.72 to -0.41; p = 0.01) and duration of mechanical ventilation (MD: -2.62 days; 95 % CI: -4.48 to -0.76; p = 0.006). However, Inhaled sedation was associated with significantly fewer VFDs (MD: -1.82; 95 % CI: -3.41 to -0.24; p = 0.02). No mortality difference was observed (p = 0.18). Inhaled agents improved PEEP on day 1 (p < 0.00001) but increased PaCO₂ (p < 0.00001) and reduced arterial pH (p = 0.001).

CONCLUSION

Inhaled sedation with volatile anesthetics may offer advantages over intravenous sedation in reducing ICU stay and mechanical ventilation duration in ARDS patients. However, the associated alterations in gas exchange parameters warrant cautious interpretation. Further large-scale studies are needed to confirm these findings and to optimize sedation strategies in this population.

CLINICAL TRIAL REGISTRATION: Not required.

REGISTRATION: This review is registered with PROSPERO (CRD420251049792).