Open lung ventilation with low tidal volumes, staircase recruitment maneuvers, high PEEP and decremental PEEP...

The impact of open lung ventilation (OLV) with low tidal volumes (TV), staircase recruitment maneuvers (SRMs), high positive end-expiratory pressure (PEEP), and decremental PEEP titration on acute respiratory distress syndrome (ARDS) patients is still uncertain. We aim to assess the impact of this OLV versus ARDS Network (ARDSNet) on patients with ARDS. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). PubMed, Scopus, Web of Science, Embase, and Cochrane were searched from inception through August 11, 2025. Statistical analysis used risk ratios (RR), weighted mean differences (WMD), and 95 % confidence intervals (95 % CI). Based on seven RCTs involving 1545 participants, it was found that for ARDS patients whose lung recruitability has not been assessed, compared to ARDSNet, OLV does not reduce hospital mortality (RR: 1.03; 95 % CI: 0.94 to 1.13; P = 0.51), ICU mortality (RR: 1.04; 95 % CI: 0.94 to 1.15; P = 0.41), mortality at day 28 (RR: 1.08; 95 % CI: 0.97 to 1.21; P = 0.18), mortality at day 60 (RR: 0.86; 95 % CI: 0.62 to 1.19; P = 0.36), or mortality at 6 months (RR: 1.07; 95 % CI: 0.98 to 1.18; P = 0.14). No significant differences were found in hospital length of stay, length of ventilation, ventilator-free days to day 28, incidence of barotrauma or rates requiring prone position. However, compared to ARDSNet, OLV improves the oxygenation index (OI) at days 1, 3, and 7, while also increasing the incidence of some adverse events such as pneumothorax requiring drainage within 7 days, hypotension within 1 h, arrhythmia, and desaturation. In ARDS patients whose lung recruitability has not been assessed, the routine application of OLV with low TV, SRMs, high PEEP, and decremental PEEP titration does not improve clinical outcomes and may result in certain adverse events.