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Updated: Jul 15, 2026
Surfactant Depletion Combined with Injurious Ventilation Results in a Reproducible Model of the Acute Respiratory Distress Syndrome (ARDS)
Published on: April 7, 2021
Ultra-low versus low tidal volume ventilation in acute respiratory distress syndrome: a systematic review and
Ya Wang1, Nickjaree Songsangvorn2,3,4, Jianchun Li1
1Department of Critical Care Medicine, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory and Health, Medical Center for Respiratory Medicine, State Key Laboratory of Respiratory Disease, Guangzhou, China.
Background:
Low tidal volume (LTV) ventilation improves outcomes in acute respiratory distress syndrome (ARDS), whereas ultra-low tidal volume (ULTV) ventilation may further reduce lung stress but often requires extracorporeal life support (ECLS) to maintain gas exchange. Existing studies differ in ARDS severity, ECLS modality, and indications for ECLS initiation. We aimed to compare ULTV versus LTV ventilation in patients with ARDS.
Methods:
A systematic review and meta-analysis of studies published up to April 2024 was conducted using PubMed, EMBASE, Cochrane, and Web of Science databases. Studies comparing ULTV (<4 mL/kg) with LTV (4-8 mL/kg) in ARDS patients were included.
Results:
Six studies involving 1,102 patients met inclusion criteria. The included studies varied in ARDS severity, ECLS modality, and indications for ECLS initiation. Five studies utilized ULTV with ECLS, and one applied ECLS only when PaO2/FiO2 was below 60 mmHg in prone patients. ULTV was associated with lower driving pressure than LTV [standardized mean difference (SMD) =-1.61, 95% confidence interval (CI): -2.62 to -0.60, P<0.01] but not with a statistically significant reduction in mortality [odds ratio (OR) =0.99, 95% CI: 0.77 to 1.26, P=0.92]. Subgroup analyses suggested non-significant trends toward lower mortality in severe ARDS (OR =0.74, CI: 0.49 to 1.11, P=0.15), patients on ECLS (OR =0.79, 95% CI: 0.52 to 1.18, P=0.25), and those with baseline driving pressure >15 cmH2O (OR =0.69, P=0.11). ULTV was associated with longer hospital (SMD =0.35, 95% CI: 0.11-0.59, P<0.01) and ICU stays (SMD =0.35, 95% CI: 0.14-0.56, P<0.01). Bleeding events were more frequent in the ULTV groups in studies involving ECLS (OR =3.60, 95% CI: 1.30 to 10.01, P=0.01).
Conclusions:
ULTV is associated with lower driving pressure, but current heterogeneous evidence does not demonstrate a statistically significant mortality benefit. Length-of-stay and bleeding findings should be interpreted cautiously because of differences in illness severity and ECLS exposure. Further adequately powered trials are needed.
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