Airway pressure release ventilation does not improve mortality in patients with acute respiratory distress syndromeNew data shows no mortality benefit for airway pressure ventilation

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.