Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis

The association of respiratory mechanics, particularly respiratory system static compliance (C(RS)), with severity of hypoxaemia in patients with COVID-19-related acute respiratory distress syndrome (ARDS) has been widely debated, with some studies reporting distinct ARDS phenotypes based on C(RS). Ascertaining whether such phenotypes exist is important, because they might indicate the need for ventilation strategies that differ from those used in patients with ARDS due to other causes. In a systematic review and meta-analysis of studies published between Dec 1, 2019, and March 14, 2022, we evaluated respiratory system mechanics, ventilator parameters, gas exchange parameters, and clinical outcomes in patients with COVID-19-related ARDS. Among 11 356 patients in 37 studies, mean reported C(RS), measured close to the time of endotracheal intubation, was 35·8 mL/cm H(2)O (95% CI 33·9–37·8; I(2)=96·9%, τ(2)=32·6). Pooled mean C(RS) was normally distributed. Increasing ARDS severity (assessed by PaO(2)/FiO(2) ratio as mild, moderate, or severe) was associated with decreasing C(RS). We found no evidence for distinct C(RS)-based clinical phenotypes in patients with COVID-19-related ARDS, and we therefore conclude that no change in conventional lung-protective ventilation strategies is warranted. Future studies should explore the personalisation of mechanical ventilation strategies according to factors including respiratory system mechanics and haemodynamic status in patients with ARDS.