Introduction: In life-threatening conditions like severe acute respiratory distress syndrome (ARDS), rescue interventions like extracorporeal membrane oxygenation (ECMO) should be initiated urgently to resolve an otherwise potentially adverse clinical outcome. Driving pressure (DP) is an independent prognosticator of the survival of ARDS during mechanical ventilation. We conducted this review with the objective to identify the optimal DP for initiating ECMO in severe ARDS and to study the change in DP during ECMO strategy in survivors and non-survivors. 

 

Materials and methods: A systematic search of EMBASE, PubMed, Cochrane Library, and SCOPUS databases was conducted from their inception to January 2024. Two investigators independently carried out the processes of literature search, study selection, data extraction, and quality assessment. The analysis was conducted using comprehensive meta-analysis software (CMA). 

 

Results: For meta-analysis, six studies comprising 668 patients were included. In survivors, the DP at ECMO initiation was lower (mean DP = 14.56 cm H₂O, 95% CI: [11.060–18.060]) than non-survivors (mean DP = 17.77 cm H₂O, 95% CI: [12.935–22.607]). During ECMO, the survivors had lower DP (mean DP = 11.63 cm H₂O, 95% CI: [10.070–13.195]) than non-survivors (mean DP = 14.67 cm H₂O, 95% CI: [12.810–15.831]). 

 

Conclusion: The optimum DP to initiate ECMO in severe ARDS patients on MV is 15 cm H₂O. Extracorporeal membrane oxygenation reduces the intensity of MV, as reflected by a reduction in DP in both survivors and non-survivors during the ECMO by 3 cm H₂O. The DP ≤ 12 cm H₂O during ECMO strategy is a predictor of survival, and DP persisting ≥ 15 cm H₂O on ECMO prompts the search for strategies to reduce DP.