Efficacy of inspiratory muscle training on weaning success in mechanically ventilated ICU patients: a systematic review and network meta-analysis of randomized controlled trials

Inspiratory muscle training (IMT) has been proposed as a strategy to mitigate ventilator-induced diaphragmatic dysfunction in mechanically ventilated intensive care unit (ICU) patients. However, its comparative effectiveness across different training intensities and impact on weaning success remain uncertain. To evaluate the efficacy of intima-media thickness (IMT) on weaning success, maximal inspiratory pressure (MIP), and rapid shallow breathing index (RSBI) in mechanically ventilated adult intensive care unit (ICU) patients. This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420251026681). PubMed, Cochrane Library, and PEDro were searched through July 2025 for randomized controlled trials (RCTs) including ICU adults receiving invasive mechanical ventilation for ≥ 48 h. The primary outcome measure was successful weaning. The secondary outcomes were MIP and RSBI. The Risk of bias was assessed using RoB 2.0. A frequentist network meta-analysis was conducted using standardized mean differences (SMD) and odds ratios (OR). Eighteen RCTs (n = 1137) were included. Network meta-analysis demonstrated that high-intensity IMT (HI-IMT) and HI-IMT combined with proprioceptive neuromuscular facilitation showed significant improvements in MIP compared to controls. No significant differences were observed between the active interventions for RSBI. For weaning success, the HI-IMT group showed a higher probability of successful weaning than the control group (odds ratio OR 0.32, 95% CI 0.14–0.75). Heterogeneity was substantial for continuous outcomes (I² >85%) and negligible for weaning success (I²=0%). IMT improves inspiratory muscle strength in mechanically ventilated ICU patients, particularly when delivered at higher intensities. Although high-intensity IMT was associated with improved weaning success in the network analysis, the overall clinical impact should be interpreted cautiously, given the heterogeneity and indirect nature of some comparisons. Further adequately powered trials with standardized protocols are warranted.