Patient outcomes in severe acute respiratory distress syndrome: a systematic review of critical care interventions managed by ICU respiratory therapists

Background: Severe acute respiratory distress syndrome is associated with profound hypoxemia, prolonged mechanical ventilation, multiorgan dysfunction, and substantial mortality. Respiratory therapists contribute directly to ventilator adjustment, lung-protective ventilation, recruitment assessment, prone-positioning procedures, secretion management, oxygen titration, extracorporeal support monitoring, and liberation planning. Objective: This systematic review evaluated the effects of respiratory and supportive critical care interventions on mortality, ventilator-free days, oxygenation, intensive care length of stay, and intervention-related complications among adults with moderate-to-severe or severe acute respiratory distress syndrome. Methods: A systematic search framework was developed for PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials. Randomized trials and comparative original studies evaluating invasive ventilation strategies, positive end-expiratory pressure, prone positioning, neuromuscular blockade, fluid restriction, recruitment maneuvers, high-frequency oscillation, corticosteroids, airway pressure release ventilation, or extracorporeal membrane oxygenation were eligible. Screening, extraction, risk-of-bias assessment, and narrative synthesis followed PRISMA principles. Results: Fourteen original studies were included in the draft synthesis. Low-tidal-volume ventilation and prolonged prone positioning produced the clearest mortality benefits. Conservative fluid management increased ventilator-free and intensive-care-free days without a significant mortality reduction. Higher positive end-expiratory pressure produced inconsistent overall survival effects, while aggressive recruitment increased mortality. Routine early neuromuscular blockade produced conflicting trial results. High-frequency oscillatory ventilation offered no survival advantage and caused harm in one major trial. Dexamethasone increased ventilator-free days and reduced mortality in persistent moderate-to-severe disease. Extracorporeal membrane oxygenation provided a clinically important rescue option despite an inconclusive primary mortality comparison. Conclusion: Effective severe acute respiratory distress syndrome care depends on timely delivery of lung protection, prolonged proning, conservative fluid management, individualized adjunctive treatment, and avoidance of harmful recruitment or oscillatory strategies.