Mechanical ventilation during cardiopulmonary resuscitation: a systematic review and meta-analysis

Ventilation during cardiopulmonary resuscitation (CPR) must avoid excessive rates and volumes that impair hemodynamics. Mechanical ventilation (MV) may provide more consistent ventilation than manual bag-valve-mask (BVM) ventilation, but its use during CPR reflects broader resuscitation system factors rather than an isolated intervention. We performed a systematic review and meta-analysis according to PRISMA guidelines (PROSPERO CRD420251147964). PubMed, Embase, Scopus, and Web of Science were searched through July 20, 2026, for randomized and observational studies comparing mechanical ventilation with manual bag-valve ventilation during adult cardiac arrest. Ventilation strategies varied across studies with respect to airway type and timing of intubation. The primary outcome was return of spontaneous circulation (ROSC). Secondary outcomes included sustained ROSC, survival to hospital discharge, and survival with favorable neurological outcome. Random-effects models were used. Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty of evidence with GRADE. Nine studies, including 7,384 patients (three randomized controlled trials and six observational studies), were analyzed. MV during CPR was associated with higher odds of ROSC (odds ratio [OR] 1.26, 95% confidence interval [CI] 1.13–1.41) and survival to hospital discharge (OR 1.74, 95% CI 1.16–2.60). Statistical heterogeneity was minimal (I 2 = 0% for both outcomes); however, randomized subgroups were underpowered and imprecise, and pooled estimates were largely driven by observational data. Overall certainty of evidence was low due to residual confounding and limited randomized data. MV during CPR was associated with higher rates of ROSC and survival to hospital discharge in pooled analyses. However, these associations were driven primarily by observational studies, whereas randomized trials did not demonstrate statistically significant benefit.