Mechanical Ventilation During CPR Linked to Better Survival Odds in Pooled Analysis

Mechanical ventilation during cardiopulmonary resuscitation was associated with higher odds of return of spontaneous circulation and survival to hospital discharge in a systematic review and meta-analysis published in BMC Emergency Medicine. The analysis pooled data from nine studies covering 7,384 adults in cardiac arrest, combining three randomized controlled trials with six observational studies.

The review, registered in PROSPERO (CRD420251147964) and conducted according to PRISMA guidelines, searched PubMed, Embase, Scopus, and Web of Science through July 20, 2026. The researchers, led by Thanat Tangpaisarn and colleagues, compared mechanical ventilation with manual bag-valve-mask ventilation during adult cardiac arrest. The primary outcome was return of spontaneous circulation, with sustained ROSC, survival to hospital discharge, and survival with favorable neurological outcome examined as secondary outcomes.

Pooled results showed that mechanical ventilation during CPR was associated with higher odds of ROSC, with an odds ratio of 1.26 and a 95 percent confidence interval of 1.13 to 1.41. Survival to hospital discharge also favored mechanical ventilation, with an odds ratio of 1.74 and a 95 percent confidence interval of 1.16 to 2.60. Statistical heterogeneity was minimal, with an I2 value of 0 percent for both outcomes, indicating remarkable consistency across the included studies.

Despite that statistical consistency, the authors urge caution in interpretation. The randomized subgroups were underpowered and imprecise, and the pooled estimates were largely driven by observational data. Randomized trials included in the analysis did not demonstrate a statistically significant benefit. Overall certainty of the evidence was rated as low, primarily because of residual confounding and the limited volume of randomized data.

The physiological rationale behind the comparison is straightforward. However, the authors note that the use of mechanical ventilation during CPR reflects broader resuscitation system factors rather than an isolated intervention, meaning that settings equipped with mechanical ventilators may differ in other important ways from those relying on manual ventilation.

That caveat matters for interpreting the observational findings. Studies comparing ventilation strategies varied with respect to airway type and the timing of intubation, adding further complexity to any direct comparison. Patients receiving advanced airway management and mechanical ventilation may systematically differ from those managed with bag-valve-mask ventilation in ways that influence survival independently of the ventilation method itself. Such confounding is precisely why the GRADE assessment downgraded certainty to low despite the tight confidence intervals.

The methodological rigor of the review itself was substantial. Risk of bias in the randomized trials was assessed with the Cochrane RoB 2 tool, while non-randomized studies were evaluated with ROBINS-I. Random-effects models were used for pooling, an appropriate choice given the varied settings and ventilation protocols across the source studies. The minimal heterogeneity observed suggests the direction of association was stable, even if the causal interpretation remains constrained.

For clinicians and resuscitation researchers, the findings position mechanical ventilation as a promising but unproven component of cardiac arrest care. The association with survival to hospital discharge is the stronger signal in magnitude, but it rests heavily on observational evidence where treatment decisions are rarely random. The authors’ conclusion is measured: mechanical ventilation during CPR was associated with higher rates of ROSC and survival to discharge in pooled analyses, but these associations were driven primarily by observational studies. Definitive answers about whether the ventilator itself, rather than the surrounding system of care, drives the benefit will require adequately powered randomized trials. Until then, the meta-analysis offers a carefully quantified signal that warrants further investigation rather than an immediate change in resuscitation practice.

Subject of Research: Association of mechanical ventilation versus manual bag-valve ventilation with outcomes in adult cardiac arrest resuscitation

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

Article References: Tangpaisarn, T., Wongtanasarasin, W., Suwannapong, P., Khemtong, S., & Phungoen, P. (2026). Mechanical ventilation during cardiopulmonary resuscitation: a systematic review and meta-analysis. BMC Emergency Medicine. https://doi.org/10.1186/s12873-026-01813-3

Image Credits: AI Generated

DOI: 10.1186/s12873-026-01813-3

Keywords: cardiac arrest, cardiopulmonary resuscitation, mechanical ventilation, bag-valve-mask, return of spontaneous circulation, systematic review, meta-analysis, survival to hospital discharge, resuscitation, emergency medicine, observational studies, randomized controlled trials