Barotrauma: The statistical fallacy. A non-conventional scoping review with Bayesian meta-analysis

Background Mechanical ventilator-associated damage has a high relevance in the clinical outcomes of critically ill patients. Barotrauma is a colloquial premise that has not been questioned, while other concepts such as mechanotransduction based on time-dependent viscoelastic models derived from materials engineering and physics appear as a more solid and clinically plausible postulate. This scoping review aims to provide a hypothesis that correlates lung injury associated with mechanical ventilation with dynamic ventilatory variables and inherent energy transfer. Methods Systematic review and Bayesian meta-analysis PubMed database was searched from inception to November 20, 2024, for studies providing ventilatory parameters collected from ICU admission. The quality of the studies was independently assessed using the RoB2 Cochrane tool. Results A total of 7 studies were included for a total of 4298 patients. Of the total sample, 6.6% exhibited pneumothorax, with a mean peak inspiratory pressure of 35.1 cmH2O and 26.2 cmH2O plateau pressure. There was no correlation with any ventilatory mode, while mechanical power presented a poor negative correlation with barotrauma. The variables that presented the highest correlation with barotrauma were respiratory rate, driving pressure and elastic static power. Conclusions Available data show that, dynamic variables such as respiratory rate, in combination with static variables such as driving pressure, could comprehensively explain the concept of lung injury associated with mechanical ventilation, giving rise to more complex hypotheses such as mechanotransduction and rendering barotrauma as an obsolete premises. Keywords: barotrauma, VALI, mechanical ventilation, energy transfer