Comparative Hemodynamic Effects of BiPAP and APRV in Patients with ARDS: A Systematic Review

Introduction: Positive pressure ventilation is key in the treatment of patients with acute respiratory distress syndrome. Bilevel Positive Airway Pressure and Airway Pressure Release Ventilation modalities aim to improve oxygenation and reduce lung injury, but their hemodynamic effects vary. Objective: To compare the clinical and hemodynamic effects of Bilevel Positive Airway Pressure and Airway Pressure Release Ventilation in acute respiratory distress syndrome patients. Materials and Methods: Clinical studies published through November 2025 in the PubMed, Scopus, and Web of Science databases were analyzed. Articles on acute respiratory distress syndrome patients treated with Bilevel Positive Airway Pressure or Airway Pressure Release Ventilation that reported hemodynamic parameters were included. Studies without hemodynamic data, those outside acute respiratory distress syndrome, and non-clinical studies were excluded. Results: Bilevel Positive Airway Pressure improves alveolar ventilation and oxygenation while modestly reducing left ventricular afterload; cardiac output remains stable in normovolemic patients. Airway Pressure Release Ventilation significantly increases oxygenation and ejection fraction, reduces alveolar shunt, and opens atelectatic alveoli, but is associated with more pronounced decreases in mean arterial pressure and preload. Clinical studies report that Airway Pressure Release Ventilation increases cardiac index and reduces central venous pressure, improving oxygenation while reducing the need for hemodynamic support. Conclusions: Bilevel Positive Airway Pressure is suitable for moderate acute respiratory distress syndrome and hypercapnic respiratory failure, offering favorable hemodynamics and noninvasive support. Airway Pressure Release Ventilation is preferred in severe acute respiratory distress syndrome with refractory hypoxemia, as it provides superior oxygenation and alveolar recruitment but requires careful hemodynamic monitoring. The choice of modality should balance respiratory benefits with cardiovascular risks.