Aquatic therapy in invasively mechanically ventilated patients: A systematic review of safety, feasibility, and clinical considerations

Background: Individuals receiving invasive mechanical ventilation experience mobility limitations and are at risk for intensive care unit-acquired weakness and functional decline. Hydrotherapy has been proposed as a potential adjunct within complex care and rehabilitation pathways, as the physical properties of water may facilitate supported movement and upright activity. However, its use in ventilator-dependent populations is often avoided due to safety and feasibility concerns. This systematic review aimed to synthesize the available evidence on the safety, feasibility, and clinical implementation of hydrotherapy in this population. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. Six electronic databases were searched. Eligible studies included individuals receiving invasive mechanical ventilation who participated in clinically supervised hydrotherapy. Given heterogeneity in study designs and outcomes, a structured narrative synthesis was undertaken with emphasis on safety, feasibility, and ventilator management. Results: Six studies were included. Across all studies, hydrotherapy was consistently reported as safe, with no airway- or ventilation-related adverse events, including accidental extubation, tracheostomy displacement, ventilator disconnection, or water ingress. Feasibility was demonstrated in intensive care, rehabilitation, long-term ventilation, and pediatric prolonged mechanical ventilation settings when structured protocols, multidisciplinary staffing, and continuous physiological monitoring were employed. Reported outcomes included stable respiratory parameters, facilitated movement, and positive experiential responses. Conclusions: Although the evidence base is limited and predominantly descriptive, available findings suggest that hydrotherapy can be safely and feasibly delivered to selected individuals receiving invasive mechanical ventilation in well-resourced clinical environments.