Clinical pathways (CPs) are multidisciplinary, structured plans of care designed to translate the best available evidence into routine clinical practice for defined patient populations and clinical problems. In critical care settings, CPs support complex, multidisciplinary clinical decision-making by standardising key interventions, reducing unwarranted variation in practice and promoting consistent, evidence-based care while allowing adaptation to local healthcare contexts. As evidence-informed tools, CPs depend on the systematic identification, appraisal and synthesis of relevant research to ensure methodological rigour, clinical relevance and contextual applicability (Albertse et al., 2023; Aspland et al., 2021; Herawati et al., 2022; Trimarchi et al., 2021).

The development of CPs is particularly important in the management of complex and high-risk conditions such as acute respiratory distress syndrome (ARDS), where care is resource intensive, and outcomes are influenced by timely, coordinated and evidence-based interventions. Acute respiratory distress syndrome is defined according to the Berlin criteria, which provide standardised diagnostic parameters based on timing of onset, chest imaging findings, severity of hypoxaemia and the origin of pulmonary oedema (Matthay et al., 2019; Papazian et al., 2019; Smith & Richards, 2021). The use of standardised diagnostic criteria ensures consistency in identifying the target population and strengthens the alignment between evidence synthesis and clinical application.

Airway pressure release ventilation (APRV) has been used for more than three decades as a mode of invasive mechanical ventilation and is associated with potential physiological and clinical benefits for patients with ARDS. Despite increasing interest in APRV therapy, there remains limited consensus and insufficient practical guidance regarding ventilator settings, initiation, titration and weaning strategies for its use in adult patients with ARDS (Andrews et al., 2022; Chen et al., 2021; Fredericks et al., 2020; Smith & Richards, 2021). This lack of standardised guidance contributes to variability in clinical practice and uncertainty among critical care clinicians, particularly nurses, highlighting the need for a structured, evidence-based clinical pathway to support the safe and consistent implementation of APRV therapy in this population (Andrews et al., 2022).

The development of an evidence-based clinical pathway requires a robust synthesis of available research. Systematic literature reviews are widely regarded as the gold standard for evidence synthesis because of their comprehensive search strategies, transparent methodologies and rigorous appraisal processes (Kabir et al., 2023; Toronto & Remington, 2020). However, traditional systematic reviews are often time consuming and resource intensive, which may limit their feasibility when timely evidence is required to inform clinical practice.

Rapid literature reviews (RLRs) offer a pragmatic alternative by retaining core principles of systematic review methodology – such as structured search processes, explicit eligibility criteria and transparent reporting – while allowing greater methodological flexibility. This flexibility commonly includes narrower research questions, focused search strategies and shorter timelines, enabling timely synthesis of evidence that is directly applicable to clinical decision-making (Devane et al., 2024; Garritty et al., 2021; Kabir et al., 2023; Snyder, 2019). Rapid reviews are increasingly used to inform healthcare interventions, including guideline development and clinical pathway design (Wilson et al., 2021).

The purpose of this study was therefore to conduct a semi-systematic RLR to synthesise evidence on ventilator settings, protocols and clinical guidance to inform the development of an evidence-based clinical pathway for APRV therapy in adult patients with ARDS. The review question guiding this study was: What evidence is available regarding ventilator settings, clinical protocols and implementation considerations for the use of APRV in adult patients with ARDS?

A semi-systematic RLR design was selected because of the narrow, practice-oriented focus of the review question and the need for timely synthesis to inform clinical pathway development. Airway pressure release ventilation represents an evolving mode of invasive mechanical ventilation, with increasing clinical interest following its expanded use during the COVID-19 pandemic (Alqahtani et al., 2020; Mahmoud et al., 2021; Rola & Daxon, 2022; Smith & Richards, 2021; Zorbas et al., 2021). The emerging nature of the evidence base and the absence of standardised clinical protocols further supported the selection of a rapid review approach to efficiently identify and synthesise relevant contemporary literature (Andrews et al., 2022; Mahmoud et al., 2021; Navas-Blanco & Dudaryk, 2020; Smith & Richards, 2021).

The review followed a structured, stepwise process comprising formulation of the review question, planning of the review, systematic searching, study selection, data extraction, thematic synthesis and presentation of findings using a synthesis matrix. Figure 1 illustrates the steps undertaken, adapted from Snyder (2019).

The review question was structured using the PICo framework, which identifies the Population, Phenomenon of Interest and Context relevant to the study (Covvey et al., 2024; Hosseini et al., 2024). The PICo elements directly informed the search strategy, study selection and eligibility criteria, as summarised in Table 1. The review question asked: What evidence is available regarding ventilator settings, clinical protocols and implementation considerations for the use of APRV in adult patients with ARDS?

A structured electronic search was conducted in PubMed, EBSCOhost (including CINAHL) and Google Scholar between May 2022 and July 2022. These databases were selected to ensure comprehensive coverage of medical, nursing and critical care literature.

Searches combined controlled vocabulary and free-text terms related to ARDS and APRV, including ‘acute respiratory distress syndrome’, ‘ARDS’, ‘airway pressure release ventilation’ and ‘APRV’, using Boolean operators. Searches were restricted to English-language publications and the predefined publication period.

Given the intended application of findings to South African critical care settings, an initial focused search for South African literature was conducted. Only one eligible South African publication was identified (Smith & Richards, 2021). Backward and forward citation tracking of this article was therefore performed to identify additional relevant international studies.

All retrieved articles were screened against the inclusion and exclusion criteria. Articles meeting eligibility criteria were included in the synthesis of evidence, focusing on ventilator settings, clinical protocols and implementation considerations for APRV in adult ARDS patients.

All identified records were collated, and duplicates were removed. Titles and abstracts were screened independently by two reviewers against the predefined eligibility criteria. Full-text articles of potentially eligible studies were retrieved and independently assessed. Discrepancies were resolved through discussion until consensus was achieved.

Studies examining APRV use in patients at risk of ARDS without a confirmed diagnosis (according to the Berlin criteria) were excluded to maintain population homogeneity. Backward and forward citation tracking of included studies was conducted using the same screening criteria. The study selection process is illustrated in the preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram (Figure 3).

The search was limited to peer-reviewed publications from January 2016 to July 2022. This timeframe follows the publication of the first randomised controlled trial evaluating APRV for ARDS (Zhou et al., 2017) and aligns with the timeline required to inform clinical pathway development by September 2022.

Data analysis followed a descriptive thematic synthesis approach, suitable for rapid reviews aiming to summarise and compare findings across heterogeneous study designs (Creswell & Creswell, 2023; Snyder, 2019). Following study selection, key data were extracted from each included article into a synthesis matrix, capturing study characteristics, APRV protocols, ventilator settings (including P_high, T_high, P_low and T_low) and adjunctive practices (e.g. sedation, FiO₂ titration, automatic tube compensation) (Albertse et al., 2023; Kabir et al., 2023).

Data coding was conducted manually. Extracted information was initially organised according to predefined clinical categories relevant to APRV use. Patterns and similarities across studies were then identified, and an inductive approach was applied to group related findings into overarching themes. This process resulted in the identification of three main themes, which are presented descriptively to highlight areas of convergence and variation across the literature rather than to generate theory.

The synthesis matrix enabled a systematic comparison of study findings and supported transparent presentation of results. Study characteristics are presented first in the Results section, followed by a thematic synthesis of findings related to APRV protocols, ventilator settings and safety considerations. A thematic map illustrating the three main themes identified from the data is presented in Figure 4.

The final sample comprised 21 peer-reviewed articles published between 2016 and 2022. Most studies originated from North America, with additional publications from Asia, the Middle East, Australia and one South African study (Smith & Richards, 2021).

The included studies represented a range of research designs:

Across the included literature, study aims and reporting focused on various aspects of APRV use in adult patients with ARDS, including ventilator settings, clinical protocols and adjunctive management strategies. Table 2 provides a descriptive summary of study characteristics, including year of publication, country of origin, study design, reported protocols and APRV ventilator settings.

The included studies, summarised in Table 2, report substantial variation in the use of APRV, including differences in ventilator settings and adjunctive management practices across institutions. The findings are synthesised under three key areas: Protocols and guidelines, ventilator settings and alarm limits in adult patients treated with APRV for ARDS.

Overall, the review revealed substantial variability in APRV application, ventilator settings and supporting protocols across studies and institutions. No universal guideline exists, and practice is largely guided by institution-specific protocols and physician preference, including the TCAV and Zhou early-application methods. Sedation management, FiO₂ titration and ATC activation are important adjuncts, but detailed guidance – particularly regarding alarm limits and safety parameters – is limited. These findings underscore the emerging role of APRV therapy in adult critical care and highlight the need for context-specific CPs to support safe and standardised implementation, especially in under-researched regions such as South Africa.

This review has several strengths. The research question was focused, feasible and directly aligned with the practical objective of informing clinical pathway development. The structured RLR methodology enabled timely synthesis of available evidence while maintaining transparency and methodological rigour. Visual tools, including the synthesis matrix and thematic map, facilitated systematic comparison of findings and enhanced their clinical applicability. Inclusion of international literature alongside one South African study (Smith & Richards, 2021), supplemented by citation tracking, further strengthened contextual relevance.

Several limitations should be acknowledged. The number of included studies was relatively small, reflecting both the emerging nature of APRV therapy and the restrictive inclusion criteria. Considerable heterogeneity across study designs, protocols and ventilator settings limits generalisability. Exclusion of grey literature may have resulted in omission of additional context-specific guidance. In addition, a formal methodological quality appraisal was not conducted, which may affect the certainty of the synthesised evidence.