Mechanical power is not associated with mortality in COVID-19 mechanically ventilated patients

(2025) 15:27 Barbeta et al. Annals of Intensive Care https://doi.org/10.1186/s13613-025-01430-6 Annals of Intensive Care Open Access RESEARCH Mechanical power is not associated with mortality in COVID‑19 mechanically ventilated patients Enric Barbeta1,2,3, Cláudia Barreiros2, Edoardo Forin4, Amedeo Guzzardella5, Anna Motos1,3, Laia Fernández‑Barat1,3, Albert Gabarrús1,3, Adrián Ceccato1,6,7, Ricard Ferrer8, Jordi Riera8, Oscar Peñuelas1,9, José Ángel Lorente1,9,10, David de Gonzalo‑Calvo1,11, Jessica Gonzalez1,11, Rosario Amaya‑Villar12, José Manuel Añón1,13, Ana Balan14, Carme Barberà15, José Barberán16, Aaron Blandino17,18, Maria Victoria Boado19, Elena Bustamante‑Munguira1,20, Jesús Caballero21, María Luisa Cantón‑Bulnes22, Cristina Carbajales23, Nieves Carbonell24, Mercedes Catalán‑González25, Nieves Franco26, Cristóbal Galbán27, Víctor D. Gumucio‑Sanguino28, Maria Del Carmen de la Torre29, Emilio Díaz30, Ángel Estella31, Elena Gallego1,32, José Manuel Gómez33, Arturo Huerta34, Ruth Noemí Jorge García35, Ana Loza‑Vázquez36, Judith Marin‑Corral37, María Cruz Martin Delgado38, Amalia Martínez39, Ignacio Martínez40, Juan Lopez41, Guillermo M. Albaiceta1,42, María Teresa Nieto43, Mariana Andrea Novo44, Yhivian Peñasco45, Felipe Pérez‑García46,47, Pilar Ricart48, Alejandro Rodríguez49, Victor Sagredo50, Angel Sánchez‑Miralles51, Susana Sancho52, Ferran Roche‑Campo53, Lorenzo Socias54, Jordi Solé‑Violan1,55, Luis Tamayo1,56, José Trenado57, Alejandro Úbeda58, Luis Jorge Valdivia59, Pablo Vidal60, Ferran Barbé1,11, Jordi Vallverdú2, Antoni Torres1,60,61*   and CIBERESUCICOVID Project investigators (COV20/00110, ISCIII) Abstract Background The relative contribution of the different components of mechanical power to mortality is a subject of debate and has not been studied in COVID-19. The aim of this study is to evaluate both the total and the rela‑ tive impact of each of the components of mechanical power on mortality in a well-characterized cohort of patients with COVID-19-induced acute respiratory failure undergoing invasive mechanical ventilation. This is a secondary analysis of the CIBERESUCICOVID project, a multicenter observational cohort study including fifty Spanish intensive care units that included COVID-19 mechanically ventilated patients between February 2020 and December 2021. We examined the association between mechanical power and its components (elastic static, elastic dynamic, total elastic and resistive power) with 90-day mortality after adjusting for confounders in seven hundred ninety-nine patients with COVID-19-induced respiratory failure undergoing invasive mechanical ventilation. Results At the initiation of mechanical ventilation, the PaO2/FiO2 ratio was 106 (78; 150), ventilatory ratio was 1.69 (1.40; 2.05), and respiratory system compliance was 35.7 (29.2; 44.5) ml/cmH2O. Mechanical power at the initiation of mechanical ventilation was 24.3 (18.9; 29.6) J/min, showing no significant changes after three days. In multivariable regression analyses, mechanical power and its components were not associated with 90-day mortality at the start of mechanical ventilation. After three days, total elastic and elastic static power were associated with higher 90-day mortality, but this relationship was also found for positive end-expiratory pressure. *Correspondence: Antoni Torres Full list of author information is available at the end of the article © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. Barbeta et al. Annals of Intensive Care (2025) 15:27 Page 2 of 11 Conclusions Neither mechanical power nor its components were independently associated with mortality in COVID19-induced acute respiratory failure at the start of MV. Nevertheless, after three days, static elastic power and total elastic power were associated with lower odds of survival. Positive end-expiratory pressure and plateau pressure, however, captured this risk in a similar manner. Keywords Mechanical power, COVID-19, Mechanical ventilation, Respiratory failure Background Ventilator-induced lung injury (VILI) occurs in patients with acute respiratory distress syndrome (ARDS) and increases mortality risk [1, 2]. Excessive strain and stress caused by mechanical ventilation (MV) are the primary mechanisms of lung injury [3]. However, given that VILI is a complex and multifactorial phenomenon [3], a definitive variable to evaluate the risk of lung injury and optimize the application of MV is currently unknown. Mechanical power is a composite variable that expresses the work that MV transfers to the respiratory system per unit of time. It accounts for the energy transferred to the lungs to produce motion [4]: the first component is the work performed by the ventilator to overcome the basal tension of the lungs produced by positive end-expiratory pressure (PEEP, elastic static power); the second component is the work needed to inflate the lungs, which depends on the elastance of the respiratory system (Ers, elastic dynamic power); the third and final component is the work performed to overcome resistance (R, resistive power). Consequently, mechanical power is a unifying concept of VILI as it considers all variables known to play a role in lung injury, including those previously neglected such as the respiratory rate [4]. For example, simultaneous changes in different ventilator settings will alter these components. However, the final contribution of such changes to VILI risk will be encompassed by mechanical power. Several observational and experimental studies have identified that mechanical power is associated with increased mortality in critically ill patients, specifically in those with ARDS [5, 6]. However, there are still controversies regarding its role as the ultimate predictor of VILI. Firstly, the relative contribution of each of its components to mortality is debated [6]. Secondly, it has not been studied in patients with COVID-19-induced respiratory failure. Therefore, the aim of this study is to evaluate both the total and the relative impact of each of the components of mechanical power on mortality in a well-characterized cohort of patients with COVID-19-induced acut (...truncated)