Sex-specific considerations for mechanical ventilation in acute respiratory distress syndrome: a narrative review of implications for female patients in the intensive care unit

SummaryAcute respiratory distress syndrome (ARDS) remains a significant clinical challenge, with high morbidity and mortality rates despite advances in supportive care. Mechanical ventilation is central to the management of this condition, yet sex-related differences have been largely overlooked in research and clinical practice. Female patients have smaller lung volumes, different chest wall mechanics, and hormonal modifications that affect inflammation, vascular tone, respiratory compliance, and respiratory drive. These have an impact on treatment and care. This narrative review synthesises current evidence on sex-specific physiological differences affecting ARDS management. It evaluates the impact of physiological differences on lung volumes, chest wall mechanics, and pharmacokinetics and emphasises the importance of personalised ventilation and sedation strategies. Female patients exhibit greater susceptibility to ventilator-induced lung injury. Recent physiological studies show that, despite lower absolute mechanical power, each 1 J min−1 increase in mechanical power is associated with a 52.8% higher mortality risk in female patients compared with males, with an excess mortality of 8.2% above a threshold of 17 J min−1. Sex-related sensitivity to sedatives and neuromuscular blocking agents has also been described, with females requiring 20–30% lower opioid doses, 30% increased propofol doses, and a 30% greater sensitivity to neuromuscular blockers. Addressing sex-based differences is crucial for personalised ARDS management. Strategies including normalisation of mechanical power to lung volume and sex-specific analgo-sedation protocols are needed. Equitable access to advanced therapies is essential for all patients. Future research must systematically integrate sex-specific analyses (e.g. the Sex And Gender Equity in Research (SAGER) guidelines) to improve understanding of reported outcomes for critically ill patients