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Background External chest-wall compression (ECC) is sometimes used in ARDS patients despite lack of evidence. It is currently unknown whether this practice has any clinical benefit in patients with COVID-19 ARDS (C-ARDS) characterized by a respiratory system compliance ( C  rs ) &lt; 35 mL/cmH 2 O. Objectives To test if an ECC with a 5 L-bag in low-compliance C-ARDS can lead to a reduction in driving pressure (DP) and improve gas exchange, and to understand the underlying mechanisms. Methods Eleven patients with low-compliance C-ARDS were enrolled and underwent 4 steps: baseline, ECC for 60 min, ECC discontinuation and PEEP reduction. Respiratory mechanics, gas exchange, hemodynamics and electrical impedance tomography were recorded. Four pigs with acute ARDS were studied with ECC to understand the effect of ECC on pleural pressure gradient using pleural pressure transducers in both non-dependent and dependent lung regions. Results Five minutes of ECC reduced DP from baseline 14.2 ± 1.3 to 12.3 ± 1.3 cmH 2 O ( P  &lt; 0.001), explained by an improved lung compliance. Changes in DP by ECC were strongly correlated with changes in DP obtained with PEEP reduction ( R  2  = 0.82,  P  &lt; 0.001). The initial benefit of ECC decreased over time (DP = 13.3 ± 1.5 cmH 2 O at 60 min,  P  = 0.03 vs. baseline). Gas exchange and hemodynamics were unaffected by ECC. In four pigs with lung injury, ECC led to a decrease in the pleural pressure gradient at end-inspiration [2.2 (1.1–3) vs. 3.0 (2.2–4.1) cmH 2 O,  P  = 0.035]. Conclusions In C-ARDS patients with  C  rs  &lt; 35 mL/cmH 2 O, ECC acutely reduces DP. ECC does not improve oxygenation but it can be used as a simple tool to detect hyperinflation as it improves  C  rs  and reduces  P  pl  gradient. ECC benefits seem to partially fade over time. ECC produces similar changes compared to PEEP reduction.

External chest-wall compression in prolonged COVID-19 ARDS with low-compliance: a physiological study