INTRODUCTION: In life-threatening conditions like severe acute respiratory distress syndrome (ARDS), rescue interventions like extracorporeal membrane oxygenation (ECMO) should be initiated urgently to resolve an otherwise potentially adverse clinical outcome. Driving pressure (DP) is an independent prognosticator of the survival of ARDS during mechanical ventilation. We conducted this review with the objective to identify the optimal DP for initiating ECMO in severe ARDS and to study the change in DP during ECMO strategy in survivors and non-survivors. MATERIALS AND METHODS: A systematic search of EMBASE, PubMed, Cochrane Library, and SCOPUS databases was conducted from their inception to January 2024. Two investigators independently carried out the processes of literature search, study selection, data extraction, and quality assessment. The analysis was conducted using comprehensive meta-analysis software (CMA). RESULTS: For meta-analysis, six studies comprising 668 patients were included. In survivors, the DP at ECMO initiation was lower (mean DP = 14.56 cm H CONCLUSION: The optimum DP to initiate ECMO in severe ARDS patients on MV is 15 cm H TRIAL REGISTRATION: PROSPERO CRD42022327846. HOW TO CITE THIS ARTICLE: Todur P, Nileshwar A, Chaudhuri S, Nagendra D, Shanbhag V, Vennila J. Prognostic Significance of Driving Pressure for Initiation and Maintenance of ECMO in Patients with Severe ARDS: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2025
29(2):177-185.