Does neuromuscular blocking help support respiratory status in Acute Respiratory Distress Syndrome (ARDS) patients?

From the Guidelines

Neuromuscular blocking agents (NMBAs) can help support respiratory status in selected patients with moderate-to-severe Acute Respiratory Distress Syndrome (ARDS), particularly when used early and for a short duration, as evidenced by the most recent study in 2024 1.

Key Points to Consider

• Early, short-term use of NMBAs like cisatracurium for 48 hours may improve oxygenation and outcomes in patients with severe ARDS.
• NMBAs work by preventing patient-ventilator dyssynchrony, reducing oxygen consumption, decreasing barotrauma, and improving lung compliance.
• Cisatracurium is often preferred because it doesn't rely on liver or kidney clearance.
• When administering NMBAs, patients must receive adequate sedation, regular monitoring of paralysis depth, and proper positioning to prevent pressure injuries.
• Potential complications include ICU-acquired weakness, particularly with prolonged use or when combined with corticosteroids.

Recommendations

• NMBAs should be used as part of a comprehensive lung-protective ventilation strategy that includes low tidal volumes and appropriate PEEP levels.
• The use of NMBAs should be reserved for patients with the most severe ARDS, mainly in the acute phase and during the first 48 hours of mechanical ventilation, as suggested by a 2020 guideline 1.
• Sedation should be reduced and partial ventilator support can be used to promote respiratory muscle activity whenever gas exchange, respiratory mechanics, and hemodynamic status have improved, as noted in a 2017 expert opinion 1.

Evidence Summary

The most recent and highest quality study, published in 2024 1, demonstrated that NMBAs may decrease mortality for patients with moderate to severe ARDS compared with those who did not receive NMBAs, with a relative risk of 0.74 (95% CI, 0.56-0.98). However, the certainty of evidence was low due to concerns related to inconsistency and individual study risk of bias.

Clinical Considerations

In clinical practice, the decision to use NMBAs in ARDS patients should be made on a case-by-case basis, taking into account the severity of the disease, the patient's response to mechanical ventilation, and the potential risks and benefits of NMBA use, as discussed in a 2016 clinical practice guideline 1.

From the Research

Neuromuscular Blocking in ARDS Patients

• The use of neuromuscular blocking agents in patients with Acute Respiratory Distress Syndrome (ARDS) has been studied in several trials to determine its effect on respiratory status and mortality rates 2, 3, 4, 5, 6.
• A study published in The New England Journal of Medicine in 2010 found that the use of cisatracurium besylate in patients with severe ARDS improved oxygenation and decreased ventilator-induced lung injury, resulting in a lower 90-day mortality rate compared to the placebo group 2.
• Another study published in The Journal of Surgical Research in 2018 found that extended neuromuscular blockade in ARDS patients did not increase mortality, suggesting that the duration of neuromuscular blocking agent therapy should not be the sole factor in deciding to discontinue treatment 3.
• A systematic review and meta-analysis of randomized controlled trials published in the Journal of Intensive Care in 2020 found that neuromuscular blocking agents improved oxygenation in moderate to severe ARDS patients, but did not reduce mortality risk or the duration of mechanical ventilation 4.
• An observational study published in the American Journal of Respiratory and Critical Care Medicine in 2018 compared the efficacy of cisatracurium and vecuronium in patients with or at risk for ARDS, and found that cisatracurium was associated with fewer ventilator days and ICU days, but not with a significant difference in mortality 5.
• A retrospective cohort study published in the Journal of Pharmacy Practice in 2024 compared fixed dosing and train-of-four titration of cisatracurium in COVID-19 ARDS patients, and found that the train-of-four titration group had improved PaO2:FiO2 ratios at 48 hours and used a lower cumulative dose of cisatracurium 6.

Key Findings

• Neuromuscular blocking agents may improve oxygenation and decrease ventilator-induced lung injury in ARDS patients 2, 4.
• The use of neuromuscular blocking agents in ARDS patients may not increase mortality, even with extended use 3.
• Cisatracurium may be associated with improved outcomes, such as fewer ventilator days and ICU days, compared to other neuromuscular blocking agents like vecuronium 5.
• Train-of-four titration of cisatracurium may be a more effective and efficient method of administration compared to fixed dosing 6.