Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome*

Gainnier, Marc; Roch, Antoine; Forel, Jean-Marie; Thirion, Xavier; Arnal, Jean-Michel; Donati, Stéphane Y.; Papazian, Laurent

doi:10.1097/01.ccm.0000104114.72614.bc

Cited by 288 publications

(265 citation statements)

References 46 publications

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“…Also, it was not powered adequately for mortality, though the authors did report a non-significant trend toward decreased ICU stay and decreased 28-day mortality (favouring cisatracurium). 10 In a follow-up study, Forel et al used a similar study design and found that early use of cisatracurium infusion in ARDS also decreased serum and pulmonary concentrations of pro-inflammatory markers when compared with control. 11 The current work by Papazian et al has built on these studies.…”

Section: Commentarymentioning

confidence: 99%

The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome

Needham

Brindley

2011

Can J Anesth/J Can Anesth

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Background Acute respiratory distress syndrome (ARDS) is defined as severe hypoxemic respiratory failure resulting from diffuse lung injury and secondary to direct and indirect insults. Despite advances, mortality remains as high as 40-60%. Neuromuscular blocking agents (NMBAs) are used to facilitate mechanical ventilation in patients with ARDS and have been shown to improve arterial partial pressure of oxygen. However, the association between NMBAs and mortality is unclear. Furthermore, morbidity concerns exist, particularly regarding a putative role in intensive care unit (ICU)-acquired weakness. Objective The purpose of this study was to compare survival in adult patients with early ARDS who were randomized to receive either a 48-hr infusion of the NMBA, cisatracurium, or a placebo. Patients Eligible patients were [ 18 yr with an intubated trachea and ventilated lungs for acute hypoxemic respiratory failure. Their PaO 2 /F I O 2 ratio was \ 150 at a tidal volume of 6-8 mLÁkg -1 ideal body weight and a positive end-expiratory pressure (PEEP) C 5 cm H 2 O for \ 48 hr. Additional inclusion criteria were radiographic evidence of bilateral pulmonary infiltrates and the absence of left atrial hypertension. Exclusion criteria included patients already receiving NMBA at enrolment; those who had increased intracranial pressure, severe chronic respiratory disease, or severe chronic liver disease; those who had received a bone marrow transplant or had chemotherapy-induced neutropenia; those who had a pneumothorax; and those who were expected to require mechanical ventilation for \ 48 hr or were enrolled in another trial within 30 days. Intervention Three hundred twenty-six patients were screened, and 340 of these underwent randomization in blocks of four and received either a 48-hr infusion of cisatracurium (15 mg bolus followed by 37.5 mgÁhr -1 ) or a volume equivalent placebo. One hundred and seventy-eight patients received a cisatracurium infusion, and one patient withdrew leaving 177 patients included in the analysis. One hundred and sixty-two patients received the placebo infusion. Prior to either infusion, patients were sedated to a Ramsay sedation score of 6. Patients' lungs were ventilated by a volume assist-controlled mode according to the ARDS Clinical Network Mechanical Ventilation Protocol (http:// www.ardsnet.org/) with the goal SpO 2 of 88-95% (or PaO 2 55-80 mmHg) and goal plateau pressure B 35 cm H 2 O. Open-label boluses of cisatracurium 20 mg (maximum of two per 24-hr period) were allowed if plateau pressures Design and setting

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Section: Commentarymentioning

confidence: 99%

The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome

Needham

Brindley

2011

Can J Anesth/J Can Anesth

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“…The NMBA group also had faster weaning of PEEP, indicating improved lung compliance at the end of the 5-d study period. 17 A separate randomized trial by Forel et al 21 reported similar improvements in oxygenation with the use of NMBAs in early ARDS. 21 The mechanism for improved oxygenation remains unclear.…”

Section: Pro: Nmbas May Improve Survival In Ardsmentioning

confidence: 95%

“…[22][23][24] The reduction in oxygen consumption might decrease demand for oxygen delivery and carbon dioxide removal, ultimately resulting in decreased cardiac output and decreased pulmonary blood flow, which then may minimize the edema seen at the alveolar-capillary level in ARDS. What is interesting to note is that for both the Gainnier et al 17 and Forel et al 21 trials, the improvement in oxygenation persisted throughout the 5-d study period, well beyond the 48 h of muscle paralysis, 17,21 which suggests that the reduction in oxygen consumption cannot be the primary mechanism of improved oxygenation.…”

Section: Pro: Nmbas May Improve Survival In Ardsmentioning

confidence: 98%

“…NMBAs improve oxygenation in ARDS. In a randomized controlled trial of 56 subjects with ARDS, Gainnier et al 17 examined the effects of NMBAs on oxygenation parameters. Compared with placebo, subjects who received NMBAs for 48 h early in the course of ARDS had significantly improved P aO 2 /F IO 2 after 48 h. This effect persisted for several days beyond discontinuation of the NMBA.…”

Section: Pro: Nmbas May Improve Survival In Ardsmentioning

confidence: 99%

“…There is convincing evidence that the use of NMBAs with a concomitant deep sedation strategy can increase oxygenation and possibly decrease mortality when used in the early stages of ARDS. [17][18][19] The mechanism by which this occurs is unclear but probably involves a combination of factors, such as improving patient-ventilator synchrony, decreasing oxygen consumption, and decreasing the systemic inflammatory response associated with ARDS. 18,20,21 The use of NMBAs and subsequently deep sedation for these patients is not without consequence.…”

Section: Introductionmentioning

confidence: 99%

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Early Paralysis for the Management of ARDS

2016

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SummaryThe use of neuromuscular blocking agents (NMBAs) early in the development of ARDS has been a strategy of interest for many years. The use of NMBAs with a concomitant deep sedation strategy can increase oxygenation and possibly decrease mortality when used in the early stages of ARDS. The mechanism by which this occurs is unclear but probably involves a combination of factors, such as improving patient-ventilator synchrony, decreasing oxygen consumption, and decreasing the systemic inflammatory response associated with ARDS. The use of NMBA and deep sedation for these patients is not without consequence. This discussion describes the rationale and evidence behind the use of NMBAs in the setting of ARDS.

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Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome

et al. 2019

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Key Points Question What is the relative association of management strategies for adult patients with moderate to severe acute respiratory distress syndrome with mortality and barotrauma? Findings In this systematic review and network meta-analysis of 25 randomized clinical trials including 7743 patients, venovenous extracorporeal membrane oxygenation and prone positioning were associated with significantly lower 28-day mortality compared with lung protective ventilation alone. Moreover, venovenous extracorporeal membrane oxygenation was the highest-ranked intervention associated with a reduction in 28-day mortality among the 9 interventions evaluated. Meaning These findings support the use of prone positioning in patients with moderate to severe acute respiratory distress syndrome and venovenous extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome.

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Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome*

Abstract: Use of NMBA during a 48-hr period in patients with acute respiratory distress syndrome is associated with a sustained improvement in oxygenation.

Cited by 288 publications

References 46 publications

The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome

The role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome

Early Paralysis for the Management of ARDS

Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome

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