Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome

Guervilly, Christophe; Bisbal, Magali; Forel, Jean Marie; Mechati, Malika; Lehingue, Samuel; Bourenne, Jérémy; Perrin, Gilles; Rambaud, Romain; Adda, Mélanie; Hraiech, Sami; Marchi, Elisa De; Roch, Antoine; Gainnier, Marc; Papazian, Laurent

doi:10.1007/s00134-016-4653-4

Cited by 97 publications

(98 citation statements)

References 32 publications

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“…Muscle paralysis with neuromuscular blocking agents may avoid dyssynchrony, prevent excessive transpulmonary pressures and breath stacking by inspiratory efforts [30] and derecruitment by expiratory efforts [31]. Neuromuscular blocking agents have been shown to benefit patients with ARDS [32], confirmed in a meta-analysis of three RCTs [33].…”

Section: Rescue Therapiesmentioning

confidence: 94%

ARDS: challenges in patient care and frontiers in research

2018

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This review discusses the clinical challenges associated with ventilatory support and pharmacological interventions in patients with acute respiratory distress syndrome (ARDS). In addition, it discusses current scientific challenges facing researchers when planning and performing trials of ventilatory support or pharmacological interventions in these patients.Noninvasive mechanical ventilation is used in some patients with ARDS. When intubated and mechanically ventilated, ARDS patients should be ventilated with low tidal volumes. A plateau pressure <30 cmH 2 O is recommended in all patients. It is suggested that a plateau pressure <15 cmH 2 O should be considered safe. Patient with moderate and severe ARDS should receive higher levels of positive endexpiratory pressure (PEEP). Rescue therapies include prone position and neuromuscular blocking agents. Extracorporeal support for decapneisation and oxygenation should only be considered when lungprotective ventilation is no longer possible, or in cases of refractory hypoxaemia, respectively. Tracheotomy is only recommended when prolonged mechanical ventilation is expected.Of all tested pharmacological interventions for ARDS, only treatment with steroids is considered to have benefit.Proper identification of phenotypes, known to respond differently to specific interventions, is increasingly considered important for clinical trials of interventions for ARDS. Such phenotypes could be defined based on clinical parameters, such as the arterial oxygen tension/inspiratory oxygen fraction ratio, but biological marker profiles could be more promising.

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Section: Rescue Therapiesmentioning

confidence: 94%

ARDS: challenges in patient care and frontiers in research

2018

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“…A total of six studies containing 1557 patients were included in the analysis [9,[16][17][18][19][20]. Figure 1 shows the detailed information of literature selection.…”

Section: Resultsmentioning

confidence: 99%

“…All the data were obtained from published papers, including a meta-analysis [21] or by contacting the author of original articles. Four studies [9,[17][18][19] performed in France, one study [20] performed in China, and one study [16] performed in United States of America. Vecuronium was used in one study [20], and cisatracurium was used in the remaining studies [9,[16][17][18][19].…”

Section: Resultsmentioning

confidence: 99%

Neuromuscular blocking agents for acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials

et al. 2020

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Backgrounds:The aim of this study is investigating the benefits and harms of neuromuscular blocking agents (NMBAs) in patients with acute respiratory distress syndrome (ARDS). Methods:We comprehensively searched PubMed, EMBASE, and Cochrane library for randomized controlled trials comparing NMBAs to any other comparator. We pooled data using relative risk (RR) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes, with 95% confidence intervals. We assessed the quality of included studies using the Cochrane tool and levels of evidence using the GRADE method.Results: Finally, six RCTs (n = 1557 patients) were eligible for analysis. The results showed NMBAs use was not associated with reduced 28 days mortality (RR 0.78; 95% CI, 0.58 to 1.06; P = 0.11), 90 days mortality (RR, 0.92; 95% CI, 0.81 to 1.04; P = 0.16), and intensive care unit (ICU) mortality (RR, 0.90; 95% CI, 0.79 to 1.03; P = 0.13) in patients with ARDS. However, 21-28 days mortality was slightly lower in patients received NMBAs (RR 0.73; 95% CI, 0.54 to 0.99; P = 0.04; I 2 = 53%). Besides, NMBAs use could improve the PaO 2 /FiO 2 ratio at 48 and 72 h, decrease plateau pressure and PEEP at 72 h. Additionally, NMBAs had no significant effects on days free of ventilation at day 28 (WMD, 0.55; 95% CI, − 0.46 to 1.57; P = 0.29), days not in ICU at day 28 (WMD, 0.12; 95% CI, − 0.85 to 1.08; P = 0.82), ICU-acquired weakness (RR, 1.23; 95% CI, 0.99 to 1.93; P = 0.06). Finally, NMBAs use was associated with a lower risk of barotrauma (RR, 0.55; 95% CI, 0.35 to 0.85; P = 0.007). Conclusion:In patients with respiratory distress syndrome, NMBAs may be beneficial in reverse refractory hypoxemia and may be associated with reduced short-term mortality and incidence of barotrauma. However, there is no significant effects of NMBAs on mid-term and long-term mortality, and further studies are required.

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“…While spontaneous breathing may be well tolerated in patients with less severe lung injury, in severe ARDS, these efforts may be harmful, which has been suggested from the survival benefit of paralytics [35,36]. The combination of large inspiratory efforts added to the ventilator-assisted breaths may lead to large swings in PL and/or larger than desired tidal volumes leading to overdistension.…”

Section: Assessment Of Ventilator Synchrony and Spontaneous Effortsmentioning

confidence: 99%

“…The combination of large inspiratory efforts added to the ventilator-assisted breaths may lead to large swings in PL and/or larger than desired tidal volumes leading to overdistension. Similarly, active expiratory efforts may counter the benefits from PEEP [36], leading to derecruitment, lung collapse, and worsened oxygenation. Again, without esophageal pressure monitoring, detecting this clinically may be quite challenging.…”

Section: Assessment Of Ventilator Synchrony and Spontaneous Effortsmentioning

confidence: 99%

Esophageal pressure: research or clinical tool?

Kassis

Loring

Talmor

2017

Med Klin Intensivmed Notfmed

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Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome

Abstract: NMBA could exert beneficial effects in patients with moderate ARDS, at least in part, by limiting expiratory efforts.

Cited by 97 publications

References 32 publications

ARDS: challenges in patient care and frontiers in research

ARDS: challenges in patient care and frontiers in research

Neuromuscular blocking agents for acute respiratory distress syndrome: an updated meta-analysis of randomized controlled trials

Esophageal pressure: research or clinical tool?

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