Education  |   June 2020
Neuromuscular Blockade Applicability in Early Acute Respiratory Distress Syndrome
Author Notes
  • From the Department of Anesthesiology, University of Cincinnati, Cincinnati, Ohio.
  • This article is featured in “This Month in Anesthesiology,” page 1A.
    This article is featured in “This Month in Anesthesiology,” page 1A.×
  • Portions of this review were presented at the 54th Respiratory Care Journal Conference on Respiratory Care Controversies III, St. Petersburg, Florida, June 5–6, 2015, and published as: Grawe ES, Bennett S, Hurford WE. Early Paralysis for the Management of ARDS. Respir Care. 2016; 61:830–8.
    Portions of this review were presented at the 54th Respiratory Care Journal Conference on Respiratory Care Controversies III, St. Petersburg, Florida, June 5–6, 2015, and published as: Grawe ES, Bennett S, Hurford WE. Early Paralysis for the Management of ARDS. Respir Care. 2016; 61:830–8.×
  • Submitted for publication September 4, 2019. Accepted for publication January 3, 2020. Published online first on February 5, 2020.
    Submitted for publication September 4, 2019. Accepted for publication January 3, 2020. Published online first on February 5, 2020.×
  • Address correspondence to Dr. Hurford: Department of Anesthesiology, University of Cincinnati, P.O. Box 670531, 231 Albert Sabin Way, Cincinnati, Ohio 45267-0531. William.hurford@uc.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Education / Clinical Focus Review
Education   |   June 2020
Neuromuscular Blockade Applicability in Early Acute Respiratory Distress Syndrome
Anesthesiology 6 2020, Vol.132, 1577-1584. doi:https://doi.org/10.1097/ALN.0000000000003180
Anesthesiology 6 2020, Vol.132, 1577-1584. doi:https://doi.org/10.1097/ALN.0000000000003180
Papazian et al.1  reported in 2010 that use of neuromuscular blocking agents within 48 h of development of acute respiratory distress syndrome (ARDS) had a positive effect on survival in patients with severe disease (Pao2/Fio2 less than 120 mmHg) compared with management with deep sedation alone. Supporting this survival benefit, a retrospective study by Steingrub et al.2  reported lower in-hospital mortality when mechanically ventilated patients with severe sepsis and a respiratory source of infection received neuromuscular blocking agents within the first two hospital days (treated: 31.9%, untreated: 39.3% in-hospital mortality; P < 0.001). Possible mechanisms by which this benefit might occur include decreasing oxygen consumption and improving oxygenation, decreasing the systemic inflammatory response associated with ARDS, and improving patient–ventilator synchrony. The general use of neuromuscular blocking agents in early ARDS, however, is not without consequence. Risks associated with this intervention include prolonged mechanical ventilation owing to excessive sedation, prolonged paralysis after discontinuation of neuromuscular blocking agents, development of critical illness myopathy and polyneuropathy, development of corneal abrasions and ulcerations, and risk of apnea with unrecognized ventilator disconnections.3  A decade later, The National Heart, Lung, and Blood Institute (Bethesda, Maryland) Prevention and Early Treatment of Acute Lung Injury Clinical Trials Network published a multicenter trial comparing a 48-h infusion of cisatracurium accompanied by deep sedation with usual-care and lighter sedation targets in patients with moderate to severe ARDS (a Pao2/Fio2 less than 150 mmHg with a positive end-expiratory pressure (PEEP) greater than or equal to 8 cm H2O.4  The trial was stopped early for futility to detect a difference in the primary outcome variable of in-hospital death at 90 days.