Home Health Acute Respiratory Distress Syndrome
Perspectives: The Appropriate Place of NMBAs in ARDS Treatment
Clear recent recommendations concerning the use of NMBAs for ARDS are lacking. The most recent guidelines from 2002  reduce the role of NMBAs to “facilitating mechanical ventilation when sedation alone is inadequate”. These guidelines were created before the RCTs were conducted and appear to be obsolete. The recent data on the beneficial effects of NMBAs on mortality have modified their use. In a recent large international survey conducted in 50 countries, NMBAs were found to be the most frequently used adjunctive measure in severe ARDS . NMBAs were also extensively used in the PROSEVA study, which demonstrated the beneficial effect of prone positioning on mortality . Overall, that NMBAs have a crucial role in the management of ARDS seems to no longer be questionable. However, the available literature conveys the following “rules” with respect to the use of NMBAs:
Adhering to these conditions might ensure the acquisition of the beneficial effects of NMBAs while preventing their deleterious side effects.
However, several questions remain to be answered. The potential antiinflammatory properties of cisatracurium [15, 26] and the efficacies of other molecules need to be investigated, the appropriate dose needs to be identified (in the ACURASYS study, high and constant doses were used to preserve the blinding for both groups), NMBA efficacy needs to be examined with train-of-four monitors and the appropriate target paralysis depth needs to be clarified.
Fig. 12.3 The place of NMBAs in protective ventilation in ARDS. NMBAs neuromuscular blocking agents, ARDS acute respiratory distress syndrome
NMBAs are the most frequently used pharmacological treatment for ARDS. Recent strong evidence indicates that NMBAs improve survival in the most severe patients. Moreover, early and short-term administration is not associated with neuromuscular side effects and should be followed with a ventilator strategy that allows for spontaneous breathing as soon as gas exchange improves. Further studies will help to precisely identify the appropriate place of NMBAs in the treatment of moderate ARDS, the doses that should be used and the monitoring that must be performed.
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