Effets de la curarisation sur les échanges gazeux lors du syndrome de détresse respiratoire aiguë

Abstract

The use of neuromuscular blocking agents (NMBA) in ventilated patients with acute respiratory distress syndrome (ARDS) is controversial and largely empirical. Few trials looked at their effectiveness on gas exchange or in improving lung mechanics in patients with ARDS. Only one randomized controlled trial compare the effects of NMBA on gas exchange in patients with ARDS receiving NMBA as compared with patients receiving placebo throughout a period of 48 hours. In this trial, the early use of NMBA in patients with ARDS was associated with a sustained improvement in oxygenation. The muscular paralysis induced by NMBA could reduce the consumption of oxygen linked to the work of breathing. Muscular paralysis could facilitate mechanical ventilation by preventing spontaneous breaths responsible for the dyssynchrony and worsening of hematosis. Muscular paralysis could increase compliance of the thoracic wall and improve mechanical ventilation during ARDS. However, these hypotheses are controversial. Finally, preliminary data show that the muscular paralysis could provide better adaptation to mechanical ventilation and better satisfaction with the protective criteria for reduction of ventilator-associated lung injuries by homogenizing the distribution of tidal volume and positive end-expiratory pressure. The role of new neuromuscular blocking agents (benzylisoquinolines) in the occurrence of critical illness neuromyopathy is largely questioned in the recent literature. It is important to design new studies to explain the mechanisms of the improvement in oxygenation associated with NMBA and to evaluate whether the use of NMBA modifies the outcome of patients with ARDS.