Abstract
BackgroundWe aimed to synthesize up-to-date trials to validate the effects of neuromuscular blocking agent (NMBA) use in patients with moderate-to-severe acute respiratory distress syndrome (ARDS).MethodsSeveral databases including PubMed, EMBASE, Web of Science, and Cochrane Central Register were searched up to November 14, 2019. All randomized trials investigating the use of NMBAs in patients with moderate-to-severe ARDS and reporting mortality data were included in the meta-analysis. The primary outcome was mortality, and the secondary outcomes were clinical outcomes, including respiratory physiological parameters, incidence of barotrauma, ICU-free days, and ventilation-free days.ResultsA total of 7 trials enrolling 1598 patients were finally included in this meta-analysis. The results revealed that the use of NMBAs in moderate-to-severe ARDS could significantly decrease the mortality truncated to day 28 (RR 0.74, 95% CI 0.56 to 0.98, P = 0.03) and day 90 (RR 0.77, 95% CI 0.60 to 0.99, P = 0.04). NMBA use could significantly decrease the incidence of barotrauma (RR 0.56, 95% CI 0.36 to 0.87, P = 0.009). No significant difference was observed in ICU-free days or ventilation-free days between the NMBA and control groups.ConclusionThe use of NMBAs could significantly decrease mortality in moderate-to-severe ARDS patients and decrease the incidence of barotrauma during mechanical ventilation. However, more large-scale randomized trials are needed to further validate the effect of NMBA use in ARDS.
Highlights
We aimed to synthesize up-to-date trials to validate the effects of neuromuscular blocking agent (NMBA) use in patients with moderate-to-severe acute respiratory distress syndrome (ARDS)
Synthesis of results Primary outcomes The data on mortality extracted from the trials were pooled and analyzed, and the results revealed a Secondary outcomes We compared the clinical outcomes between the NMBA and control groups and found that the use of NMBAs significantly increased the PaO2/FiO2 ratio change; reduced FiO2 by approximately 4% (MD − 0.04, 95% confidence interval (CI) − 0.09 to 0.00, P = 0.03); decreased the minute ventilation change (L/min, mean difference (MD) -0.51, 95% CI − 0.76 to − 0.07, P = 0.02); and decreased the positive endexpiratory pressure (PEEP) level change
The use of NMBAs decreased the incidence of barotrauma in mechanical ventilation (RR 0.56, 95% CI 0.36 to 0.87, P = 0.009)
Summary
We aimed to synthesize up-to-date trials to validate the effects of neuromuscular blocking agent (NMBA) use in patients with moderate-to-severe acute respiratory distress syndrome (ARDS). Only a few approaches have been proven to be effective in reducing mortality in ARDS patients, including a lung-protective ventilation strategy [4,5,6] and prone positioning [7, 8]. Neuromuscular blocking agents (NMBAs) have been the only pharmaceutical approach that is supposed to benefit patients with ARDS. NMBAs prevent the patient-initiated generation of high volumes and active exhalation, facilitate patient-ventilator synchrony, provide protection from VILI, and reduce mortality in patients with ARDS [10,11,12]. In the updated guideline for ARDS management, NMBAs are recommended for a subgroup
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