Neuromuscular Blocking Agents for ARDS: A Systematic Review and Meta-Analysis

Background: Studies evaluating neuromuscular blocking agents (NMBAs) in the management of ARDS have produced inconsistent results in terms of their effect on mortality. The purpose of this systematic review and meta-analysis was to evaluate differences in mortality comparing subjects with ARDS who received NMBA to those who received placebo or usual care.

Methods: We searched Ovid, MEDLINE, Embase, CINAHL, Cochrane, Scopus, and Web of Science for randomized controlled trials evaluating administration of NMBAs in subjects with ARDS.

Results: We included 6 studies (N = 1,558 subjects) from 1,814 abstracts identified by our search strategy. The use of early, continuous-infusion NMBAs reduces the risk of short-term (ie, 21-28-d) mortality (relative risk 0.71 [95% CI 0.52-0.98], P = .030, I ² = 60%) in subjects with ARDS but does not reduce the risk of long-term (ie, 90-d) mortality (relative risk 0.81 [95% CI 0.64-1.04], P = .10, I ² = 54%). NMBAs decreased the risk of barotrauma (relative risk 0.55 [95% CI 0.35-0.85], P = .008, I ² = 0%) and pneumothorax (relative risk 0.46 [95% CI 0.28-0.77], P = .003, I ² = 0%) compared to control.

Conclusions: In subjects with ARDS, early use of NMBAs improves oxygenation, reduces the incidence of ventilator-induced lung injury, and decreases 21-28-d mortality, but it does not improve 90-d mortality. NMBAs should be considered for select patients with moderate-to-severe ARDS for short durations.