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Critical Care
Published in: Critical Care 1/2020

01-12-2020 | Acute Respiratory Distress-Syndrome | Research

Validation of neuromuscular blocking agent use in acute respiratory distress syndrome: a meta-analysis of randomized trials

Authors: Wei Chang, Qin Sun, Fei Peng, Jianfeng Xie, Haibo Qiu, Yi Yang

Published in: Critical Care | Issue 1/2020

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Abstract

Background

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).

Methods

Several 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.

Results

A 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.

Conclusion

The 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.
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Literature
1.
Sweeney RM, McAuley DF. Acute respiratory distress syndrome. Lancet. 2016;388(10058):2416–30.CrossRef
2.
Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377(6):562–72.CrossRef
3.
Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800.CrossRef
4.
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351(4):327–36.CrossRef
5.
Acute Respiratory Distress Syndrome N, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–8.CrossRef
6.
Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747–55.CrossRef
7.
Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–68.CrossRef
8.
Hu SL, He HL, Pan C, et al. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. Crit Care. 2014;18(3):R109.CrossRef
9.
Blanch L, Villagra A, Sales B, et al. Asynchronies during mechanical ventilation are associated with mortality. Intensive Care Med. 2015;41(4):633–41.CrossRef
10.
Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107–16.CrossRef
11.
Slutsky AS. Neuromuscular blocking agents in ARDS. N Engl J Med. 2010;363(12):1176–80.CrossRef
12.
Beitler JR, Sands SA, Loring SH, et al. Quantifying unintended exposure to high tidal volumes from breath stacking dyssynchrony in ARDS: the BREATHE criteria. Intensive Care Med. 2016;42(9):1427–36.CrossRef
13.
Fanelli V, Morita Y, Cappello P, et al. Neuromuscular blocking agent cisatracurium attenuates lung injury by inhibition of nicotinic acetylcholine receptor-alpha1. Anesthesiology. 2016;124(1):132–40.CrossRef
14.
Chiumello D, Brochard L, Marini JJ, et al. Respiratory support in patients with acute respiratory distress syndrome: an expert opinion. Crit Care. 2017;21(1):240.CrossRef
15.
Kress JP, Pohlman AS, O'Connor MF, et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471–7.CrossRef
16.
Shehabi Y, Bellomo R, Reade MC, et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med. 2012;186(8):724–31.CrossRef
17.
Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19:274.CrossRef
18.
Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9):e825–e73.CrossRef
19.
Alhazzani W, Alshahrani M, Jaeschke R, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2013;17(2):R43.CrossRef
20.
Tao W, Yang LQ, Gao J, et al. Neuromuscular blocking agents for adult patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2018;85(6):1102–9.CrossRef
21.
Moss M, Huang DT, Brower RG, et al. Early neuromuscular blockade in the acute respiratory distress syndrome. N Engl J Med. 2019;380(21):1997–2008.CrossRef
22.
Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.CrossRef
23.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.CrossRef
24.
Force ADT, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526–33.
25.
Bernard GR, Artigas A, Brigham KL, et al. The American-European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149(3 Pt 1):818–24.CrossRef
26.
Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.CrossRef
27.
Pogue JM, Yusuf S. Cumulating evidence from randomized trials: utilizing sequential monitoring boundaries for cumulative meta-analysis. Control Clin Trials. 1997;18(6):580–93 discussion 661-6.CrossRef
28.
Gainnier M, Roch A, Forel JM, et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2004;32(1):113–9.CrossRef
29.
Forel JM, Roch A, Marin V, et al. Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2006;34(11):2749–57.CrossRef
30.
Lyu G, Wang X, Jiang W, et al. Clinical study of early use of neuromuscular blocking agents in patients with severe sepsis and acute respiratory distress syndrome. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2014;26(5):325–9.PubMed
31.
Guervilly C, Bisbal M, Forel JM, et al. Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome. Intensive Care Med. 2017;43(3):408–18.CrossRef
32.
Rao Z, Li J, Yan M, et al. To retain spontaneous breathing or eliminate spontaneous breathing with neuromuscular blockers in acute respiratory distress syndrome patients? Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2016;28(11):973–7.
33.
Akoumianaki E, Lyazidi A, Rey N, et al. Mechanical ventilation-induced reverse-triggered breaths: a frequently unrecognized form of neuromechanical coupling. Chest. 2013;143(4):927–38.CrossRef
34.
Bourenne J, Guervilly C, Mechati M, et al. Variability of reverse triggering in deeply sedated ARDS patients. Intensive Care Med. 2019;45(5):725–6.CrossRef
35.
Torbic H, Krishnan S, Duggal A. Neuromuscular blocking agents for acute respiratory distress syndrome: how did we get conflicting results? Crit Care. 2019;23(1):305.CrossRef
36.
Slutsky AS, Villar J. Early paralytic agents for ARDS? Yes, no, and sometimes. N Engl J Med. 2019;380(21):2061–3.CrossRef
Metadata
Title
Validation of neuromuscular blocking agent use in acute respiratory distress syndrome: a meta-analysis of randomized trials
Authors
Wei Chang
Qin Sun
Fei Peng
Jianfeng Xie
Haibo Qiu
Yi Yang
Publication date
01-12-2020
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2020
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-020-2765-2

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