How I Use Neuromuscular Blocking Agents in ARDS Patients
What are the modes of action supposed of the curares during the ARDS?
Acute respiratory distress syndrome (ARDS) is a common cause of intensive care unit (ICU) admission and involves almost a quarter of patients requiring mechanical ventilation (MV). Despite a constant improvement in its symptomatic management, ARDS remains associated with a high mortality, especially in its severe and moderate forms. Non-ventilatory therapies combined with a protective MV are often necessary in the most hypoxemic patients. Of these, neuromuscular blocking agents (NMBAs) are the most frequently used. In addition to an early and persistent improvement in oxygenation, they probably allow a reduction in ventilator induced lung injury and have shown, in a randomized controlled trial, a reduction of mortality in the most severe patients. The transient use of cisatracurium at the initial phase of lung aggression is now recognized as a part of ARDS treatment. However, their indications should be limited to patients with moderate to severe ARDS (PaO2/ FiO2 < 150 mmHG or even 120 mmHg), for a short period, guided by the patient’s improvement. Indeed, the abolition of spontaneous ventilation is reasonable only at the early stage of the disease for the most severe patients, in association with prone positioning, and it must be followed by a strategy integrating spontaneous breathing as soon as possible. The accurate dosing of NMBAs as well as the monitoring of patients still needs to be clarified. The aim of this review is to provide a synthetic and pragmatic overview of these different aspects of the use of NMBAs during ARDS.