Authors:
However, this strategy might be considered for selected patients with acute respiratory distress syndrome and ventilator dyssynchrony. Ten years ago, a large randomized trial demonstrated lower mortality when patients with severe acute respiratory distress syndrome (ARDS) were treated with neuromuscular blockade (NMB; NEJM JW Hosp Med Oct 2010 and N Engl J Med 2010; 363:1107). Concerns about the deep sedation required for NMB, as well as the neuromuscular weakness associated with its use, led investigators to reexamine this benefit. More than 1000 patients with moderate-to-severe ARDS (partial pressure of oxygen: fraction of inspired oxygen [PaO2:FIO2], <150) were randomized to 48 hours of either cisatracurium with deep sedation or light sedation without NMB. More than half of patients had pneumonia; prone positioning was used rarely. The trial included a high positive end-expiratory pressure (PEEP) strategy. The trial was stopped early for futility. Mortality was quite high (43%) but was not different between groups. Lengths of stay (hospital and intensive care unit) and days free from mechanical ventilation were similar between groups; neuromuscular weakness and patient-reported quality of life at 3, 6, and 12 months also did not differ between groups. |
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The high mortality seen in this study is perplexing. Some people have proposed that higher PEEP was not helpful (as the authors suggest) but potentially harmful. Despite this, the results mean that patients with moderate-to-severe ARDS should not be treated uniformly with early NMB. However, I agree with the editorialists’ position that NMB still should be considered on an individual basis, particularly for patients with ventilator dyssynchrony. In other patients, early, “moderate-to-severe” ARDS might resolve relatively quickly, mitigating the need for NMB and the downsides of deep sedation.