Pharmacological Interventions: Neuromuscular Blocking Agents

Samuel Lehingue, Sami Hraiech, and Laurent Papazian


Several pharmacological treatments have been tested and found to improve the prognoses of patients presenting with acute respiratory distress syndrome (ARDS). Among these treatments, only the use of neuromuscular blocking agents (NMBAs) has been proven to be associated with increased survival in a randomized controlled trial (RCT). However, considering the current lack of clear recommendations, the role and appropriate place of NMBAs in ARDS treatment deserve to be clarified. The aims of this chapter are therefore to summarize the evidence supporting their use in this indication, to present elements of the pathophysiology to increase understanding of their beneficial role and to precisely delineate for which patients and in what conditions NMBAs should be administered.

Clinical Practice and Historical Context

Despite their frequent use, the guidelines concerning NMBAs have not been revised since 2002 [1]. NMBAs are frequently used in intensive care units (ICUs) [2] , specifically during episodes of ARDS. From 25% to 85% of patients with ARDS enrolled in contemporary multicentre randomized controlled trials (RCTs) received NMBAs [3-6]. In a recent large survey [7], 37.8% of patients with severe ARDS were treated with continuous neuromuscular blockade.

S. Lehingue, MD • S. Hraiech, MD, PhD (*) • L. Papazian, MD, PhD

Assistance Publique - Hopitaux de Marseille, Hopital Nord, Reanimation - Detresses

Respiratoires et des Infections Severes, Chemin des Bourrely, 13015 Marseille, France

Aix-Marseille Universite, Faculte de Medecine de Marseille,

22 boulevard Jean Moulin, 13305 Marseille, France

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© Springer International Publishing Switzerland 2017 D. Chiumello (ed.), Acute Respiratory Distress Syndrome (ARDS), DOI 10.1007/978-3-319-41852-0_12

Indeed, protective ventilation objectives, i.e. the prevention and the treatment of patient/ventilator asynchronies and the use of prone positioning, often require neuromuscular blockade [6, 8, 9].

The accurate place of NMBAs in ARDS treatment has been clarified in the last decade. The first publications concerning NMBAs were case reports and small non- randomized studies that reported controversial results concerning improvements in oxygenation [10-12]. The absence of strong scientific evidence demonstrating a benefit to the prognosis and potential adverse events, especially ICU-acquired weakness, were often responsible for a distrust of paralytics. Lagneau opened the path towards the era of RCTs and demonstrated that the continuous infusion of NMBAs for 2 h improves the PaO2/FiO2 ratio in a study that included 102 patients who presented with moderate to severe ARDS [13].

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