Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is characterised by rapid-onset respiratory failure, diffuse alveolar damage and profound hypoxaemia. Mechanical ventilation with a lung-protective strategy—low tidal volumes and appropriately titrated positive end-expiratory pressure—remains the cornerstone of supportive care. Neuromuscular blocking agents (NMBAs) have been adopted as adjuncts to improve patient–ventilator synchrony, attenuate vigorous spontaneous respiratory efforts and minimise ventilator-induced lung injury. By abolishing diaphragmatic movement and accessory-muscle activity, NMBAs reduce high transpulmonary pressures and inflammatory mediator release, thereby lowering the risk of barotrauma and biotrauma. Short-term infusions of benzylisoquinolinium compounds, such as cisatracurium, are generally preferred for their organ-independent elimination and predictable duration of action. Although early studies demonstrated reductions in hospital mortality and barotrauma without a significant increase in intensive care unit-acquired weakness, more recent evidence has questioned whether continuous NMBA infusions confer a survival advantage when lighter sedation protocols are implemented. Ongoing debate centres on optimal timing, dosing and sedation depth, balanced against potential adverse effects—particularly neuromuscular weakness—and resource implications for monitoring and rehabilitation.

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Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome publication trend

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Technical terms

Acute respiratory distress syndrome (ARDS): A syndrome of acute-onset hypoxaemia, bilateral pulmonary infiltrates and non-cardiogenic respiratory failure.

Neuromuscular blocking agents (NMBAs): Drugs that induce skeletal muscle paralysis by blocking transmission at the neuromuscular junction.

Lung-protective ventilation: A ventilation strategy using low tidal volumes and optimised positive end-expiratory pressure to minimise ventilator-induced lung injury.

Barotrauma: Lung tissue injury resulting from excessive transalveolar pressure during mechanical ventilation.

Sedation depth: The level of central nervous system depression, ranging from light (responsive to verbal stimuli) to deep (minimal or no response to physical stimuli), which influences outcomes in ventilated patients.

References

1. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Critical Care (2013).
2. Neuromuscular blockade in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Journal of Intensive Care (2020).
3. Neuromuscular blocking agents in acute respiratory distress syndrome: updated systematic review and meta-analysis of randomized trials. Intensive Care Medicine Experimental (2020).
4. Neuromuscular Blockade in the Pre- and COVID-19 ARDS Patients. Journal of Personalized Medicine (2022).