Neuromuscular blocking agents for acute respiratory distress syndrome: Current controversies

The purpose of this paper is to discuss the controversies and challenges in clinical decision-making related to the use of neuromuscular blocking agents (NMBAs) in adult patients with acute respiratory distress syndrome (ARDS) and identify directions for future research.

ARDS is a common occurrence in critically ill patients and is associated with high morbidity and mortality. Four clinical practice guidelines published since 2020 provide recommendations for NMBA administration in patients with ARDS. Recommendations regarding NMBA selection and dosing are largely derived from 2 multicenter trials with discordant results, one conducted in France and the other in the US. Both trials utilized a fixed-rate, high-dose cisatracurium infusion for 48 hours, with mortality benefit observed in only the French trial. Despite the regimen being consistent between these clinical trials, the utilization of NMBAs in practice has significant heterogeneity and variability. This paper will address 5 controversies surrounding NMBA use in ARDS: the mechanistic benefit of NMBAs, which patients derive benefit from NMBAs, how NMBAs should be dosed and administered, NMBA agent selection, and use of sedation.

Current clinical guidelines suggest use of NMBAs in patients with ARDS who are persistently hypoxemic despite sedation. However, they lack specific recommendations on NMBA and sedation dosing and titration approaches. Future studies should investigate NMBA agent selection, dosing regimens, duration, and monitoring approaches.