University of Lynchburg DMSc Doctoral Project Assignment Repository

University of Lynchburg DMSc Doctoral Project Assignment Repository


Pulmonary and Critical Care Medicine


Dipu Patel


Purpose: This systematic review integrates recent meta-analyses pertaining to the use of neuromuscular blocking agents (NMBAs) in the treatment of moderate to severe Acute Respiratory Distress Syndrome (ARDS) in the wake of the landmark Reevaluation of Systemic Early Neuromuscular Blockade (ROSE) trial.

Method: A structured literature review of meta-analyses was undertaken on PubMed and rendered ten publications for inclusion. Analyses were required to include the ROSE trial in their statistical modeling, be published in English, and exclude patients with ARDS from SARS-CoV-2 infection.

Results: There is compelling evidence that 48 hours of continuous NMBA use reduced 21 to 28-day mortality, intensive care unit (ICU) mortality, and barotrauma incidence among patients with moderate to severe ARDS requiring deep sedation regimens. These estimates were not statistically meaningful when narrowed to trials that included patients on lighter sedation protocol in their control arms (eg, ROSE trial). There were no significant reported differences in pooled outcomes related to 60 to 90-day mortality, hospital length of stay, ICU length of stay, ventilator-free days, or ICU-acquired weakness. There is notable heterogeneity among published study designs.

Conclusion: Present evidence does not support the routine use of NMBA in all patients with moderate to severe ARDS. Rather, the data favor their application in patients who require deep, continuous sedation protocols to reduce short-term mortality and ventilator-induced lung injury. Further research is needed to more clearly isolate the effects of these drugs and directly compare numerous paralytic and sedation dosing strategies.


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