Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome (ARDS)

  • ARDS is associated with a high mortality (26% - 58%) and is characterized by inflammation, ventilator dyssynchrony, microatelectasis, hypoxia and barotrauma.
  • A recent study (see below) found that physicians are using less-studied strategies more frequently while under-utilizing more well-studied strategies, suggesting that we can do better for our patients!
  • Neuromuscular blocking (NMB) agents have been shown to improve morbidity and mortality because these drugs aid in the work of breathing, ventilator synchrony and barotrauma. NMBs are not without risks, however, such as worsening atelectasis and ICU-associated weakness.
  • A systematic review in 2013 found that short (48-hour) infusions of cisatracurium was associated with lower mortality and reduced barotrauma (NNT=9) and had an insignificant effect on duration of mechanical ventilation or ICU-associated weakness.
  • One of the included studies (Papazian et al.) reported a significant difference of ventilator-free days in the cisatracurium group compared to the control group.

Take Home Point: NMBs seem to improve mortality and reduces barotrauma without causing worsening ICU-associated weakness and their implementation should be considered sooner and more frequently in ARDS patients.



  1. Alhazzani W, Alshahrani M, Jaeschke R, et al. Neuromuscular blocking agents in acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2013;17(2):R43.
  2. Duan EH, Adhikari NKJ, D'aragon F, et al. Management of Acute Respiratory Distress Syndrome and Refractory Hypoxemia. A Multicenter Observational Study. Ann Am Thorac Soc. 2017;14(12):1818-1826.
  3. Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363(12):1107-16.