When is the use of paralytics indicated for the treatment of acute respiratory distress syndrome (ARDS)?

Updated: Mar 27, 2020
  • Author: Eloise M Harman, MD; Chief Editor: Michael R Pinsky, MD, CM, Dr(HC), FCCP, FAPS, MCCM  more...
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Answer

The use of paralytics remains controversial. Patients with severe ARDS may also benefit from the early use of neuromuscular blocking agents. In a group of patient with severe ARDS (PaO2/FiO2< 120) diagnosed within 48 hours, paralysis with cisatracurium for the next 48 hours was shown to improve 90-day mortality, when compared with placebo (31.6% for cisatracurium vs 40.7% for placebo); increase ventilator-free days; and reduced barotrauma. There was no increased incidence of prolonged muscle weakness in the group that was paralyzed. [39] However, a more recent study in 2019 of patients with a PaO2/FiO2 ratio of less than 150 mm Hg for less than 48 hours did not demonstrate any improvement in mortality, ventilator-free days, or rates of barotrauma. [40] Neuromuscular blocking agents should be used selectively. These agents may be beneficial in patients with very severe ARDS, those who have problems synchronizing breathing with the ventilator, and patients with poor lung compliance.

Managing physicians should not use paralytics in all cases; rather, they should use them only in those where length of ventilation is expected to exceed a few hours. Patients should not remain ventilated for longer than it takes for the paralytics to have their effect. The duration of paralysis will depend upon the condition. [39]


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