Balancing neuromuscular blockade versus preserved muscle activity.

PURPOSE OF REVIEW: Acute respiratory distress syndrome (ARDS) is still associated with a high mortality. The best way to ensure mechanical ventilation in ARDS patients is still debated, recent data arguing for a muscle paralysis and a controlled ventilation whereas other elements being in favor of a preserved spontaneous breathing. The purpose of this review is to discuss the benefits and the disadvantages of both strategies.

RECENT FINDINGS: Randomized controlled trials have brought the evidence that at the acute phase of ARDS, a 48-h administration of cisatracurium is associated with a decrease in mortality for the most severe hypoxemic patients. Other studies suggest that spontaneous breathing could be deleterious at this period. In the less severe patients (mild ARDS), however, a few studies have demonstrated the benefits of preserving spontaneous breathing with an improvement in oxygenation and a decrease in the length of mechanical ventilation.

SUMMARY: In ARDS patients, the ventilator strategy should be a balance between muscle paralysis in the most hypoxemic patients and preserved spontaneous breathing after improvement or from the acute phase in less severe forms. However, monitoring plateau pressure, tidal volume and perhaps also transpulmonary pressure seems crucial to limit the occurrence of ventilator-induced lung injury.