ARDS on ventilator: no mortality effects of neuromuscular blockade

  • Moss M & al.
  • N Engl J Med
  • 19 May 2019

  • International Clinical Digest
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  • Among patients with acute respiratory distress syndrome (ARDS) undergoing mechanical ventilation (MV) with high positive end-expiratory pressure (PEEP), neuromuscular blockade (NMB) did not lower mortality vs usual care with lighter sedation.
  • Editorial :
    • Suggests difference in sedation vs ACURASYS could explain discordant results.
    • Recommends against routine NMB in moderate-to-severe ARDS, unless breath stacking or increased respiratory drive.
    • Postulates dyssynchrony may affect outcomes.

Why this matters

  • In ACURASYS (2010), NMB reduced ARDS mortality vs deep sedation alone, yet intervention seldom used: 
    • Modern practice favors lighter sedation.
    • Little is known about NMB's downstream outcomes.

Study design

  • Randomized multicenter controlled open-label ROSE trial (n=1006).
  • Researchers randomly assigned participants with moderate-to-severe ARDS undergoing MV to either:
    • 48-hour continuous cisatracurium (Nimbex; AbbVie, Inc.) plus deep sedation, or
    • Usual care without routine NMB; with lighter sedation (controls). 
  • Both groups underwent high-PEEP mechanical ventilation, conservative fluid strategy.
  • Outcome: 90-day in-hospital mortality.
  • Funding: NIH.

Key results

  • High protocol adherence.
  • Trial halted for futility.
  • Cisatracurium vs control:
    • Primary outcome: 42.5% vs 42.8%; between-group difference, −0.3% (95% CI, −6.4 to 5.9; P=.93).
    • Serious cardiovascular events: 14 vs 4 (P=.02).
    • No differences in 28-day hospital mortality; ventilation-, ICU-, or hospital-free days; pneumothorax; barotrauma.
  • 1 death possibly related to cisatracurium.


  • Open-label.

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