Impact of the Depth of Neuromuscular Blockade on Respiratory Mechanics in Moderate to Severe ARDS Patients
Study Details
Study Description
Brief Summary
Neuromuscular blockade (NMB) is proposed in patients with moderate to severe acute respiratory distress syndrome (ARDS). The supposed benefit of these muscle relaxants could be partly linked to their effects on respiratory mechanics by reducing ventilator induced lung injuries (VILI), especially the so called atelectrauma. Although its monitoring is recommended in clinical practice, data about the depth of NMB necessary for an effective relaxation of the thoracic and diaphragmatic muscles and, therefore, the reduction of the chest wall elastance, are scarce. The investigators hypothesised that complete versus partial NMB can modify respiratory mechanics and its partitioning.
| Condition or Disease | Intervention/Treatment | Phase |
|---|---|---|
|
Detailed Description
The investigators conducted a prospective study to compare the respiratory mechanics of patients with moderate to severe ARDS according to the NMB depth, using an oesophageal pressure catheter (NutriVent®, Sidam) for transpulmonary pressure (PL) assessment, and facial train of four (TOF) for neuromuscular blockade monitoring. The oesophageal balloon was calibrated according to the method recently described to estimate the individual target volume which is assumed to be more adequate. Each patient was analysed at two different times: deep NMB (TOF = 0) and intermediate to light NMB (TOF > 0). The mechanical ventilation parameters were identical for these two measurements. The primary endpoint was the proportion of patients with expiratory transpulmonary pressure (PLexp) greater than or equal to 0 according to the NMB level, in order to assess the risk of region-dependent atelectasis and alveolar opening/closing injury (atelectrauma). Secondary endpoints included: the impact of the depth of NMB on other partition parameters of respiratory mechanics, and the variability of results according to the type of oesophageal balloon calibration.
Study Design
Arms and Interventions
| Arm | Intervention/Treatment |
|---|---|
| Moderate to severe ARDS adult patients under mechanical ventilation and neuromuscular blockade no intervention |
Other: Modulation of the depth of the neuromuscular blockade
Analysis of the respiratory mechanics at two times:
Facial train of four = 0, indicating a deep neuromuscular blockade
Facial train of four > 0, indicating a intermediate to light neuromuscular blockade
|
Outcome Measures
Primary Outcome Measures
- Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 [one day]
Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 according to the level of neuromuscular blockade (%)
Secondary Outcome Measures
- Inspiratory transpulmonary pressure [one day]
Inspiratory transpulmonary pressure according to the level of neuromuscular blockade (cmH20)
- Respiratory system compliance [one day]
Respiratory system compliance according to the level of neuromuscular blockade (ml/cmH20)
- Chest wall elastance [one day]
Chest wall elastance according to the level of neuromuscular blockade (cmH2O/l)
- Pulmonary elastance [one day]
Pulmonary elastance according to the level of neuromuscular blockade (cmH2O/l)
- Driving pressure [one day]
Driving pressure according to the level of neuromuscular blockade (cmH20)
- Transpulmonary driving pressure [one day]
Transpulmonary driving pressure according to the level of neuromuscular blockade (cmH20)
- Plateau pressure [one day]
Plateau pressure according to the level of neuromuscular blockade (cmH20)
- Oesophageal balloon calibration [one day]
Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 according to the oesophageal balloon calibration volume (%)
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Moderate to severe ARDS patients with PaO2/FiO2 ratio < 150 mmHg
-
Mechanical ventilation, deep sedation and neuromuscular blockade with continuous infusion of cisatracurium for more than 24 hours
-
Presence of an oesophageal catheter
-
Written informed consent
Exclusion Criteria:
- contraindication of oesophageal catheter
Contacts and Locations
Locations
| Site | City | State | Country | Postal Code | |
|---|---|---|---|---|---|
| 1 | Centre Hospitalier de Saint Brieuc | Saint-Brieuc | Brittany | France | 22000 |
Sponsors and Collaborators
- Centre Hospitalier de Saint-Brieuc
Investigators
- Principal Investigator: Nicolas BARBAROT, MD, Centre Hospitalier Saint Brieuc
Study Documents (Full-Text)
None provided.More Information
Publications
- Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guerin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L; PLUG Working Group (Acute Respiratory Failure Section of the European Society of Intensive Care Medicine). The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014 Mar 1;189(5):520-31. doi: 10.1164/rccm.201312-2193CI.
- Alhazzani W, Belley-Cote E, Moller MH, Angus DC, Papazian L, Arabi YM, Citerio G, Connolly B, Denehy L, Fox-Robichaud A, Hough CL, Laake JH, Machado FR, Ostermann M, Piraino T, Sharif S, Szczeklik W, Young PJ, Gouskos A, Kiedrowski K, Burns KEA. Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Med. 2020 Nov;46(11):1977-1986. doi: 10.1007/s00134-020-06227-8. Epub 2020 Oct 26.
- Baedorf Kassis E, Train S, MacNeil B, Loring SH, Talmor D. Monitoring of neuromuscular blockade: a comparison of train-of-four and the Campbell diagram. Intensive Care Med. 2018 Dec;44(12):2305-2306. doi: 10.1007/s00134-018-5420-5. Epub 2018 Oct 22. No abstract available.
- Guervilly C, Bisbal M, Forel JM, Mechati M, Lehingue S, Bourenne J, Perrin G, Rambaud R, Adda M, Hraiech S, Marchi E, Roch A, Gainnier M, Papazian L. Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome. Intensive Care Med. 2017 Mar;43(3):408-418. doi: 10.1007/s00134-016-4653-4. Epub 2016 Dec 24.
- 2023-A00165-40