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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.
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.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Moderate to severe ARDS adult patients under mechanical ventilation and neuromuscular blockade | no intervention |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Modulation of the depth of the neuromuscular blockade | Other | Analysis of the respiratory mechanics at two times:
|
| Measure | Description | Time Frame |
|---|---|---|
| Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 | Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 according to the level of neuromuscular blockade (%) | one day |
| Measure | Description | Time Frame |
|---|---|---|
| Inspiratory transpulmonary pressure | Inspiratory transpulmonary pressure according to the level of neuromuscular blockade (cmH20) | one day |
| Respiratory system compliance | Respiratory system compliance according to the level of neuromuscular blockade (ml/cmH20) |
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Inclusion Criteria:
Exclusion Criteria:
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The population includes mainly pulmonary ARDS with a predominance of SARS-CoV2 pneumonia
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| Name | Affiliation | Role |
|---|---|---|
| Nicolas BARBAROT, MD | Centre Hospitalier Saint Brieuc | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Centre Hospitalier de Saint Brieuc | Saint-Brieuc | Brittany Region | 22000 | France |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 24467647 | Background | 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. | |
| 33104824 |
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| one day |
| Chest wall elastance | Chest wall elastance according to the level of neuromuscular blockade (cmH2O/l) | one day |
| Pulmonary elastance | Pulmonary elastance according to the level of neuromuscular blockade (cmH2O/l) | one day |
| Driving pressure | Driving pressure according to the level of neuromuscular blockade (cmH20) | one day |
| Transpulmonary driving pressure | Transpulmonary driving pressure according to the level of neuromuscular blockade (cmH20) | one day |
| Plateau pressure | Plateau pressure according to the level of neuromuscular blockade (cmH20) | one day |
| Oesophageal balloon calibration | Proportion of patients with expiratory transpulmonary pressure greater than or equal to 0 according to the oesophageal balloon calibration volume (%) | one day |
| Background |
| 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. |
| 28013329 | Background | 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. |
| 30350170 | Background | 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. |
| ID | Term |
|---|---|
| D012128 | Respiratory Distress Syndrome |
| D055397 | Ventilator-Induced Lung Injury |
| ID | Term |
|---|---|
| D008171 | Lung Diseases |
| D012140 | Respiratory Tract Diseases |
| D012120 | Respiration Disorders |
| D055370 | Lung Injury |
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