2- A Literature Review in Relation to the Efficacy of the Neuromuscular Blockade in Moderate to Severe Acute Respiratory Distress Syndrome in Reducing Mortality

A Literature Review in Relation to the Efficacy of the Neuromuscular Blockade in Moderate to Severe Acute Respiratory Distress Syndrome in Reducing Mortality

Contents:
List of Figures and Tables: …………………………………………………………….X
List of Abbreviations: …………………………………………………………………X
Glossary: ………………………………………………………………………………X
Introduction: X
Aims: X
Search Strategy: X
Literature Review: X
Discussion…………………………………………………………………………….X
Conclusion…………………………………………………………………………….X
References: X
Appendices: …………………………………………………………………………..X

Introduction
This literature review analyses the complexity of acute respiratory distress syndrome (ARDS), which has been studied extensively for half a century. However, to date, regardless of improved comprehension, ARDS remains associated with 10% of all intensive care unit (ICU) admissions and high 35-46% mortality (Bellani et al. 2016). NHS UK (2020) states that 1 in 3 ARDS patients die. ARDS represents inflammatory processes that lead to lung injury, reducing lung compliance that leads to severe hypoxemia (Nanchal and Truwit 2018). In 2011, the updated and revised Berlin Definition for ARDS proposed three categories of ARDS, based on the level of hypoxemia: mild (PaO2/FIO2 ≤ 300 mmHg), moderate (PaO2/FIO2 ≤ 200 mmHg), and severe (PaO2/FIO2 ≤ 100 mmHg), in conjunction with the accompanying factors for severe ARDS (Figure 1) (Ranieri et al. 2012). Once patients develop ARDS, the main interventions aim to reduce Ventilator-Induced Lung injury (VILI) (Thompson et al. 2017). Improved interventions used for ARDS patients include low tidal volumes, higher positive end-expiratory pressure (PEEP), prone position during ventilation, fluid management, sedation, neuromuscular blockade, and extracorporeal membrane oxygenation (ECMO) (He et al. 2022). Furthermore, neuromuscular blocking agents (NMBAs) are a known prescription for ARDS; as believed, they minimise inflammation, rate of oxygen use, and blood pumped per minute, and most importantly, assist with ventilator synchrony (Torbic and Duggal, 2019).

In 2010, the ACURASYS trial was conducted by 20 ICUs reporting improved adjusted survival using early neuromuscular blockade (NMB) for moderate to severe ARDS (Papazian et al 2010). However, there was a notable reluctance to NMB usage due to the side effects. Furthermore, many argued that the mortality difference was not significant, and the study was underpowered, involving only 340 participants. Subsequently, in 2019, the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) supported by the British Thoracic Society (BTS) formed guidelines for the management of adult patients with ARDS recommending using NMB. On the other hand, due to a lack of studies comparing NMB with deep sedation with light sedation only, the ROSE trial had been conducted and published in 2019, reporting that neuromuscular blockade was not beneficial in patients with ARDS (PETAL 2019). However, it had a higher positive end-expiratory pressure (PEEP), proved to be beneficial for ARDS patients (Sahetya et al. 2017) which could have affected the results.
Aim:
This literature review deals with the effectiveness of NMB with heavy sedation compared to usual care with light sedation in patients with moderate to severe ARDS. The primary outcome will be to investigate the effect of NMB on 28-day mortality. The secondary outcomes are to investigate its impact on the 90-day mortality rate, VILI prevention/reduction and increase in ventilator-free days. The author recognises the importance of improving the management of ARDS patients in view of reducing mortality and will examine and evaluate existing literature to support or challenge current practice.

To do:

1. Literature review: Of 5 papers /approx. 1400 words

When you are actually writing the review you need to:
• Review up to date evidence which should be research / audit / evidence based guidelines
• You should always introduce the evidence by providing author, date, type of study, and aim of study.
• Discuss the strengths and weaknesses, advantages and disadvantages of the study methodology, considering their relevance to EBP and to the aims of your assignment.
• Analyse and synthesize the sample: inclusion / exclusion criteria; generalisability to clinical practice and comparability to other studies; sample size; power calculations etc.
• Avoid description, you don’t gain marks for this – You can use tables to provide descriptive text about the research however, these are not compulsory. In the main text you MUST analyse, synthesize and evaluate the evidence.
• Provide your analysis (not the researchers), again you gain marks for your comments and reflections, not theirs.
• Use the key research terms in your analysis- these are rigour, bias, (internal or external) validity and reliability etc.,
• Always include specific results for quantitative and /or qualitative evidence, to inform argument. Consider and show understanding of statistical tools used and the results they produce.
• Create an argument and reflect on practice and to specific examples from clinical practice
• You need to challenge the evidence, don’t accept it at face value. Just because it is a published RCT, does not mean it is rigorous.
• Also make sure that you evaluate evidence in terms of what it is. e.g. if it’s a survey, challenge its survey methods, don’t expect all evidence to be ‘gold standard’. Use an appropriate critiquing tool to help you to do this.
• Also, keep asking yourself ‘so what’? ‘What does this suggest?
• Summarise the study, its relevance to the aim of your assignment and to clinical practice (in your final assignment you should also consider it to the other papers you have included). Assign and discuss the hierarchy of evidence.

2. Discussion: approx. 500 words
3. Conclusion: approx. 300 words

References :