Neuromuscular blocking agents, corticosteroids and nitric oxide, among other agents, are discussed in this review.
The use of neuromuscular blocking agents was systematically studied and found to be beneficial early in the course of ARDS, for 48 hours, in this trial. The study population consisted of patients with a pO2 to FiO2 ratio of below 150. Ventilator mechanics and oxygenation were improved. Mortality benefit was confined to patients with a ratio of below 120. Prolonged post treatment paresis was not observed more frequently in the treatment group. This result was supported in a meta-analysis. UpToDate considers neuromuscular blockade potentially beneficial in severe disease, probably safe when used within limitations as illustrated by recent clinical trials but not recommended for routine use and in need of further study.
Inhaled nitric oxide may buy some time as a rescue modality but has not been shown to improve clinical outcomes.
Corticosteroids have been considered in a variety of situations in both early and later stages of ARDS, and remain controversial. At present the only clearly established role is in specific steroid responsive conditions (e.g. acute eosinophilic pneumonia) causing ARDS.