Lung protective therapy using long-term neuromuscular blockade guided by the airway occlusion pressure in severe ARDS due to COVID-19 pneumonia: A case report

Abstract

There is no effective drug therapy for the treatment of acute respiratory distress syndrome (ARDS) due to novel coronavirus disease 2019 (COVID-19) pneumonia. Lung protective strategies for severe ARDS to prevent ventilatorassociated and/or patient self-inflicted lung injuries are the main treatment measures. However, it is still unclear how to use neuromuscular blocking agent (NMBA) for lung protection on ARDS due to COVID-19. A 60s-year-old male diagnosed as ARDS due to COVID-19 was referred to our hospital. On the second day following hospitalization, the extracorporeal membrane oxygenation (ECMO) and prone positioning were implemented for the lung protection. Even under deep sedation, strong spontaneous inspiratory effort was observed, and we decided to use continuous infusion of NMBA to reduce the risk of the patient self-inflicted lung injury. We daily evaluated the necessity for the use of NMBA using physical examination and airway occlusion pressure measurement as the indicators of inspiratory effort. As lung function gradually recovered, the inspiratory effort also decreased. Eventually 19 days of prone positioning and 26 days of continuous infusion of NMBA for preventing the lung injuries were required. The patient was weaned from the ECMO on the 47th day. After further stay at our ICU and general ward, he was discharged home with an oxygen therapy. Preparing for upcoming similar cases, we report the case with a literature review to share our experience and the feasibility of the airway occlusion pressure on the necessity for NMBA.