Efficacy and safety of several common drugs in the treatment of acute respiratory distress syndrome: A systematic review and network meta-analysis.

Summary

Across 27 RCTs (n=3492), neuromuscular blockers reduced 28-day mortality in ARDS (OR 0.52), whereas inhaled vasodilators and mesenchymal stem cells did not improve mortality, ventilator-free days, or oxygenation. Benefits did not extend to 90-day outcomes.

Key Findings

• Neuromuscular blockers reduced 28-day mortality versus standard care (OR 0.52, 95% CI 0.31–0.88).
• Inhaled vasodilators and mesenchymal stem cells did not reduce hospital mortality (OR 0.89 and 0.90, respectively).
• No significant differences were found for 90-day mortality, ventilator-free days, or oxygenation across interventions versus standard care.

Clinical Implications

Consider early, protocolized neuromuscular blockade in selected moderate-to-severe ARDS while recognizing that inhaled vasodilators and mesenchymal stem cells lack demonstrated mortality benefit. Emphasize non-pharmacologic standards (lung-protective ventilation, prone positioning) alongside judicious NMB use.

Limitations

• Heterogeneity across trials and two-arm designs may limit transitivity and precision.
• Benefits did not extend to 90-day outcomes or secondary endpoints.

Future Directions

Define optimal timing/duration of neuromuscular blockade, identify phenotypes most likely to benefit, and evaluate combinations with lung-protective strategies in pragmatic RCTs.