Comparative outcomes of corticosteroids, neuromuscular blocking agents, and inhaled nitric oxide in ARDS: a systematic review and network meta-analysis.

Summary

Across 26 trials (5,071 patients), vecuronium ranked best for reducing 28-day mortality, dexamethasone maximized 28-day ventilator-free days and had a favorable infection profile, and inhaled nitric oxide showed no significant benefit. Findings support corticosteroids and selective NMBAs as beneficial adjuncts in ARDS.

Key Findings

• Vecuronium bromide ranked highest for reducing 28-day mortality (SUCRA 96.6%; OR vs comparators 0.23–0.38).
• Dexamethasone increased ventilator-free days at 28 days versus conventional therapy and cisatracurium (MD ~3.4–3.6 days; SUCRA 93.2%).
• Methylprednisolone ranked highest for preventing ICU mortality (SUCRA 88.5%).
• Inhaled nitric oxide did not demonstrate significant beneficial effects and dexamethasone had a favorable infection-risk profile.

Clinical Implications

Consider early dexamethasone to improve ventilator-free days and selective NMBA (e.g., vecuronium) in appropriate ARDS phenotypes; avoid routine iNO given lack of mortality benefit.

Limitations

• Heterogeneity in trial designs, dosing regimens, and ARDS populations may affect transitivity assumptions.
• Some comparisons had wide confidence intervals; lack of patient-level data limits subgroup analyses.

Future Directions

Head-to-head RCTs comparing NMBA agents and standardized steroid regimens; individual patient data meta-analysis to define phenotype-specific benefits.