The Effect of Continuous Neuromuscular Blockade in a Cohort of Patients with Evolving or Grade 3 Bronchopulmonary Dysplasia

Abstract

Objective

This study aimed to describe the use of continuous neuromuscular blockade (NMBA) in patients with life-threatening hypoxia and/or hypercarbia secondary to evolving or grade 3 bronchopulmonary dysplasia (BPD) and its association with short-term death, as well as clinical measures of respiratory severity.

Study Design

We identified a cohort of patients with evolving or grade 3 BPD at Riley Children's Health who received continuous infusion vecuronium for greater than 48 hours. We analyzed data using descriptive and inferential statistics.

Results

Of the 18 patients identified, 77% survived beyond 7 days after discontinuation of a single course of continuous vecuronium. All but one patient demonstrated decreased respiratory severity score (RSS) and oxygenation saturation index (OSI) across the period of NMBA administration. Mean RSS and OSI decreased significantly across the time of administration (p = 0.003) and was higher in the group that died versus the group that survived (p < 0.001, p = 0.001). Of those that survived to discharge, six received a tracheostomy, and one was discharged in room air.

Conclusion

A majority of a cohort of patients with life threatening hypoxia and/or hypercarbia and evolving or grade 3 BPD exposed to continuous NMBA demonstrated a clinically significant incidence of short-term survival and reduced respiratory severity.

Key Points

• Evidence for NMBA use in BPD is limited.

• Unstable gas exchange on high BPD ventilator settings may necessitate NMBA use.

• NMBA use may decrease respiratory support needed and improve clinical stability in unstable BPD patients.

Keywords

bronchopulmonary dysplasia - neuromuscular blockade - premature - infant

Contributors' Statement

R.R. designed the work. R.R. and F.A.F. did data collection. Analysis and interpretation were done by R.R. and A.C. The article was drafted by A.C. Critical revision and final approval of the publishable version were done by all the authors.

Publication History

Received: 30 December 2024

Accepted: 21 September 2025

Article published online:
06 October 2025

• References

• 1 Schmidt AR, Ramamoorthy C. Bronchopulmonary dysplasia. Paediatr Anaesth 2022; 32 (02) 174-180
• 2 Doyle LW, Carse E, Adams AM, Ranganathan S, Opie G, Cheong JLY. Victorian Infant Collaborative Study Group. Ventilation in extremely preterm infants and respiratory function at 8 years. N Engl J Med 2017; 377 (04) 329-337
• 3 Jensen EA, Schmidt B. Epidemiology of bronchopulmonary dysplasia. Birth Defects Res A Clin Mol Teratol 2014; 100 (03) 145-157
• 4 Gibbs K, Jensen EA, Alexiou S, Munson D, Zhang H. Ventilation strategies in severe bronchopulmonary dysplasia. Neoreviews 2020; 21 (04) e226-e237
• 5 House M, Nathan A, Bhuiyan MAN, Ahlfeld SK. Morbidity and respiratory outcomes in infants requiring tracheostomy for severe bronchopulmonary dysplasia. Pediatr Pulmonol 2021; 56 (08) 2589-2596
• 6 Smith HAB, Besunder JB, Betters KA. et al. 2022 Society of Critical Care Medicine Clinical Practice Guidelines on prevention and management of pain, agitation, neuromuscular blockade, and delirium in critically ill pediatric patients with consideration of the ICU environment and early mobility. Pediatr Crit Care Med 2022; 23 (02) e74-e110
• 7 Needham CJ, Brindley PG. Best evidence in critical care medicine: the role of neuromuscular blocking drugs in early severe acute respiratory distress syndrome. Can J Anaesth 2012; 59 (01) 105-108
• 8 Rudolph MW, Kneyber MCJ, Asaro LA, Cheifetz IM, Wypij D, Curley MAQ. for the Randomized Evaluation of Sedation Titration for Respiratory Failure ( RESTORE ) Study Investigators. Early neuromuscular blockade in moderate to severe pediatric acute respiratory distress. Crit Care Med 2022; 50 (05) e445-e457
• 9 Da Silva PS, Neto HM, de Aguiar VE, Lopes Jr E, de Carvalho WB. Impact of sustained neuromuscular blockade on outcome of mechanically ventilated children. Pediatr Int 2010; 52 (03) 438-443
• 10 Wilsterman MEF, de Jager P, Blokpoel R. et al. Short-term effects of neuromuscular blockade on global and regional lung mechanics, oxygenation and ventilation in pediatric acute hypoxemic respiratory failure. Ann Intensive Care 2016; 6 (01) 103
• 11 Jensen EA, Dysart K, Gantz MG. et al. The diagnosis of bronchopulmonary dysplasia in very preterm infants: an evidence-based approach. Am J Respir Crit Care Med 2019; 200 (06) 751-759
• 12 Malkar MB, Gardner WP, Mandy GT. et al. Respiratory severity score on day of life 30 is predictive of mortality and the length of mechanical ventilation in premature infants with protracted ventilation. Pediatr Pulmonol 2015; 50 (04) 363-369
• 13 Jung YH, Jang J, Kim HS. et al. Respiratory severity score as a predictive factor for severe bronchopulmonary dysplasia or death in extremely preterm infants. BMC Pediatr 2019; 19 (01) 121
• 14 Rawat M, Chandrasekharan PK, Williams A. et al. Oxygen saturation index and severity of hypoxic respiratory failure. Neonatology 2015; 107 (03) 161-166
• 15 Højsgaard S, Halekoh U, Yan J. The R package geepack for generalized estimating equations. J Stat Softw 2006; 15 (02) 1-11
• 16 R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria. 2025 .Accessed September 24, 2025 at: https://www.R-project.org/
• 17 Johnson ED, Keppel K, McNamara L, Collaco JM, Boss RD. Continuous neuromuscular blockade for bronchopulmonary dysplasia. Am J Perinatol 2024; 41 (13) 1848-1857