Zhiyuan Xu ¹ Xiao Liu ^2* Liang Zhang ^1* Xianliang Yan ^2*

• ¹ Department of Emergency Medicine, Xuzhou No 1 People's Hospital, Xuzhou City, Jiangsu Province 221100, China, XuZhou, China
• ² Department of Emergency Medicine, Affiliated Hospital of Xuzhou Medical University, Xuzhou City, Jiangsu Province 221006, China, XuZhou, China

OBJECTIVES: Acute respiratory distress syndrome (ARDS) is linked to high rates of morbidity and mortality. Evidence examining commonly used corticosteroids, neuromuscular blocking agents (NMBAs) and inhaled nitric oxide (iNO) remains uncertain. The aim of the study was to compare and rank these three treatments to identify the best one. DATA SOURCES: We searched Pubmed, Embase, Cochrane Library, and Web of Science from the earliest records to May 1, 2024 for clinic trials. STUDY SELECTIONT AND DATA EXTRACTION: Clinical trials of three interventions compared with control group for ARDS, no language restricted. Data were extracted by 2 independent reviewers. Frequentist network meta-analyses (NMA) were performed to identify the best intervention and treatments were ranked using the surface under the cumulative ranking (SUCRA) curve. Primary outcome was 28-day mortality. Secondary outcomes varied ventilator-free days at 28 days, ICU mortality, In-hospital mortality and new infection events.DATA SYNTHESIS: Data were combined from 26 clinical trials which included 5071 patients. Vecuronium bromide was the best strategy to reduce 28-day mortality compared with the conventional treatment, iNO, methylprednisolone and placebo (OR 0.38, 95% CI 0.15-1.00 and OR 0.30, 95% CI 0.10-0.85 and OR 0.25, 95% CI 0.08-0.74 and OR 0.23, 95% CI 0.08-0.65; SUCRA: 96.6%). Dexamethasone was the best treatment option for increasing ventilator-free days at 28 days compared to conventional therapy and cisatracurium (MD 3.60, 95% CI 1.77-5.43 and MD 3.40, 95% CI 0.87-5.92; SUCRA: 93.2%). Methylprednisolone was the most effective treatment option to prevent ICU mortality (SUCRA: 88.5%). Though dexamethasone, cisatracurium, conventional therapy, methylprednisolone and iNO treatment showed no significant superiority of in-hospital mortality protection over placebo, suggesting that it had the highest probability of being the best treatment option (SUCRA: 79.7%) for reducing in-hospital mortality. Dexamethasone treatment showed the highest safety for decreasing the incidence of new infection events compared with placebo and iNO (OR 0.61, 95% CI 0.42-0.88 and OR 0.33, 95% CI 0.19-0.58; SUCRA: 91.8%).Conclusions: This NMA suggested that corticosteroids are possibly beneficial in the patients with ARDS while application of NMBAs may reduce 28-day mortality, iNO as a therapeutic measure which did not show a prominent beneficial effect.