Early neuromuscular blockade in moderate to severe acute respiratory distress syndrome: do not throw the baby out with the bathwater!

Light sedation with daily interruption and analgesia-based sedation are currently recommended in critically ill, mechanically ventilated patients (1). However, in the context of acute respiratory distress syndrome (ARDS), the benefits of this sedative strategy remain controversial. A lung protective ventilation strategy to minimize ventilator-induced lung injury (VILI) significantly decreases mortality in patients with ARDS (2), and therefore is mandatory for early management of these patients. However, deep sedation could be required to obtain patient-ventilator synchronization (3). In particular, deep sedation involving neuromuscular blocking agents (NMBAs) is frequently needed during several adjunctive therapies, such as with high positive end-expiratory pressure (PEEP) levels, prone positioning, or extracorporeal membrane oxygenation.