LAUSR

We read with interest the recent meta-analysis by Chang et al. who investigated the role of neuromuscular blocking agent (NMBA) use in moderate-to-severe acute respiratory distress syndrome (ARDS) and discuss the potential mechanisms involved in the identified improvements due to the use of NMBA in ARDS [1]. They conclude that the use of NMBAs could significantly decrease mortality in moderate-to-severe ARDS patients and decrease the incidence of barotrauma during mechanical ventilation [1]. We would like to make some comments. Firstly, expert opinion challenges the conclusions of Chang et al., suggesting that NMBA use should be limited to the most hypoxemic patients (PaO2/FiO2 ratio < 120 mmHg, based on the subgroup analysis of the ACURASYS study) and not to moderate ARDS [2, 3]. The same authors also recommend that, at the early phase of mild or moderate ARDS, spontaneous breathing should be preserved [3]. Chang et al. note that NMBAs prevent patient-initiated generation of high volumes and active exhalation, facilitate patient-ventilator synchrony, provide protection from ventilator-induced lung injury (VILI), and ultimately reduce mortality in patients with moderate-to-severe ARDS [1]. The beneficial effects of NMBAs likely include not only abolition of patient-ventilator asynchronies, better lung recruitment, and decrease of VILI, but also less oxygen consumption