title: Balancing neuromuscular blockade versus preserved muscle activity.
abstract: OBJECTIVE
  Acute respiratory distress syndrome (ARDS) is still associated with a high mortality. The best way to ensure mechanical ventilation in ARDS patients is still debated, recent data arguing for a muscle paralysis and a controlled ventilation whereas other elements being in favor of a preserved spontaneous breathing. The purpose of this review is to discuss the benefits and the disadvantages of both strategies.
  
  
  RESULTS
  Randomized controlled trials have brought the evidence that at the acute phase of ARDS, a 48-h administration of cisatracurium is associated with a decrease in mortality for the most severe hypoxemic patients. Other studies suggest that spontaneous breathing could be deleterious at this period. In the less severe patients (mild ARDS), however, a few studies have demonstrated the benefits of preserving spontaneous breathing with an improvement in oxygenation and a decrease in the length of mechanical ventilation.
  
  
  CONCLUSIONS
  In ARDS patients, the ventilator strategy should be a balance between muscle paralysis in the most hypoxemic patients and preserved spontaneous breathing after improvement or from the acute phase in less severe forms. However, monitoring plateau pressure, tidal volume and perhaps also transpulmonary pressure seems crucial to limit the occurrence of ventilator-induced lung injury.
authors.affiliation: aAssistance Publique - Hôpitaux de Marseille, Hôpital Nord, Réanimation des Détresses Respiratoires et des Infections Sévères bAix-Marseille Université, Faculté de Médecine, Marseille, France cDepartment of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.
authors.forename: Sami
authors.initials: S
authors.lastname: Hraiech
authors.forename: Takeshi
authors.initials: T
authors.lastname: Yoshida
authors.forename: Laurent
authors.initials: L
authors.lastname: Papazian
mesh_terms: D006801:Humans; D019148:Neuromuscular Blockade; D012121:Respiration, Artificial / Q000379:methods*; D012128:Respiratory Distress Syndrome / Q000503:physiopathology / Q000628:therapy*; D012133:Respiratory Paralysis; D013990:Tidal Volume; D055397:Ventilator-Induced Lung Injury / Q000517:prevention & control*