{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T18:21:03Z","timestamp":1784744463369,"version":"3.55.0"},"reference-count":46,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T00:00:00Z","timestamp":1784160000000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>The purpose of this paper is to discuss the controversies and challenges in clinical decision-making related to the use of neuromuscular blocking agents (NMBAs) in adult patients with acute respiratory distress syndrome (ARDS) and identify directions for future research.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>ARDS is a common occurrence in critically ill patients and is associated with high morbidity and mortality. Four clinical practice guidelines published since 2020 provide recommendations for NMBA administration in patients with ARDS. Recommendations regarding NMBA selection and dosing are largely derived from 2 multicenter trials with discordant results, one conducted in France and the other in the US. Both trials utilized a fixed-rate, high-dose cisatracurium infusion for 48\u2005hours, with mortality benefit observed in only the French trial. Despite the regimen being consistent between these clinical trials, the utilization of NMBAs in practice has significant heterogeneity and variability. This paper will address 5 controversies surrounding NMBA use in ARDS: the mechanistic benefit of NMBAs, which patients derive benefit from NMBAs, how NMBAs should be dosed and administered, NMBA agent selection, and use of sedation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Current clinical guidelines suggest use of NMBAs in patients with ARDS who are persistently hypoxemic despite sedation. However, they lack specific recommendations on NMBA and sedation dosing and titration approaches. Future studies should investigate NMBA agent selection, dosing regimens, duration, and monitoring approaches.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ajhp\/zxag220","type":"journal-article","created":{"date-parts":[[2026,7,16]],"date-time":"2026-07-16T11:49:11Z","timestamp":1784202551000},"source":"Crossref","is-referenced-by-count":0,"title":["Neuromuscular blocking agents for acute respiratory distress syndrome: Current controversies"],"prefix":"10.1093","author":[{"given":"Gretchen L","family":"Sacha","sequence":"first","affiliation":[{"name":"Department of Pharmacy, Cleveland Clinic, Cleveland, OH, and Cleveland Clinic Lerner College of Medicine, Case Western Reserve University , Cleveland, OH ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mojdeh S","family":"Heavner","sequence":"additional","affiliation":[{"name":"Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy , Baltimore, MD ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan E","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Clinical and Administrative Pharmacy, The University of Georgia College of Pharmacy , Athens, GA ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brian L","family":"Erstad","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy , Tucson, AZ ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,7,16]]},"reference":[{"issue":"8","key":"2026072213280377600_zxag220-B1","doi-asserted-by":"crossref","first-page":"788","DOI":"10.1001\/jama.2016.0291","article-title":"Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries","volume":"315","author":"Bellani","year":"2016","journal-title":"JAMA"},{"issue":"11","key":"2026072213280377600_zxag220-B2","doi-asserted-by":"crossref","first-page":"1977","DOI":"10.1007\/s00134-020-06227-8","article-title":"Neuromuscular blockade in patients with ARDS: a rapid practice guideline","volume":"46","author":"Alhazzani","year":"2020","journal-title":"Intensive Care Med"},{"issue":"7","key":"2026072213280377600_zxag220-B3","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1007\/s00134-023-07050-7","article-title":"ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies","volume":"49","author":"Grasselli","year":"2023","journal-title":"Intensive Care Med"},{"issue":"1","key":"2026072213280377600_zxag220-B4","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1164\/rccm.202311-2011ST","article-title":"An update on management of adult patients with acute respiratory distress syndrome: an official American Thoracic Society clinical practice guideline","volume":"209","author":"Qadir","year":"2024","journal-title":"Am J Respir Crit Care Med"},{"issue":"3","key":"2026072213280377600_zxag220-B5","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1097\/CCM.0000000000007002","article-title":"Society of Critical Care Medicine guidelines for the administration of neuromuscular blockade in adults with acute respiratory distress syndrome","volume":"54","author":"Erstad","year":"2026","journal-title":"Crit Care Med"},{"issue":"12","key":"2026072213280377600_zxag220-B6","doi-asserted-by":"crossref","first-page":"1735","DOI":"10.1007\/s00134-002-1508-y","article-title":"A comparison of two depths of prolonged neuromuscular blockade induced by cisatracurium in mechanically ventilated critically ill patients","volume":"28","author":"Lagneau","year":"2002","journal-title":"Intensive Care Med"},{"issue":"1","key":"2026072213280377600_zxag220-B7","doi-asserted-by":"crossref","first-page":"113","DOI":"10.1097\/01.CCM.0000104114.72614.BC","article-title":"Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome","volume":"32","author":"Gainnier","year":"2004","journal-title":"Crit Care Med"},{"issue":"11","key":"2026072213280377600_zxag220-B8","doi-asserted-by":"crossref","first-page":"2749","DOI":"10.1097\/01.CCM.0000239435.87433.0D","article-title":"Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome","volume":"34","author":"Forel","year":"2006","journal-title":"Crit Care Med"},{"issue":"12","key":"2026072213280377600_zxag220-B9","doi-asserted-by":"crossref","first-page":"1107","DOI":"10.1056\/NEJMoa1005372","article-title":"Neuromuscular blockers in early acute respiratory distress syndrome","volume":"363","author":"Papazian","year":"2010","journal-title":"N Engl J Med"},{"issue":"21","key":"2026072213280377600_zxag220-B10","doi-asserted-by":"crossref","first-page":"1997","DOI":"10.1056\/NEJMoa1901686","article-title":"National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. Early neuromuscular blockade in the acute respiratory distress syndrome","volume":"380","author":"Moss","year":"2019","journal-title":"N Engl J Med"},{"issue":"9","key":"2026072213280377600_zxag220-B11","doi-asserted-by":"crossref","first-page":"865","DOI":"10.1001\/jama.2010.218","article-title":"Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis","volume":"303","author":"Briel","year":"2010","journal-title":"JAMA"},{"issue":"9","key":"2026072213280377600_zxag220-B12","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1513\/AnnalsATS.202411-1225OC","article-title":"Sedation practices during continuous neuromuscular blockade for acute respiratory distress syndrome","volume":"22","author":"Dunbar","year":"2025","journal-title":"Ann Am Thorac Soc"},{"issue":"12","key":"2026072213280377600_zxag220-B13","doi-asserted-by":"crossref","first-page":"1176","DOI":"10.1056\/NEJMe1007136","article-title":"Neuromuscular blocking agents in ARDS","volume":"363","author":"Slutsky","year":"2010","journal-title":"N Engl J Med"},{"issue":"5","key":"2026072213280377600_zxag220-B14","doi-asserted-by":"crossref","first-page":"725","DOI":"10.1007\/s00134-018-5500-6","article-title":"Variability of reverse triggering in deeply sedated ARDS patients","volume":"45","author":"Bourenne","year":"2019","journal-title":"Intensive Care Med"},{"issue":"6","key":"2026072213280377600_zxag220-B15","doi-asserted-by":"crossref","first-page":"606","DOI":"10.1164\/rccm.202201-0099ED","article-title":"The double-edged sword of reverse triggering: impact on the diaphragm","volume":"205","author":"Sassoon","year":"2022","journal-title":"Am J Respir Crit Care Med"},{"issue":"3","key":"2026072213280377600_zxag220-B16","doi-asserted-by":"crossref","first-page":"423","DOI":"10.1007\/s00134-026-08328-2","article-title":"Consensus on identifying and ranking ventilator asynchronies in invasively ventilated ICU patients: a modified Delphi study (SYNAPsE)","volume":"52","author":"Molenaar","year":"2026","journal-title":"Intensive Care Med"},{"issue":"6","key":"2026072213280377600_zxag220-B17","doi-asserted-by":"crossref","first-page":"663","DOI":"10.1164\/rccm.202105-1089OC","article-title":"Impact of reverse triggering dyssynchrony during lung-protective ventilation on diaphragm function: an experimental model","volume":"205","author":"Damiani","year":"2022","journal-title":"Am J Respir Crit Care Med"},{"issue":"7","key":"2026072213280377600_zxag220-B18","doi-asserted-by":"crossref","first-page":"698","DOI":"10.1001\/jama.2017.21907","article-title":"Acute respiratory distress syndrome: advances in diagnosis and treatment","volume":"319","author":"Fan","year":"2018","journal-title":"JAMA"},{"issue":"3","key":"2026072213280377600_zxag220-B19","doi-asserted-by":"crossref","first-page":"408","DOI":"10.1007\/s00134-016-4653-4","article-title":"Effects of neuromuscular blockers on transpulmonary pressures in moderate to severe acute respiratory distress syndrome","volume":"43","author":"Guervilly","year":"2017","journal-title":"Intensive Care Med"},{"issue":"12","key":"2026072213280377600_zxag220-B20","doi-asserted-by":"crossref","first-page":"2357","DOI":"10.1007\/s00134-020-06297-8","article-title":"Myorelaxants in ARDS patients","volume":"46","author":"Hraiech","year":"2020","journal-title":"Intensive Care Med"},{"issue":"5","key":"2026072213280377600_zxag220-B21","doi-asserted-by":"crossref","first-page":"478","DOI":"10.1164\/rccm.202401-0012ED","article-title":"Neuromuscular blockade improves results in acute respiratory distress syndrome: a mechanism may be prevention of expiratory muscle activity, which allows more lung expansion","volume":"209","author":"de Vries","year":"2024","journal-title":"Am J Respir Crit Care Med"},{"issue":"6","key":"2026072213280377600_zxag220-B22","doi-asserted-by":"crossref","first-page":"966","DOI":"10.1164\/rccm.202406-1231OC","article-title":"Elastance may determine the neuromuscular blockade effect on mortality in acute respiratory distress syndrome","volume":"211","author":"Zalucky","year":"2025","journal-title":"Am J Respir Crit Care Med"},{"key":"2026072213280377600_zxag220-B23","doi-asserted-by":"crossref","first-page":"154505","DOI":"10.1016\/j.jcrc.2023.154505","article-title":"The depth of neuromuscular blockade is not related to chest wall elastance and respiratory mechanics in moderate to severe acute respiratory distress syndrome patients. A prospective cohort study","volume":"80","author":"Barbarot","year":"2024","journal-title":"J Crit Care"},{"issue":"5","key":"2026072213280377600_zxag220-B24","doi-asserted-by":"crossref","first-page":"563","DOI":"10.1164\/rccm.202308-1376OC","article-title":"Expiratory muscle activity counteracts positive end-expiratory pressure and is associated with fentanyl dose in patients with acute respiratory distress syndrome","volume":"209","author":"Plens","year":"2024","journal-title":"Am J Respir Crit Care Med"},{"issue":"2","key":"2026072213280377600_zxag220-B25","doi-asserted-by":"crossref","first-page":"e151","DOI":"10.1097\/CCM.0000000000002849","article-title":"The association between ventilator dyssynchrony, delivered tidal volume, and sedation using a novel automated ventilator dyssynchrony detection algorithm","volume":"46","author":"Sottile","year":"2018","journal-title":"Crit Care Med"},{"issue":"1","key":"2026072213280377600_zxag220-B26","doi-asserted-by":"crossref","first-page":"2042","DOI":"10.1038\/s41598-024-52243-9","article-title":"Identification of four latent classes of acute respiratory distress syndrome using PaO2\/FIO2 ratio: an observational cohort study","volume":"14","author":"Loewen","year":"2024","journal-title":"Sci Rep"},{"issue":"9","key":"2026072213280377600_zxag220-B27","doi-asserted-by":"crossref","first-page":"1615","DOI":"10.1007\/s00134-025-08064-z","article-title":"Heterogenous treatment effect of neuromuscular blocking agents for moderate-to-severe ARDS: a post hoc Markov model re-analysis of the ACURASYS trial","volume":"51","author":"Brunini","year":"2025","journal-title":"Intensive Care Med"},{"issue":"12","key":"2026072213280377600_zxag220-B28","doi-asserted-by":"crossref","first-page":"2399","DOI":"10.1007\/s00134-025-08183-7","article-title":"Refining the use of neuromuscular blockade in ARDS: lessons from a post hoc Markov model re-analysis of the ACURASYS trial","volume":"51","author":"Lakbar","year":"2025","journal-title":"Intensive Care Med"},{"issue":"1","key":"2026072213280377600_zxag220-B29","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1007\/s00134-025-08251-y","article-title":"The medical management of acute respiratory distress syndrome","volume":"52","author":"Morris","year":"2026","journal-title":"Intensive Care Med"},{"issue":"7","key":"2026072213280377600_zxag220-B30","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1177\/10600280251388441","article-title":"Comparison of continuous neuromuscular blocking agent titration strategies in acute respiratory distress syndrome","volume":"60","author":"Maier","year":"2026","journal-title":"Ann Pharmacother"},{"issue":"4","key":"2026072213280377600_zxag220-B31","doi-asserted-by":"crossref","first-page":"588","DOI":"10.1097\/CCM.0000000000004171","article-title":"Rescue neuromuscular blockade in acute respiratory distress syndrome should not be flat dose","volume":"48","author":"Flannery","year":"2020","journal-title":"Crit Care Med"},{"issue":"10","key":"2026072213280377600_zxag220-B32","doi-asserted-by":"crossref","first-page":"876","DOI":"10.1136\/thoraxjnl-2016-209719","article-title":"Identification and validation of distinct biological phenotypes in patients with acute respiratory distress syndrome by cluster analysis","volume":"72","author":"Bos","year":"2017","journal-title":"Thorax"},{"issue":"12","key":"2026072213280377600_zxag220-B33","doi-asserted-by":"crossref","first-page":"2648","DOI":"10.1097\/00003246-199912000-00007","article-title":"Paralysis in the critically ill: intermittent bolus pancuronium compared with continuous infusion","volume":"27","author":"de Lemos","year":"1999","journal-title":"Crit Care Med"},{"key":"2026072213280377600_zxag220-B34","doi-asserted-by":"crossref","first-page":"154165","DOI":"10.1016\/j.jcrc.2022.154165","article-title":"Physicians\u2019 attitudes and perceptions of neuromuscular blocker infusions in ARDS","volume":"72","author":"Train","year":"2022","journal-title":"J Crit Care"},{"key":"2026072213280377600_zxag220-B35","doi-asserted-by":"crossref","first-page":"3651","DOI":"10.2147\/IJGM.S524089","article-title":"Neuromuscular blocking agents and reversal agents usage, and neuromuscular blockade monitoring in the intensive care unit\u2014review article","volume":"18","author":"Szewczyk","year":"2025","journal-title":"Int J Gen Med"},{"issue":"7","key":"2026072213280377600_zxag220-B36","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1016\/j.bjae.2021.02.002","article-title":"Neuromuscular blocking drugs in the critically ill","volume":"21","author":"Welhengama","year":"2021","journal-title":"BJA Educ"},{"issue":"7","key":"2026072213280377600_zxag220-B37","doi-asserted-by":"crossref","first-page":"947","DOI":"10.4187\/respcare.05102","article-title":"Comparison of cisatracurium versus atracurium in early ARDS","volume":"62","author":"Moore","year":"2017","journal-title":"Respir Care"},{"issue":"5","key":"2026072213280377600_zxag220-B38","doi-asserted-by":"crossref","first-page":"212","DOI":"10.1177\/87551225231194031","article-title":"Atracurium versus cisatracurium in the treatment of acute respiratory distress syndrome","volume":"39","author":"Carabetta","year":"2023","journal-title":"J Pharm Technol"},{"issue":"11","key":"2026072213280377600_zxag220-B39","doi-asserted-by":"crossref","first-page":"969","DOI":"10.1177\/10600280251329195","article-title":"Association between rocuronium administration and clinical outcomes in patients with moderate-to-severe acute respiratory distress syndrome: a retrospective cohort study","volume":"59","author":"Tonai","year":"2025","journal-title":"Ann Pharmacother"},{"issue":"2","key":"2026072213280377600_zxag220-B40","first-page":"e1370","article-title":"Guideline-concordant sedative and analgesia use in critically ill patients receiving sustained neuromuscular blockade","volume":"8","author":"Feeney","year":"2026","journal-title":"Crit Care Explor"},{"issue":"8","key":"2026072213280377600_zxag220-B41","doi-asserted-by":"crossref","first-page":"856","DOI":"10.1002\/jac5.1747","article-title":"Survey of critical care pharmacists on sedation and analgesia practices in adult and pediatric patients receiving continuous neuromuscular blocking agents","volume":"6","author":"Kenneally","year":"2023","journal-title":"J Am Coll Clin Pharm"},{"issue":"11","key":"2026072213280377600_zxag220-B42","doi-asserted-by":"crossref","first-page":"1106","DOI":"10.1111\/j.1365-2044.2010.06509.x","article-title":"Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008","volume":"65","author":"Arnot-Smith","year":"2010","journal-title":"Anaesthesia"},{"issue":"2","key":"2026072213280377600_zxag220-B43","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1002\/j.1875-9114.1998.tb03862.x","article-title":"Patient recall of therapeutic paralysis in a surgical critical care unit","volume":"18","author":"Wagner","year":"1998","journal-title":"Pharmacotherapy"},{"issue":"1","key":"2026072213280377600_zxag220-B44","doi-asserted-by":"crossref","first-page":"86","DOI":"10.4037\/ajcc2006.15.1.86","article-title":"Patients\u2019 recollections of therapeutic paralysis in the intensive care unit","volume":"15","author":"Ballard","year":"2006","journal-title":"Am J Crit Care"},{"issue":"3","key":"2026072213280377600_zxag220-B45","doi-asserted-by":"crossref","first-page":"151","DOI":"10.1002\/pds.1196","article-title":"Adverse effects of neuromuscular blocking agents based on yellow card reporting in the U.K.: are there differences between males and females?","volume":"15","author":"Light","year":"2006","journal-title":"Pharmacoepidemiol Drug Saf"},{"issue":"1","key":"2026072213280377600_zxag220-B46","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1186\/s13054-024-05105-9","article-title":"A plea for enhanced monitoring of depth of sedation in patients who are intubated and ventilated","volume":"28","author":"Romagnoli","year":"2024","journal-title":"Crit Care"}],"container-title":["American Journal of Health-System Pharmacy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxag220\/69071155\/zxag220.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxag220\/69071155\/zxag220.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T17:28:15Z","timestamp":1784741295000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article\/doi\/10.1093\/ajhp\/zxag220\/8736029"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,16]]},"references-count":46,"URL":"https:\/\/doi.org\/10.1093\/ajhp\/zxag220","relation":{},"ISSN":["1079-2082","1535-2900"],"issn-type":[{"value":"1079-2082","type":"print"},{"value":"1535-2900","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,16]]},"article-number":"zxag220"}}