Although these results are impressive, limitations to the study should be noted. This was a single study that has not yet been duplicated. While true, it is worth noting that it was a high-level study published in a high-impact journal and is no less assailable a study than others that have dramatically changed clinical practice in critical care medicine, such as the use of early goal-directed therapy for sepsis.15 If NMB confers benefit to patients by eliminating patient-ventilator asynchrony early in the course of ARDS, it could be argued that adjustment of the ventilator rather than pharmacologic adjustment of the patient is preferable. Unfortunately, no clear ventilator approaches have been described to effectively eliminate patient-ventilator asynchrony in this context. It might also be argued that mortality difference was significant only when adjusted for differences between the patient groups, yet these very differences were predefined by the investigators and are known to be associated with outcomes from ALI/ARDS. The blinding of the study was likely not complete given clinical differences that might have existed between the patients receiving NMB and those simply receiving heavy sedation. This problem is inherent in any study of NMB. Additionally, full paralysis could not be confirmed by TOF determination because use of TOF itself would break blinding. However, to the extent that some fraction of the patients did not achieve complete paralysis, one would assume that the results would have been less impressive. Finally, the end point for ICU-AW (MRC score at 28 days) may not speak to differences between the groups during the more protracted period of recovery from ARDS. While true, it is worth observing that a prerequisite for recovering from ARDS itself and the complication of ICU-AW is survival. In addition, although physical therapy can certainly occur while patients are receiving mechanical ventilation,16 it is greatly enhanced by liberation from mechanical ventilation, and the increased number of ventilator-free days in the patients undergoing NMB suggests a greater window of opportunity for their rehabilitation.