In this pivotal study,2 the benefit of cisatracurium was limited to patients with very severe hypoxemia as reflected by a Pao2/Fio2 ratio < 120 mm Hg, with no evidence of benefit if the baseline Pao2/Fio2 was 121 to 150 mm Hg. First, this observation is consistent with those of other interventions for ARDS that potentially add risk, such as high positive end-expiratory pressure and prone positioning, which have the greatest potential benefit in patients with the most severe physiologic derangements. Second, recommendations for use of paralytics in severe ARDS should be limited to cisatracurium. Virtually all the demonstrated safety and efficacy for neuromuscular blockade in these patients is limited to cisatracurium.2-4 Although the absence of evidence does not necessarily exclude a potential role of agents such as the steroid nucleus neuromuscular blocking agent vecuronium, risk of prolonged weakness is increased with these agents, particularly in patients with organ dysfunction.5,6 Third, as Papazian et al2 concluded, additional studies are needed before widespread use of cisatracurium for severe ARDS is adopted. Because the majority of published research is European, generalizability would be enhanced by performing multicenter RCTs in other locales. Fourth, limiting the duration of paralysis to 48 h, as done in the Papazian et al2 study, should be emphasized because the risk for adverse effects increases as the duration of therapy is extended.