LETTER TO THE EDITOR Potential Hazards of Neuromuscular Blocking Agents in the Treatment of Acute Respiratory Distress Syndrome. Comment on: “Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome”

While the mechanisms responsible for the adjusted mortality benefit reported by Papazian et al. remain speculative, it is highly likely that lower transpulmonary pressures (TPPs) in the cisatracurium group were responsible for some portion of the reported benefit. This is suggested by the three-fold incidence of pneumothorax in the placebo group compared to the cisatracurium group despite no difference in plateau pressures between the groups. This complication is significant in its own right, and probably serves as a marker for less obvious barotrauma at the alveolar level.