While mechanical ventilation is lifesaving for children with acute respiratory distress syndrome (ARDS), it has become clear that it can lead to significant harm from ventilator-induced lung injury, patient self-inflicted lung injury, and ventilator-induced diaphragm dysfunction. To that end, therapeutic strategies that try to balance lung and diaphragm protection have become a priority in both pediatric and adult ARDS. In this month’s issue, Ijland et al. provide provocative results evaluating the effect of fluid strategies on diaphragm function in an experimental model of pediatric ARDS. The results highlight that fluid management can have potentially competing effects on the lung and the diaphragm.

The authors should be commended for an elegant and comprehensive controlled study, conducted in 19 lambs with on average moderate ARDS. The authors hypothesized that lambs managed with a liberal fluid strategy would have more impairment in diaphragm strength, because the liberal strategy would...

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