The ROSE trial tested whether early continuous neuromuscular blockade with cisatracurium improves outcomes in patients with moderate-to-severe ARDS who are managed with mechanical ventilation. Patients were randomised to a 48-hour infusion with deep sedation or to usual care without routine paralysis and with lighter sedation targets. The study found no significant difference in 90-day mortality or days free of mechanical ventilation between the two groups. These results contrasted with the earlier ACURASYS trial and were influential in redefining when paralysis should be considered. A key difference was that the usual-care group in ROSE received contemporary lung-protective ventilation and high-quality supportive care, including lighter sedation. The findings suggest that routine paralysis for all patients with moderate-to-severe ARDS is not necessary. Instead, neuromuscular blockade can be reserved for selected situations such as severe ventilator dyssynchrony, inability to maintain lung-protective targets despite appropriate sedation, or other specific clinical indications. The trial also reinforces the importance of minimising deep sedation whenever possible because lighter sedation can support mobilisation, communication and neurologic assessment. For clinicians, ROSE is a reminder that a treatment can remain useful as a rescue tool even when it is not beneficial as a universal protocol.