Clinical Research Directory

Inclusion Criteria: 1. Patients admitted to the medical intensive care unit at Department of Medicine, Siriraj Hospital 2. Age ≥18 years old 3. Receiving mechanical ventilation due to acute respiratory failure within 72 hours before enrollment (including patients receiving mechanical ventilation before ICU admission) Exclusion Criteria: 1. Patients receiving mechanical ventilation due to indications other than acute respiratory failure, such as postoperative procedures or airway protection in comatose patients 2. Patients receiving mechanical ventilation for \>72 hours before enrollment 3. Patients receiving neuromuscular blocking agents prior to randomization 4. Patients with impaired secretion clearance or upper airway obstruction anticipating a tracheostomy 5. Patients with severe metabolic acidosis (arterial pH \<7.2) who do not have a plan for renal replacement therapy 6. Patients intubated for neurological conditions, including intracranial hypertension, intracranial hemorrhage, large cerebral infarction, status epilepticus, or neuromuscular diseases 7. Post-cardiac arrest patients 8. Patients with severe liver dysfunction, including acute fulminant liver failure or cirrhosis with the Child-Pugh score B or C 9. Patients who have a previous allergy to any of the opioid, sedation, or neuromuscular blocking drugs 10. Pregnancy 11. Patients with do-not-resuscitate (DNR) orders or decisions to withhold life-sustaining treatments 12. Patients who refuse to participate in the study or cannot identify legally authorized representatives (LAR) within 24 hours after enrollment