Acute respiratory distress syndrome (ARDS) is a critical disease with high mortality. The choice of maintaining spontaneous breathing or using neuromuscular blocking agents is remaining controversial during mechanical ventilation. This article reviews the clinical research and progress, advantages and disadvantages, and potential mechanism of these two options in the treatment of ARDS, so as to deepen the understanding of maintaining spontaneous breathing and using neuromuscular blocking agents for ARDS patients during mechanical ventilation and provide suggestions for clinical decision.