Abstract Introduction Acute Respiratory Distress Syndrome (ARDS) refractory to established treatment guidelines can pose major challenges. Heterogeneity in patient populations can predispose certain individuals to prolonged mechanical ventilation. High sedation requirements, refractory bronchospasm, and underlying inflammation can further worsen ventilator dyssynchrony and gas exchange. Volatile anesthetics such as isoflurane may improve compliance, reduce resistance, and mitigate ventilator-induced lung injury. However, their use in critical care in the United States is rare, and outcome data are mixed. Early pilot data suggested probable benefit, whereas a subsequent retrospective study showed possible harm. We report a case where the use of isoflurane provided rapid physiologic improvement in a patient with severe ARDS refractory to standard medical treatment. Case A 53-year-old female with history of obesity underwent elective jejunojejunostomy revision complicated by abdominal sepsis and respiratory failure. Chest CT demonstrated dense bilateral airspace opacities; echocardiography showed preserved biventricular function; infectious work-up was negative. She underwent intubation and mechanical ventilation for ARDS. Despite lung-protective ventilation, proning, bronchodilators, deep intravenous sedation (midazolam, propofol, ketamine), and neuromuscular blockade, she continued to have worsening agitation and persistent airflow obstruction, leading to auto-PEEP, further ventilator dyssynchrony, and acid-base abnormalities. Isoflurane was initiated as a rescue therapy via an anesthetic-conserving device, leading to rapid improvement in agitation, bronchospasm, and air trapping. Over the subsequent few days, there was significant improvement in lung mechanics, ventilator synchrony, and gas exchange, with eventual liberation from mechanical ventilation and discharged to rehabilitation. Discussion This case highlights the uncommon use of volatile anesthetics refractory ARDS. Volatile anesthetic use in the intensive care unit (ICU) remains non-standard in North America, largely due to delivery-system limitations, training differences, and unfamiliarity among intensivists. At certain doses, Isoflurane’s bronchodilatory and anti-inflammatory properties may explain the rapid physiologic benefit we observed, which extended beyond sedation to improve airflow obstruction, thus reducing auto-PEEP and improving gas exchange. In a pilot randomized trial, Jabaudon et al. reported that sevoflurane in ARDS was feasible, improved oxygenation, and reduced biomarkers of lung epithelial injury compared with midazolam. However, the subsequent SESAR trial found that sevoflurane use led to fewer ventilator-free days and lower survival versus propofol, arguing against broader application. Our case suggests this conflicting data may reflect heterogeneity: while routine inhaled anesthetic use is not supported, certain patients may represent a phenotype where such therapy may act as rescue therapy, particularly those with high sedation requirements and refractory bronchospasm leading to persistent ventilator dyssynchrony and gas exchange abnormalities. This abstract is funded by: None
Khan et al. (Fri,) studied this question.