What question did this study set out to answer?

This report aims to highlight the effectiveness of sevoflurane as a rescue therapy for refractory status asthmaticus.

May 20, 2026

A52-10 Taming the Auto-PEEP Beast: A Case of Refractory Status Asthmaticus Managed With Sevoflurane

Key Points

This report aims to highlight the effectiveness of sevoflurane as a rescue therapy for refractory status asthmaticus.
Case report of a 33-year-old female with severe asthma requiring intubation and treatment with sevoflurane in the ICU.
Initial management included BiPAP, high-dose intravenous corticosteroids, inhaled medications, and magnesium sulfate.
Sevoflurane inhalation started after failure of conventional therapies and monitored airway pressures.
Sevoflurane inhalation achieved rapid bronchodilation, decreasing peak airway pressures from 60 cm H2O to 31 cm H2O.
Plateau airway pressures reduced from 46 cm H2O to 29 cm H2O within treatment duration.
The patient was successfully extubated on day five and later discharged without complications.

Abstract

Abstract Introduction Status asthmaticus is a severe, life-threatening asthma exacerbation that can be refractory to standard therapy. Dynamic hyperinflation and auto-positive end-expiratory pressure (auto-PEEP) can contribute to respiratory failure and obstructive shock. While conventional therapies form the mainstay of management, alternative interventions may be necessary in extreme cases. This report discusses the successful use of sevoflurane in such a scenario. Case Description A 33-year-old female with a history of asthma presented with worsening dyspnea, cough, and vomiting. She was tachycardic, tachypneic, and hypoxemic. Physical exam revealed tripod positioning and diffuse wheezing. Arterial blood gas showed hypercapnia and acidosis. Initial management included bilevel positive airway pressure (BiPAP), high-dose intravenous corticosteroids, inhaled albuterol and ipratropium, and intravenous magnesium sulfate. Despite these interventions, she required intubation. Within 12 hours, she developed rising airway pressures: auto-PEEP of 33 cm H2O, peak of 60 cm H2O, and plateau of 46 cm H2O. She developed hypotension requiring epinephrine infusion. No significant improvement was noticed with sedation, paralysis, or bicarbonate therapy. Sevoflurane inhalation (minimum alveolar concentration 2.3%) was initiated with the collaboration of anesthesia faculty in the intensive care unit. Her pressures rapidly decreased to a peak of 31 cm H2O and a plateau of 29 cm H2O. Sevoflurane was slowly weaned during the next 24 hours. She was subsequently extubated on day five and discharged posteriorly. Discussion Notably, this case underscores sevoflurane as a critically important rescue therapy in refractory status asthmaticus, achieving rapid bronchodilation and reduced airway pressures after conventional measures failed.1 Sevoflurane relaxes airway smooth muscle, markedly decreasing airway resistance, dynamic hyperinflation, and intrinsic PEEP.2 By significantly reducing severely elevated plateau airway pressures and auto-PEEP, sevoflurane likely relieved obstructive shock, thus facilitating ventilation and hemodynamic recovery. Published series consistently report that nearly all patients with life-threatening asthma improved with sevoflurane, although dose-dependent hypotension is a potential complication.1 This outcome supports inhaled anesthetics as a multidisciplinary salvage strategy in extreme, life-threatening asthma when standard therapies fail. REFERENCES 1. Ho GWK, Thaarun T, Ee NJ, et al. A systematic review on the use of sevoflurane in the management of status asthmaticus in adults. Crit Care. 2024;28(1):334. Published 2024 Oct 14. doi:10.1186/s13054-024-05122-8 2. Maltais F, Sovilj M, Goldberg P, Gottfried SB. Respiratory mechanics in status asthmaticus. Effects of inhalational anesthesia. Chest. 1994;106(5):1401-1406. doi:10.1378/chest.106.5.140 This abstract is funded by: None

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