Management of refractory status asthmaticus with sevoflurane in the intensive care unit: Case reports

Status asthmaticus represents a severe asthma exacerbation requiring prompt medical attention and often necessitating intensive care. These case reports describe two adult patients with refractory status asthmaticus who required advanced interventions, including invasive mechanical ventilation and sevoflurane administration due to persistent bronchospasm despite standard therapies. The first case involves a 66-year-old female with a history of asthma and type 2 diabetes who developed bronchospasm following elective cataract surgery, leading to respiratory failure and cardiac arrest. The second case concerns a 26-year-old female with poorly controlled allergic eosinophilic asthma, exacerbated by non-adherence to treatment and environmental exposures, resulting in near-fatal respiratory distress. In both instances, sevoflurane was employed for its bronchodilatory effects via calcium channel inhibition and modulation of inflammatory responses, leading to improved bronchospasm and successful weaning from mechanical ventilation. Ventilatory strategies emphasized low respiratory rates and extended I:E ratios to prevent air trapping and dynamic hyperinflation. Spontaneous breathing trials with zero PEEP facilitated extubation, followed by high-flow nasal cannula support in the first case. Both patients stabilized and were discharged from the ICU. These cases highlight the challenges in managing refractory asthma exacerbations, particularly in perioperative and non-adherent contexts, and underscore sevoflurane's potential as a rescue therapy when conventional treatments fail. They emphasize the importance of vigilant monitoring, timely escalation of care, and tailored ventilatory management to optimize outcomes in status asthmaticus.