Volatile anesthetic sedation in acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS) arises from a heterogenous set of inciting injuries and produces its classic sequelae of hypoxia and lung damage through multiple pathways. Over decades, therapeutic efforts have focused on targeting the inflammatory response and providing excellent supportive care. Volatile anesthetics have been proposed as agents that could achieve both of these aims by protecting against inflammatory lung injury, allowing effective sedation, and through respiratory effects including bronchodilation and maintenance of respiratory drive. Promising preliminary data demonstrated reductions in inflammatory mediators and improvements in oxygenation with volatile anesthetics for patients with ARDS. However, a recent multicenter randomized controlled trial found that sevoflurane sedation for patients with moderate-to-severe ARDS reduced ventilator free days at day 28 and increased mortality compared to propofol sedation. Ongoing and recently completed clinical trials may provide additional context for patients with respiratory failure including ARDS, although none are being conducted solely in ARDS patients. Priorities for future trials of volatile anesthetic sedation in ARDS include reconsideration of the dose, agent selection, and duration of volatile sedation, and potential heterogeneity of treatment effect across ARDS sub-phenotypes. Pending further high-quality data suggesting benefit, routine clinical use of volatile ICU sedation in ARDS is currently not recommended outside of clinical trials.