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Invasive mechanical ventilation is standard but carries substantial risk. This case report describes severe ARDS in a 78-year-old woman managed without intubation using a strategy of permissive hypoxemia and high-dose corticosteroids. Haemophilus influenzae was identified, antibiotics were given, imaging raised suspicion of APT, prednisone was escalated, clinical improvement began day five, follow-up CT on day 10 showed radiological clearance, and discharge occurred without intubation.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/avoiding-intubation-in-severe-acute-respiratory-distress-syndrome-due-to-mixed-amiodarone-toxicity-and-haemophilus-influenzae-a-case-of-permissive-hypoxemia/437845/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/avoiding-intubation-in-severe-acute-respiratory-distress-syndrome-due-to-mixed-amiodarone-toxicity-and-haemophilus-influenzae-a-case-of-permissive-hypoxemia/437845.png","ImageObject",300,407,{"name":92,"@type":93},"Guten tag","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-06","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":52},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Why is intubation avoided in severe ARDS in this case?","Question",{"text":112,"@type":113},"Intubation was avoided by using permissive hypoxemia combined with high-dose corticosteroids, prioritizing avoidance of ventilator-associated pneumonia in the setting of steroid-induced infection susceptibility.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What diagnostic clue suggested amiodarone pulmonary toxicity?",{"text":117,"@type":113},"A review of historical imaging together with the patient’s long-term amiodarone therapy raised suspicion of underlying APT when hypoxemia worsened despite targeted antibiotics.",{"name":119,"@type":110,"acceptedAnswer":120},"How was the patient managed during severe hypoxemia?",{"text":121,"@type":113},"The patient remained on high-flow nasal cannula with 100% inspired oxygen despite a low PaO2/FiO2 nadir, while corticosteroid dosing was escalated and close hemodynamic monitoring showed stability.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},437845,1790794807,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":52,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":19,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":52,"preview_page_count":4},687212321768,"https://ap-avatar.wpscdn.com/avatar/a0010bdbe886d2fe77?x-image-process=image/resize,m_fixed,w_180,h_180&k=1789897067658708522","Review began 11/24/2025  \nReview ended 12/02/2025  \nPublished 12/06/2025  \n© Copyright 2025  \nLa Brocca et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited.  \nDOI: 10.7759/cureus.98563  \nOpen Access Case Report  \nAvoiding Intubation in Severe Acute Respiratory Distress Syndrome Due to Mixed Amiodarone Toxicity and Haemophilus Influenzae: A Case of Permissive Hypoxemia  \nUbaldo La Brocca 1 , Giulia Dina Giuseppina Benincasa 2, Massimiliano Parlanti Garbero 1 , Michele Grio 1  \n1. Department of Anesthesia and Intensive Care, Rivoli Hospital, Rivoli, ITA 2. Department of Respiratory Medicine, San Luigi Gonzaga University Hospital, Orbassano, ITA  \nCorresponding author: Ubaldo La Brocca, [ubaldo.labrocca@aslto3.piemonte.it](ubaldo.labrocca@aslto3.piemonte.it)  \nAbstract  \nAmiodarone pulmonary toxicity (APT) is a diagnostic challenge that can mimic or complicate communityacquired pneumonia. In cases of severe acute respiratory distress syndrome (ARDS), invasive mechanical ventilation is the standard of care but carries significant risks. We report a case of severe ARDS successfully managed without intubation through a strategy of \"permissive hypoxemia \" and high-dose corticosteroids. A 78-year-old female was admitted to the ICU for acute hypoxic respiratory failure. Initial workup  \nidentified Haemophilus influenzae on bronchoalveolar lavage, leading to a diagnosis of severe pneumonia. Despite targeted antibiotic therapy, hypoxemia worsened. On day two, a review of historical imaging and the patient 's long-term amiodarone therapy raised the suspicion of underlying APT. The steroid regimen was escalated to prednisone 160 mg/day. On day three, the patient reached a nadir PaO2/FiO2 ratio of 58 while on a high-flow nasal cannula at 60 L/min and 100% fraction of inspired oxygen. Despite profound hypoxemia, the patient remained hemodynamically stable. A decision was made to tolerate hypoxemia primarily to avoid ventilator-associated pneumonia, given the high susceptibility to infection induced by high-dose steroids. This strategy relied on the hypothesis of rapid reversibility of the inflammatory toxicity upon steroid escalation. Clinical improvement began on day five. A follow-up CT scan on day 10 demonstrated significant radiological clearance. The patient was discharged without requiring intubation. This case highlights the importance of reviewing historical imaging to identify drug-induced toxicity and suggests that, in selected patients with preserved respiratory drive, a noninvasive approach tolerating severe hypoxemia may be a viable alternative to intubation.  \nCategories: Emergency Medicine, Pulmonology, Anesthesiology  \nKeywords: acute respiratory distress syndrome [ards], aipt(amiodarone-induced pulmonary toxicity), drug-induced lung disease (dild), haemophilus influenzae, high-flow nasal cannula (hfnc), permissive hypoxemia, rox index  \nIntroduction  \nAmiodarone is a widely used antiarrhythmic drug, but its utility is limited by potential life-threatening adverse effects, most notably amiodarone pulmonary toxicity (APT), which affects up to 5-10% of long-term users [1] . Diagnosing APT in the acute setting is notoriously difficult, as its clinical presentation, dyspnea, fever, and pulmonary infiltrates often mimic community-acquired pneumonia (CAP) or heart failure. This diagnostic uncertainty is compounded when an infectious pathogen is co-identified, creating a \"double hit \"  \nscenario that can mask the underlying toxicity.  \nFurthermore, the management of severe acute respiratory distress syndrome (ARDS), defined as a  \nPaO2/FiO2 ratio \u003C 100 mmHg, typically mandates invasive mechanical ventilation (IMV) . However, recent evidence suggests that in selected phenotypes, spontaneous breathing with high-flow nasal cannula (HFN","cbCaiaSwqWyVmtu7","https://ap.wps.com/l/cbCaiaSwqWyVmtu7","pdf",1236555,"English","# Abstract\n# Introduction\n# Case Presentation","[{\"question\":\"Why is intubation avoided in severe ARDS in this case?\",\"answer\":\"Intubation was avoided by using permissive hypoxemia combined with high-dose corticosteroids, prioritizing avoidance of ventilator-associated pneumonia in the setting of steroid-induced infection susceptibility.\"},{\"question\":\"What diagnostic clue suggested amiodarone pulmonary toxicity?\",\"answer\":\"A review of historical imaging together with the patient’s long-term amiodarone therapy raised suspicion of underlying APT when hypoxemia worsened despite targeted antibiotics.\"},{\"question\":\"How was the patient managed during severe hypoxemia?\",\"answer\":\"The patient remained on high-flow nasal cannula with 100% inspired oxygen despite a low PaO2/FiO2 nadir, while corticosteroid dosing was escalated and close hemodynamic monitoring showed stability.\"}]","Avoiding Intubation in Severe Acute Respiratory Distress Syndrome Due to Mixed Amiodarone Toxicity and Haemophilus Influenzae - A Case of Permissive Hypoxemia | PDF",1790683355]