Avoiding Intubation in Severe Acute Respiratory Distress Syndrome Due to Mixed Amiodarone Toxicity and Haemophilus Influenzae: A Case of Permissive Hypoxemia

Amiodarone pulmonary toxicity (APT) is a diagnostic challenge that can mimic or complicate community-acquired 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 identified <i>Haemophilus influenzae</i> 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.