ACE inhibitors (ACEi) are widely used antihypertensive agents with proven cardioprotective effects. Previous mechanistic and clinical studies have suggested ACEi therapy may slow disease progression and reduce mortality in idiopathic pulmonary fibrosis (IPF).

A 67-year-old woman presents for a second opinion for insomnia. She reports falling asleep with ease but difficulty maintaining sleep, with several nighttime awakenings. She has previously undergone cognitive behavioral therapy for insomnia without any improvement in her symptoms. She denies snoring and witnessed apneas but reports occasional daytime sleepiness, with an Epworth Sleepiness Score of 11 out of 24, indicating significant sleepiness. The remainder of her sleep history is unremarkable. Additionally, she has a medical history of anxiety, depression, and chronic pain, which is managed with aripiprazole, bupropion, clonazepam (as needed), and gabapentin. Her surgical history is pertinent for a tonsillectomy at age 5.

A 47-year-old woman presented to the emergency department with sudden-onset dull nonradiating chest pain and palpitations. She denied other symptoms such as shortness of breath, dizziness, or diaphoresis. Her medical history was significant for generalized anxiety disorder, obesity, and former tobacco use (less than 1 pack per day for 5 years, quit more than 20 years ago). Her only medications included daily multivitamins and ibuprofen as needed for knee pain.

A 63-year-old man who had never smoked was seen in the outpatient clinic with complaints of exercise-induced dyspnea and a tightness in the upper chest when reaching maximal exercise. He had a medical history of a multinodular goiter, with tracheal compression resulting in a successful total thyroidectomy in November 2023. No spirometry was performed after thyroid surgery. There was no wheezing nor stridor present. The patient did not have any cough, sputum production, or fever. Mild gastroesophageal reflux complaints were also present. There was a mild irritation in the throat when swallowing. He performed regular physical activity, cycling 3 times per week. There was no relevant familial history. Before the current evaluation, the patient was diagnosed with asthma based on an elevated fractional exhaled nitric oxide and exercise-induced dyspnea, but without other typical symptoms of asthma. A treatment with inhaled corticosteroids/long-acting beta-agonists did not improve exercise-induced symptoms. Subsequently, the patient also underwent cardiologic evaluation (symptoms possibly resembling angina): a coronarography was performed, showing a mild stenosis of the left anterior descending artery with a fractional flow reserve of 0.75. Coronary artery disease was suspected, and a drug-eluding stent was placed, again without resolving the exercise-induced symptoms.

Traumatic pulmonary hemorrhage is uncommon and rarely results in respiratory failure requiring mechanical circulatory support. Indications for extracorporeal membrane oxygenation (ECMO) in injured patients are not well-defined, but recent work indicates a potential survival benefit. Additionally, coughing-induced hemorrhage requires a complex sedation strategy. We describe management of a young polytrauma patient with traumatic lung failure requiring advanced venovenous (VV)-ECMO support and novel sedation strategy to facilitate healing. An 18-year-old boy sustained a 40-foot fall and developed widespread traumatic hemorrhagic pneumatoceles leading to respiratory arrest, ultimately requiring parallel-circuit VV-ECMO support, as well as systemic isoflurane sedation achieved through the ECMO circuit. Orthopedic fixation was performed while on VV-ECMO. This young polytrauma patient had a primary traumatic pulmonary hemorrhagic process and orthopedic traumatic injuries that were successfully managed with parallel-circuit VV-ECMO and isoflurane sedation through the circuit.