Tehran University of Medical Sciences Archives of Anesthesiology and Critical Care 2423-5849 0 0 2026 11 07 1664 1664 Rizya Mahesa Departement of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. & Departement of Anesthesiology and Reanimation, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Bambang Semedi Departement of Anesthesiology and Reanimation, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Naomi Rahmasena Departement of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. & Departement of Anesthesiology and Reanimation, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. Dian Gibran Departement of Anesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia. & Departement of Anesthesiology and Reanimation, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. 2026 06 15 2026 07 11 Trauma-associated acute respiratory distress syndrome (ARDS) with refractory hypoxemia remains difficult to manage, especially when conventional lung-protective ventilation fails. Inverse ratio ventilation (IRV) may improve oxygenation by increasing mean airway pressure and alveolar recruitment. A patient with spinal cord injury and massive hemothorax developed severe hypoxemia and low lung compliance despite conventional mechanical ventilation. Ventilation was escalated to pressure-controlled ventilation with prolonged inspiratory time, higher PEEP, deep sedation, and IRV-oriented settings. Oxygenation and lung compliance improved progressively without significant hemodynamic instability or ventilator-related complications. Prone positioning was not feasible because of spinal trauma. IRV-oriented ventilation may serve as an effective rescue strategy in trauma-induced ARDS with refractory hypoxemia when standard lung-protective ventilation is insufficient. Careful titration and monitoring are essential to optimize oxygenation while minimizing complications. https://aacc.tums.ac.ir/index.php/aacc/article/view/1664