Objective: To highlight the case of a patient with acute respiratory failure, whose diagnosis of Boerhaave’s syndrome only became apparent after a trial of non-invasive ventilation. Clinical Presentation and Intervention: A 68-year-old female presented with a clinical picture of community-acquired pneumonia and exacerbation of asthma that was supported by radiological evidence of a large left-sided pleural effusion. Within 20 h, she deteriorated and progressed to severe type 2 respiratory failure. After initiation of first non-invasive and then invasive ventilation, a tension pneumothorax developed. An emergency decompression of the chest revealed gastric contents in the left hemithorax. A diagnosis of Boerhaave’s syndrome was made. Subsequent management included a thoracotomy, defunctioning oesophagectomy, and gastrostomy with ventilatory and inotropic support. However, despite best efforts, the severe systemic inflammatory response resulted in death 3 weeks after initial presentation. Conclusion: It is important to have an open diagnostic mind with a thorough review of investigations and therapy as a patient deteriorates. This case illustrates the importance of considering the remote possibility of oesophageal rupture prior to commencing non-invasive ventilation, especially with regard to chest radiograph features.

Non-invasive ventilation as an alternative to the endotracheal intubation is associated with less infectious complications and injury to the airways. In a study cohort that included 50 patients with type II respiratory failure with the commonest diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation with or without associated co-morbidities, mechanical ventilation with non-invasive positive pressure ventilation (NIPPV) was applied and the response was observed in terms of change in various clinical and laboratory parameters after 1 hour, at the time of weaning, and 6 hours after weaning. There was significant improvement with NIPPV in form of increase in pH and PaO 2 and decrease in PaCO2 and HCO3 after 1 hour of NIPPV application, which also persisted after successful weaning. The patients who failed NIPPV had significantly high respiratory rate, low pH value, and high PaCO 2 on admission.

Extrapulmonary causes of respiratory failure include conditions that exclusively or primarily cause respiratory failure by their effects on structures other than the lungs i.e. the extra pulmonary compartment. They are mainly responsible for the hypercapnic respiratory failure. An analysis of 50 such patients was done at our I.C.U. We tried studying their clinical presentation, their causes and the outcome. The most common age group was 21-40 yrs with a male preponderance. Autonomic dysfunction, ophthalmoplegia, motor and bulbar weakness were the common presentations. Many of them had single breath count (SBC) <20 on presentation. Most common causes were neurotoxic snake bites and Organophosphorus poisoning. The outcome was relatively good if patients were brought early.