A Case of Boerhaave’s Syndrome Presenting after a Trial of Non-Invasive Ventilation

Abstract

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.

Development of bilateral tension pneumothorax under anesthesia in a Boerhaave's syndrome patient: a case report

“…The mediastinal pleura rupture simultaneously with the rupture of the esophagus, or after digesting the stomach contents. Within 12 hours after the esophageal rupture, the mediastinal pleura are usually not ruptured, and the patient may have normal vital signs [ 1 2 6 7 ]. Accordingly, the prognosis is favorable if the operation is performed during this time.…”

“…When the mediastinal pleura become ruptured, pleural effusion develops, and negative pressure pushes the stomach contents and gastric juice into the thoracic cavity. Consequently, inflammation increases, and shock, sepsis, and other respiratory problems, such as pleural effusion, pneumothorax, hydrothorax, and tension pneumothorax can develop [ 1 2 6 ].…”

“…The mechanism of the development of the tension pneumothorax in our case is possibly due to the positive pressure ventilation during manual ventilation prior to intubation or during mechanical ventilation [ 6 ].…”

Gastric Perforation Because of Non-Invasive Positive-Pressure Ventilation: Review of Complications

“…Four previous case reports associated with intestinal perforation induced by NIPPV hyperinflation were found [7][8][9][10]. Two cases of Boerhaave syndrome, esophageal pneumatosis, and gastric perforation were published.…”

A Rare but Lethal Cause of Chest Pain

“…In cases of esophageal rupture, it also has the potential to increase intrathoracic pressure, which could lead to complications such as tension pneumothorax (17). Eleanor Anderson: Because this is such a rare disease, it is difficult to study, and most recommendations are based on expert opinion and case studies.…”