A case of Boerhaave's syndrome presenting after a trial of non-invasive ventilation.
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.


METHODS
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.


CONCLUSIONS
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.
Patel
M S
MS
Department of Intensive Care, St Helier Hospital, Surrey, UK. mehuliopatel@hotmail.com
Chakraborty
P U
PU
D000368:Aged; D003937:Diagnosis, Differential; D004939:Esophageal Perforation / Q000150:complications / Q000175:diagnosis*; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D011030:Pneumothorax / Q000150:complications; D012121:Respiration, Artificial / Q000379:methods*; D012131:Respiratory Insufficiency / Q000150:complications; D013577:Syndrome