Fatal pneumomediastinum in COPD and interstitial lung fibrosis associated with use of non invasive mechanical ventilation

We present a case of fatal pneumomediastinum (FP) in a patient with acute respiratory failure due to acute exacerbated chronic obstructive pulmonary disease (AECOPD) and non specific interstitial pneumonia (NSIP) precipitated by non invasive mechanical ventilation (NIMV). Spontaneous pneumomediastinum is a rare disorder that is usually benign and self-limited. Cases of FP are reported during invasive mechanical ventilation in patients with interstitial lung disease (ILD). Protective ventilation with lower tindal volume is best mode of invasive ventilation to reduce acute lung injury and potential fatal complications. Use of NIMV in end stage ILD is not standardized and efficacy is to be proven. Cause of FP in this case is explained with barotrauma due to application of NIMV in patient with AECOPD and ILD. Inhomogeneous distribution of areas of pulmonary fibrosis characterized by reduced lung compliance and areas affected by COPD characterized by overdistension of lung tissue due to air trapping can be considered to explain this fatal complication. NIMV is very useful to treat acute respiratory failure due to AECOPD improving survival and avoiding endotracheal intubation. In presence of AECOPD and ILD, NIMV can be used with particular attention due to potential serious complications. This is the first report of pneumomediastinum due to NIMV that lead to death a patient with AECOPD and ILD. This case emphasized potential fatal and uncommon complication of NIMV