Positive-Pressure Ventilation-induced Pneumothorax After Intubation: A Pandora's Box of Early Diagnostic Pitfalls and Ultrasound-First Management

Pneumothorax under positive-pressure ventilation can present within hours of intubation, particularly when a small, non-recruitable "baby lung" bears most of the mechanical load. We report a 67-year-old man with hypertrophic cardiomyopathy, hypertension, diabetes, and hypothyroidism who arrived obtunded (Glasgow Coma Scale 6) with severe hypoxaemia. He was intubated and initially ventilated in volume control; because saturations remained low with high airway pressures, he was switched to pressure control with higher positive end-expiratory pressure (PEEP). After a brief improvement, he acutely deteriorated with desaturation, hypotension, tachycardia, reduced minute ventilation, and rising airway pressures. Bedside lung ultrasound showed absent sliding with a barcode/stratosphere pattern and a lung point on the right; high-resolution computed tomography (HRCT) confirmed a large right pneumothorax with near-complete right-lung collapse and extensive ipsilateral consolidation. A right intercostal drain produced rapid physiological improvement. Initial studies showed neutrophilic leucocytosis, mild acute kidney injury, a cholestatic-predominant liver profile, markedly elevated NT-proBNP with normal high-sensitivity troponin, and near-normal coagulation; cultures remained negative, and bronchoalveolar lavage GeneXpert and cytology were negative. Endotracheal bleeding with anaemia and thrombocytopenia prompted bronchoscopy, which removed a lower-lobe endobronchial clot. Despite stabilisation, he sustained two intensive care unit (ICU) cardiac arrests with the return of spontaneous circulation; echocardiography demonstrated a dilated left atrium, asymmetric septal hypertrophy with paradoxical septal motion, grade-I diastolic dysfunction, and pulmonary hypertension. Weaning to pressure support occurred on days 4 and 5; he was extubated on day 6, stepped down from ICU on day 7, the chest drain was removed on day 10, and he was discharged home on day 12 on oral antibiotics. At two-week follow-up, he remained stable with no recurrent pneumothorax. This case emphasises three practical points: pneumothorax may occur immediately post-intubation in severely consolidated, low-compliance lungs; ultrasound outperforms supine radiography for rapid bedside diagnosis and should guide timely decompression when physiology is unstable; and power-aware ventilation - limiting driving pressure and avoiding injudicious PEEP escalation in non-recruitable lungs - helps prevent a transient oxygenation "win" from tipping into structural failure.