Hazardous Hernia: Mechanical Ventilation in an Adult With a Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernias (CDHs) are developmental defects often found in infancy; however, they may be rarely found as a delayed diagnosis in adults. Although often an incidental finding, adult patients with preexisting CDH who present with symptoms of respiratory distress pose unique challenges in airway management. Complications include gastric insufflation, mechanical compression of the surrounding viscera, exacerbation of respiratory distress, and failed ventilatory weaning. We present the case of a 70-year-old female with acute hypoxic respiratory failure requiring mechanical ventilation in the setting of a large, preexisting CDH. The patient’s hospital course was complicated by gastric insufflation requiring gastric decompression, with the need for prolonged ventilator support and repeated extubation failure requiring tracheostomy placement. The literature on ventilator management in adults with CDH remains limited; however, lung-protective ventilation is recommended due to the risk of gastric insufflation and mediastinal compression due to preexisting CDH.