A 31 years woman, under treatment for Myasthenia gravis and no past history of underlying respiratory disease, was admitted with breathlessness, diplopia and ptosis. On evaluation she was found to have a thymoma. Soon after admission she eveloped a severe Myasthenic crisis (MC) with respiratory failure requiring steroids, immunosuppressive, mechanical ventilation and Plasmapheresis. She also underwent thymectomy after stabilisation. Her postoperative ventilatory management was difficult, prolonged and complicated by autonomic instability, poor respiratory muscle function, and anticholinesterase-induced increase in airway reactivity. High airway pressures, airway resistance, and air trapping led to bilateral pneumothoraces
requiring intercostal drainage. The airway reactivity and resistance settled after discontinuing pyridostigmine and instituting inhaled Ipratropium bromide, an anticholinergic agent. Pneumothoraces resolved rapidly and the patient could be weaned successfully via a tracheostomy.