A 22 year old, otherwise healthy man was admitted to hospital for removal of nasal polyps under general anesthesia. After placement of standard monitors, anesthesia was induced with fentanyl, propofol, and succinylcholine, and an endotracheal tube was inserted. Anesthesia was maintained with sevoflurane–oxygen. At the conclusion of the 55-min operation, spontaneous ventilation was established and the sevoflurane was discontinued. Soon thereafter, he responded to commands to take a deep breath and the endotracheal tube was removed. A mask from the anesthesia circuit was placed on his face with an oxygen flow of 8 L/min. He appeared to be breathing adequately, but after a few minutes, the oxygen saturation began to decline below 90 %. Positive pressure ventilation via mask with jaw thrust was attempted without success. The patient was given succinylcholine 60 mg i/v, and after 2–3 min positive pressure ventilation was established. Shortly thereafter, pink-stained fluid began to come out of his mouth. His airway was suctioned; he was placed on a CPAP mask with 100 % oxygen; put in a semi-sitting position; and given a single dose of furosemide. Over the next 12 h, his oxygen saturation, which was in the mid-80s gradually increased to the mid-90s. He was admitted to hospital and discharged on the second postoperative day with a normal saturation breathing room air. The finding of pink-tinged fluid in the oropharynx several minutes after extubation of the trachea suggests that laryngospasm may have caused negative pressure pulmonary edema .

A 72 year old, 188-pound man was admitted to hospital for radiation treatment for cancer of the prostate. His other medical problems were hypertension and non-insulin dependent diabetes. His vital signs and laboratory values were within normal limits and he was rated an ASA II. The surgical plan was to place radiation seeds into the prostate, and the anesthetic plan was general anesthesia with insertion of an LMA. Anesthesia was induced with midazolam, fentanyl, propofol, and low dose rocuronium. An LMA #4 was inserted and anesthesia was maintained with desflurane–oxygen. Controlled ventilation was instituted and the patient was placed in lithotomy position. Shortly thereafter, peak airway pressure, which had been below 20 cmH₂O, rapidly increased to greater than 30 cmH₂O. The LMA was repositioned without improvement, so it was removed and replaced. Ventilation still could not be established so the LMA was removed and bag-mask ventilation attempted after insertion of an oral airway. This was also unsuccessful. Direct laryngoscopy was attempted but only the tip of the epiglottis could be visualized. Multiple subsequent attempts at intubation using a blind technique, the Fastrach LMA^TM, and fiberoptic intubation were unsuccessful. The patient went into cardiac arrest and cardiopulmonary resuscitation was started. Ultimately, a #6 endotracheal tube was passed under direct laryngoscopy, but the patient died several days later. The cause of death was deemed to be prolonged hypoxemia secondary to mechanical obstruction of the airway from laryngospasm and subsequent inability to ventilate the lungs or intubate the trachea .

This case is that of Joan Rivers, the famous comedienne who had an untoward event in an outpatient facility in New York City. The facts cited here are those widely circulated in the press and on television following the event. Ms. Rivers went into an outpatient facility for an esophagoscopy under intravenous sedation because of a history of gastroesophageal reflux. During the esophagoscopy, a lesion was noted on a vocal cord, and an ear, nose and throat specialist was consulted. A biopsy of the lesion was performed, and immediately thereafter Ms. Rivers went into complete airway obstruction. Attempts to reestablish ventilation failed and she went into cardiopulmonary arrest. Ultimately an airway and circulation were established, but she did not regain consciousness and died about a week later in a nearby hospital.