A 52 year-old woman underwent a diagnostic right cervical node biopsy under general anesthesia at the patient’s request. Anesthesia consisted of induction with propofol and maintenance with sevoflurane/nitrous oxide/oxygen breathing spontaneously via an LMA. At the conclusion of the 30-min procedure, the LMA was removed and the patient has a brief period of laryngospasm that was treated with bilateral pressure at the laryngospasm notch (see Chap. 5). By the time she reached the post-anesthesia care room, she was fully awake, conscious, responsive and breathing normally. She could take a deep breath without difficulty. About 30 min later, the patient stated to the recovery room nurse that she was having some difficulty breathing. The nurse listened to the patient’s lungs but did not detect any abnormality. The patient’s respiratory rate had increased from 10 to 18 breaths/min, but since her oxygen saturation was 97 % breathing room air, the nurse thought the problem might be anxiety, since the patient denied any pain. Ten minutes later the patient complained again of shortness of breath, so the nurse called the patient’s surgeon. When he arrived, he noted that the oxygen saturation was 94 % breathing room air, the respiratory rate was 24/min, and that breath sounds seemed distant but similar bilaterally. He had the patient placed on mask oxygen at 2 L/min, ordered a chest x-ray and asked the anesthesia provider to come and evaluate the patient.

When the anesthesia provider arrived, he noted that the patient was having considerable respiratory distress, her oxygen saturation was 82 % on mask oxygen, and her breath sounds were distant bilaterally. Over the next few minutes she appeared to lose consciousness and her blood pressure, which had been normal, was recorded as 52/37 mmHg and a pulse of 122 b/min. The anesthesia provider immediately took a 5 mL syringe, attached a 20 g 1½ needle, and inserted the needle into the right chest at the second intercostal space. The plunger of the syringe flew up and hit the ceiling putting a dent in the acoustic tile. The next blood pressure increased to 105/65 mmHg, the patient awakened, and with a deep breath the oxygen saturation increased to 93 %. A chest x-ray showed a pneumomediastinum and residual air in the right chest cavity outside the lung and a right chest tube was placed. A follow-up x-ray showed a normal left lung and full expansion of the right lung. The chest tube was removed the next day and the patient returned home.