We report the case of a 46-year-old woman who came to our emergency department with generalized weakness and abdominal pain. Shortly thereafter, she became hypotensive and had a respiratory arrest that required endotracheal intubation and mechanical ventilation.

The patient had a history of hypertension, migraines, and emphysema. Medications included aspirin, butalbital, and caffeine taken for headaches, and laxatives. A chest radiograph obtained after intubation revealed hyperinflated lungs with diminished vascularity and a flattened diaphragm suggestive of emphysematous lung disease.

Within a few hours after intubation, the patient’s respiratory status deteriorated and her oxygen saturation decreased precipitously. Peak airway pressures were elevated and hypotension developed. Because of the potential for pneumothorax, the on-call physician placed a small-bore chest tube connected to a Heimlich 1-way valve. In order for the patient to be transferred for computed tomography, mechanical ventilation was temporarily...

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