A patient in the PACU following thoracotomy has SpO2 88% on 8 L/min O2 via face mask. Respiratory rate is 28/min, and paradoxical abdominal movement is noted. Breath sounds are absent on the right. The MOST likely diagnosis and immediate action is:

• A Pulmonary oedema; administer furosemide and increase PEEP
• B Residual neuromuscular block; administer sugammadex
• C Bronchospasm; administer nebulised salbutamol
• D Tension pneumothorax; immediate needle decompression in second intercostal space mid-clavicular line ✓

Explanation

Absent unilateral breath sounds with hypoxia, tachypnoea, and paradoxical breathing following thoracotomy are highly suggestive of pneumothorax or tension pneumothorax. The absence of breath sounds on the surgical side combined with haemodynamic instability would indicate tension pneumothorax — a life-threatening emergency requiring immediate needle decompression at the 2nd ICS mid-clavicular line, followed by formal chest drain insertion. Residual NMB causes diffuse weakness without unilateral chest findings. Bronchospasm causes diffuse wheeze, not absent breath sounds.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.