Abstract
RATIONALE: Oxygen therapy is a critical component of postoperative care, particularly after general anesthesia. Although generally safe, its improper administration can lead to serious complications. This report details an incident of lung overinflation during postoperative oxygen therapy that resulted in pneumothorax and pneumoperitoneum. PATIENT CONCERNS: A 63-year-old female patient with tracheostomy underwent pressure sore reconstruction under general anesthesia. Postoperatively, the patient was transferred to the recovery room, and oxygen therapy was initiated. During oxygen administration, the anesthesiology nurse omitted the connection of a heat-moisture exchanger and thereby inadvertently administered excessive dry positive pressure ventilation. Subsequently, the patient developed acute respiratory distress. DIAGNOSES: Clinical examination revealed decreased bilateral breathing sounds and abdominal distension. Computed tomography confirmed bilateral pneumothorax and pneumoperitoneum. INTERVENTIONS: Conservative management was chosen. OUTCOMES: The patient's condition stabilized, and she was discharged after 3 weeks with no long-term complications. LESSONS: This case highlights the importance of careful monitoring and adherence to appropriate techniques during postoperative oxygen therapy. Overinflation of the lungs can lead to life-threatening conditions such as pneumothorax and pneumoperitoneum. This incident highlights the need for rigorous training and vigilance among healthcare professionals to prevent such occurrences. Although oxygen therapy is essential for patients recovering from general anesthesia, this case illustrates the potential risks associated with improper administration. Awareness and preventive measures are crucial for avoiding similar adverse events and ensuring patient safety and optimal outcomes.