Achalasia is an idiopathic motility disorder causing progressive dysphagia and dilation of the esophagus. Rarely this esophageal dilation can cause acute respiratory insufficiency and/or failure. We describe a 63-year-old woman presenting for total knee arthroplasty in whom induction of anesthesia was complicated by pulmonary aspiration requiring postoperative ventilation, hypotension requiring vasopressor therapy, and postextubation, recurrent, acute respiratory failure. Computed tomography of the chest performed for suspected pneumothorax revealed severe esophageal dilation with a mass effect. As this case describes, achalasia may present with the life-threatening complication of respiratory failure and requires a high index of suspicion for timely diagnosis and appropriate interventions.