An 80-yr-old, 90 kg, 5'7" male with a past medical history of coronary artery disease, diabetes mellitus, right inguinal hernia, hypertension, chronic obstructive pulmonary disease, and end-stage renal disease requiring hemodialysis is admitted to an intermediate ICU with upper gastrointestinal bleeding. He is conscious, pale, cold, and clammy. Because he complains of being cold, he is covered with several blankets. His BP is 90/40 and his heart rate is 120 sinus. His hematocrit is 20 and he is transfused with 3 units of packed red blood cells over a 40-min period. After this, he becomes unresponsive, with very weak respiratory efforts. A one-stick radial arterial blood gas shows pH 6.9, pCO2 107, and paO2 53 on a 100% O2 nonrebreather mask. At this point, you are called to manage the airway. When you arrive, he is being vigorously ventilated with an Ambu bag via a facemask; despite this, his O2 saturation remains in the mid 70s. He is supine in his bed, and he is still covered with several blankets from his nipples down to his toes, with the exception of the right inguinal region, which reveals a balloon like mass. You notice this because the intern has just placed an arterial line in his femoral artery. His femoral arterial line shows a blood pressure of 80/40 mmHg and a heart rate of 120 sinus rhythm. You confirm the blood pressure is not below 60 mmHg, as you can palpate the superfi cial temporal artery. You turn your attention to his airway and note there is hematemesis on his pillow. You immediately place an endotracheal tube (ETT) in his trachea without sedation or relaxation. You ventilate his lungs with an FIO2 of 100%. End-tidal CO2 is seen and bilateral breath sounds are heard. You are very concerned as you notice that the pressure required to hand-ventilate the patient is extraordinarily high and seems to get higher and higher. Unfortunately, the oxygenation only improves to the mid 80s. You repeat the laryngoscopy and confirm the correct placement of the ETT. A suction catheter is passed throughout the entire length of the ETT and no secretion of note is obtained. You give the patient vecuronium 60 mg and spray down the ETT with albuterol; there is only marginal improvement. You obtain a capnometer and confi rm that CO2 is present in the expired air and, as expected, the CO2 trace shows an obstructive pattern. A chest x-ray has been called for, but has not been done yet. Is there anything else you would like to do, and what is the cause of the dilemma?