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Tough to ventilate.

A 57-year-old man with acquired immunodeficiency syndrome (AIDS) and a CD4 cell count of less than 50 cells/ml of blood presented to the emergency department with large-volume hematemesis. He was tachypneic, tachycardic, and hypotensive on initial examination and rapidly deteriorated, prompting intubation and mechanical ventilation. The rest of his physical examination was unremarkable and he was anemic, with hemoglobin at 8 mg/dl. Chest radiography showed normal lung fields with no opacities. An emergency upper endoscopy revealed a large bleeding esophageal ulcer extending from 1 cm below the upper esophageal sphincter to the mid-esophagus with suspected erosion into the trachea (Figures 1A and 1B). Persistently elevated peak airway pressures of 50–60 cm H2O were noted despite adequate sedation and neuromuscular blockade. Given the difficulties with ventilation and the findings on endoscopy, an urgent flexible bronchoscopy was performed at bedside, which revealed a necrotic mass lesion protruding through the posterior tracheal wall with 80–90% obstruction of the tracheal lumen along with associated dynamic airway collapse (Figure 2A). In addition, a tracheoesophageal fistula measuring approximately 6 cm in length was noted. Endobronchial biopsies were obtained from the posterior tracheal mass. The high airway pressures were believed to be related to the mass lesion coupled with the dynamic airway collapse, likely through a ball valve effect. The large TEF in the presence of high airway pressures was also thought to carry the possible risk of progressive gastric insufflation and worsening ventilatory dysfunction. To address both issues, a fully polyurethane-covered 18 3 8 cm self-expandable metallic stent was placed over a guidewire under fluoroscopic guidance in the intensive care unit, using flexible bronchoscopy (Figure 2B). Immediately after stent placement, airway pressures normalized and the patient clinically stabilized. On the basis of his clinical presentation and profound underlying immunosuppression, he