The patient is a 56 year old man who was brought in via EMS for severe respiratory distress. He is sitting straight up in bed, tripoding, diaphoretic with dinner plate eyes. The patient is able to convey that he thinks he might die. He was given one albuterol/atrovent nebulizer per EMS without relief. The patient is unable to provide any further history due to his severe respiratory distress. On exam he has accessory muscle use and has a prolonged expiratory phase to his breathing. Auscultation reveals coarse wheezing bilaterally. BP 220/152 P 130 R 35 T 98.2 O2 80% RA.