An elderly man with a history of COPD on home oxygen presented to the ED with shortness of breath of 2 days’ duration. On physical examination, the patient had jugular venous distension and distant breath sounds without rales bilaterally. Laboratory evaluation was significant for leukocytosis (29,000 WBC/μL, 94% neutrophils), acute renal failure (BUN, 87 mg/dL and creatinine, 2.36 mg/dL), and a troponin T level of 0.44 ng/mL. ECG revealed an incomplete right bundle branch block and no significant ST segment or T-wave changes. Chest radiograph revealed hyperinflated lung fields with bibasilar atelectasis without a focal opacity. Arterial blood gas analysis results were significant for combined hypoxemic and hypercapnic respiratory failure. Bilevel positive airway pressure ventilation was initiated, and the patient subsequently became hypotensive and was endotracheally intubated. The patient remained hypotensive with systolic BP in the 70 to 80 mm Hg range despite aggressive resuscitation with IV fluids. In the ED, a femoral central venous catheter (CVC) was placed, and a norepinephrine drip was initiated. The patient was then admitted to the medical ICU with a diagnosis of acute respiratory failure due to acute exacerbation of COPD and shock. On arrival to the ICU, an assessment of mechanical ventilatory graphics for assessment of intrinsic positive end-expiratory pressure (PEEPi) revealed significant PEEPi; however, with adjustments to the ventilator modes and resolution of PEEPi, the need for vasopressors decreased but persisted. To evaluate the shock further, the intensivist should perform a bedside echocardiogram (ECHO) (Video 1).