CASE PRESENTATION: A 63 year-old female patient with end-stage lung disease from IPF underwent a bilateral lung transplant. At 24 hours the patient was hemodynamically stable and on lung protective mechanical ventilation with estimated PaO2/FIO2 at 215. The patient was extubated and FO2 was weaned down to 0.45 by post-op day 1. Early on the post-op day 2, the patient became more hypertensive and an infusion of nicardipine was initiated. Soon after, the patient developed worsening respiratory failure and her oxygen requirements increased progressively. She was titrated up to a FO2 of 1.0 on a high flow nasal cannula. An ABG revealed a normal pCO2 and pH, but severe hypoxemia with estimated PaO2/FIO2 of 69 (Table 1). A follow up chest radiograph showed no acute change.