CASE PRESENTATION: Mr. R, is a 69 years old nursing home resident with history of diabetes, hypertension, valvular heart disease, DVT, seizures and stroke with residual hemiparesis and motor aphasia. He was admitted to the ICU with acute respiratory failure and agitation 2 days after being treated and discharged for aspiration pneumonia. His wife reported that he was eating when he suddenly started “choking”. On admission he was afebrile, normotensive but tachycardic and chest X-ray was significant for a chronic right base infiltrate. He was intubated after failing oxygen via Non-Rebreather Mask (NRM) with saturation of 80%. A GlideScope Video Laryngoscope was used; it was a difficult intubation with visible “white mucous plugging”. He was restless and agitated after intubation. Two days later he self-extubated; he saturated 96% on NRM for a few hours, and then he was in respiratory distress. A bed-side scope showed a foreign body (FB) in the larynx. He taken to the Operating Room emergently, re-intubated and a FB was removed from the right lung, which turned out to be piece of apple. Patient’s respiratory and mental status improved and he was successfully liberated from ventilator shortly after FB removal.