A 68 year-old man presents by squad with shortness of breath.  He is noted to have a nearly quiet chest with very poor air movement, to be using accessory respiratory muscles, and to be slightly lethargic.  Quick perusal of old records discloses a history of severe COPD, steroid and O2 dependence, HTN and ulcer disease.  The squad reports that his O2 sat was 86% at the scene, improving to 92% on a NRBM and two nebs.

His vitals are:  p 138, r 22 and labored, bp 156/96, O2 sat 92% on a high-flow NRBM.  His POC renal returns with a pCO2 of 88.  His estimated weight is about 175 lbs.

A decision is made to intubate.