Mrs. D is a 60-year-old woman with history of smoking (2 pack per day for 40 years), right sided heart failure with last exacerbation 6 months ago. At that time, she had been intubated and placed on a ventilator for COPD exacerbation and respiratory failure 4 months ago.

She presents to emergency room with dyspnea.
HR 120, RR 36, SaO2 84%; breath sounds very diminished all fields.
Her physical appearance includes truncal obesity w/stretch marks, round face, bruised arms.
What do you think is happening?
What do you want to do?