A 25-yr-old woman with morbid obesity (BMI: 54 kg/m2) and noninsulin-dependent diabetes was scheduled for cochlear implant surgery. She had two previous surgeries without incident during childhood. She denied any history of atopy or drug allergy. Chest auscultation was normal before anesthesia. She was premedicated with hydroxyzine (100 mg) the day before and 1 h before anesthesia, which was induced with sufentanil (20 µg IV) and propofol (350 mg IV). Tracheal intubation (Cormack and Lehane grade I) was facilitated with succinylcholine (130 mg IV). After tracheal intubation was performed, chest auscultation revealed a complete absence of bilateral breath sounds. Initial concentrations of end-tidal carbon dioxide (ETco2) were low. The patient was immediately extubated and mask ventilation attempted. Mask ventilation was difficult to perform because of dramatically decreased lung compliance, whereas ETco2 demonstrated a marked prolonged expiratory upstroke of the capnogram. Rapid arterial oxygen desaturation (oxygen saturation measured by pulse oximetry [Spo2], 55%) followed by arterial hypotension (from 130/75 to 50/20 mmHg) associated with a moderate tachycardia (100 beats/min) occurred in less than 5 min.