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Flail chest syndrome occurs following trauma to the chest wall with 4 or more adjacent rib fractures in 2 or more places leading to separation of the fractured chest wall section from the rest of the thorax. During spontaneous ventilation, the flail section of the chest wall moves inward on inspiration and then moves outward during expiration leading to decreased tidal volumes and ineffective gas exchange. In addition, patients who suffer from flail chest often have an underlying pulmonary contusion, pneumothorax, or hemothorax that requires specific treatment. This patient is hypoxic despite 10 liters of oxygen delivered by face mask. Treatment is necessary in order to improve oxygenation with either intubation and mechanical ventilation or noninvasive positive pressure ventilation. Positive pressure ventilation is effective in restoring adequate tidal volumes in patients with flail chest by preventing the inward movement during inspiration. A chest tube will not improve oxygenation or pulmonary function and is not indicated. The patient is not hypotensive and neither epinephrine nor vasopressin would improve the patient’s oxygenation.