Angela is a 22yo 49kg female with a history of scleroderma and lupus since age 12, along with asthma, severe failure to thrive, and dysphagia. She has had a Nissen fundoplication and is fed through a gastrostomy tube, both performed at age 14. She is on numerous home medications including chronic methylprednisolone. She was admitted to an outside hospital five weeks ago with SOB, and was treated for pneumonia with antibiotics, although the BAL culture from the bronchoscopy was eventually negative. She was discharged to home, but readmitted less than a week later with severe SOB, and was intubated about 10 days later. She was transferred to your institution for a higher level of care and possible repeat Cytoxan therapy, as she is cared for by a rheumatologist at your center. Over the next 8 days her respiratory status gradually worsens, she is paralyzed and sedated, and on a trial of nitric oxide when you are consulted for possible ECMO.