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An end-expiratory hold measures intrinsic (auto-) PEEP—the pressure remaining in the system at end expiration due to incomplete exhalation. Elevated auto-PEEP confirms dynamic hyperinflation, consistent with obstructive physiology suggested by wheeze and “shark-fin” EtCO₂. Inspiratory hold (A) evaluates compliance; here the wide peak–plateau gap already points to resistance, not compliance. Lengthening inspiratory time (C) worsens air trapping by shortening expiration. Position change (D) may aid secretion drainage but does not quantify auto-PEEP. Once confirmed, reduce minute ventilation load: lower rate, reduce tidal volume, increase inspiratory flow (shorter inspiratory time), and bronchodilate. Monitor hemodynamics because high intrathoracic pressure reduces venous return. Reassess auto-PEEP after changes, and consider short-acting paralysis only if severe dyssynchrony persists despite optimal sedation and ventilator adjustments.