The occurrence of respiratory failure as a result of a large diaphragmatic hernia is a well-described entity in infants with congenital hernias. On reviewing the literature, the authors did not find a smiliar clinical presentation in the adult population. They report the case of an elderly patient with a large hiatus hernia who developed recurrent episodes of life- threatening respiratory failure and hemodynamic compromise due to recurrent gastric dilatation. Decompression with nasogastric suction resulted in dramatic and immediate relief of the respiratory distress. One should keep in mind the possibility of intrathoracic gastric dilatation as a cause of acute respiratory insufficiency in patients with hiatal hernia.