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You are sedating a 16 year old boy with past medical history of spontaneously resolved VSD as an infant with ketamine for tube thoracostomy to treat a spontaneous pneumothorax. Before the tube thoracostomy procedure can begin, the patient has a sudden episode of oxygen desaturation, lack of end-tidal CO2 waveform, and gurgling noises. It successfully resolves after a couple of minutes of bag-valve-mask ventilation, and the practitioners prepare to begin the procedure again. However, immediately thereafter the patient begins to cough up pink frothy secretions and to desaturate again, although the end-tidal CO2 waveform does not change this time. 

What is the most likely cause of this patient’s deterioration?