Achalasia is a rare condition that most often presents with progressive dysphagia to solids and liquids. We report a case of achalasia presenting with acute respiratory failure and hemodynamic instability requiring both ventilator and vasopressor support because of extrinsic compression of the airway and left atrium by a dilated and fluid-filled esophagus. This is the first case reported of achalasia, causing both left atrial compression and airway compression.