Case presentation

A woman in her 60s with a medical history of chronic obstructive pulmonary disease, obstructive sleep apnoea and diabetes mellitus presents for 1 week of worsening shortness of breath and fever despite increasing usage of her home nebulisers. The patient describes daily fever, increased cough and mild achy chest pain. She denies abdominal pain, nausea, vomiting, orthopnoea, leg swelling or other symptoms on review of systems. Her temperature is 38.9°C, HR is 112 beats per minute, BP is 108/72 mm Hg, RR is 28 breaths per minute and pulse oxygenation on room air is 82%.

On examination, you see an ill-appearing woman sitting up in bed in obvious respiratory distress. She is talking in two to three-word sentences. Diffuse wheezing is heard throughout all lung fields with focal rhonchi in the left lower lung field. Cardiac examination is notable for tachycardia with a regular rhythm and no murmurs to auscultation. Capillary refill is less than 2 s. The remainder of the examination is unremarkable.

Despite a brief trial of bilevel positive pressure ventilation with continuous in-line albuterol and ipratropium nebulisers the patient develops confusion and worsening respiratory distress. The decision to intubate is made and sedative and paralytic medications are administered. The laryngoscope is inserted and a Cormack-Lehane grade 3 view is obtained with only the epiglottis visualised. After some difficulty, you are able to pass the endotracheal tube (ETT) over a bougie. You place a linear ultrasound probe over the suprasternal notch and obtain this view (figure 1).