A 63-year-old woman with severe COPD presented to the ED with progressively worsening dyspnea and wheezing. Her past medical history was significant for numerous COPD exacerbations requiring noninvasive ventilation. In the ED, her vital signs showed a heart rate of 115 beats/min, BP of 155/92 mm Hg, respiratory rate of 24 breaths/min, and oxygen saturation of 90% on 4 L of supplemental oxygen via nasal cannula. The patient was in severe respiratory distress, and physical examination revealed the presence of accessory muscle use and diffuse bilateral expiratory wheezing. Except for tachycardia, her cardiac and abdominal examinations were unremarkable, and her extremities showed no signs of clubbing, cyanosis, or edema. Arterial blood gas results revealed an acute-on-chronic respiratory acidosis. Portable chest radiograph showed hyperinflated lungs with no obvious infiltrate, interstitial edema, or pleural effusions. Because of worsening respiratory distress despite repeated doses of bronchodilators and IV corticosteroids, noninvasive positive pressure ventilation was begun. A medical ICU consult was called. After initial history and physical examination, bedside ultrasonography was performed to evaluate the etiology of respiratory failure (Video 1).