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A 48 year old woman was brought by ambulance to the department with a history of shortness of breath of five days duration.Examination revealed a normotensive, tachypneic, tachycardic, afebrile woman who was in obvious respiratory distress with an audible wheeze. Her saturation was 91% on five litres of oxygen by mask on admission. Her chest examination showed bilateral basal crepitations and few expiratory crepitations in the right lung field. She received a single dose of frusemide, based on a working diagnosis of acute left ventricular failure. Her ECG showed sinus tachycardia and her chest radiograph showed a widened superior mediastinum ( fig 1). Her blood gases showed a low hydrogen ion concentration, low PaCO 2 , low PaO 2 with normal bicarbonate. A diagnosis of pulmonary embolism was considered and intravenous heparin was started. Within the next 15 minutes, she decreased her saturation further to 83% and finally to 61%. Despite undergoing a rapid sequence induction and endotracheal intubation, it was diYcult to maintain her saturation above 85%. Urgent spiral chest computed tomography, to rule out a pulmonary embolus, showed a large mass posterior to the trachea arising from an invasive oesophageal carcinoma. The left main bronchus was narrowed to a slit with left lung collapse with compensatory hyperinflation of the right lung (fig 2).The most common presentation of oesophageal carcinoma is progressive dysphagia.

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