Hospitalized (1.11.22 - present - currently in ICU);  COVID-19 positive 1.11.22; fully vaccinated (no booster) HISTORIES:  (1.11.22) HPI: This is a 75 y/o female with past medical history significant for HTN, persistent Afib on Coumadin, prior DVT, cardiomyopathy with normalization of LV function, obesity, OSA, chronic lymphedema. She presented to ED this evening with complaints of SOB.  Evidently patient's caregiver came to her residence today at which time the patient complained of shortness of breath. It is unclear as to the duration of the patient's symptoms. EMS was ultimately called and it is reported that patient was saturating around 50% on room air upon their arrival. She was thus placed on oxygen and transferred to the ED. Upon arrival to the ED, patient was urgently intubated. VBG following intubation noted pH-7.17, pCO2-64.5, pO2 <20. Basic labs were significant for positive COVID PCR (patient vaccinated with Pfizer in 1/2021 but has not received booster), pro-bnp of 1858, normal troponin, WBC-11.5, INR-2, normal renal function, and UA which was abnormal and possibly suggestive of infection. CXR with dense bilateral airspace opacities. Patient received 80 mg of IV lasix along with 20 mg of labetalol due to post-intubation hypertension/tachycardia. She also received empiric Vanc/Zosyn, as well as IV Solumedrol. She is currently paralyzed with vecuronium and is receiving sedation with fentanyl/propofol. Assessment and Plan Acute hypoxic respiratory failure secondary to  COVID-19 PNA Status post both Pfizer vaccines Feb 21 Symptom onset unknown Positive testing in ER 1/11 Intubated upon arrival to ED on 1/11  Currently sedated and paralyzed Current respiratory support: Device (Oxygen Therapy): ventilator Vent Settings: FIO2 (%): 100 % Type of Mechanical Vent: Vela Mechanical Rate: 26 breaths/min Set/Target Tidal Volume: 400 PEEP (cm H2O): 12 cm H2O Lung mechanics: Plateau Pressure: 26 cmH2O REC  Continue sedation and chemical paralysis Lung protective ventilation - tidal volume should be closer to 310 ml - currently 400 ml Adjust resp rate first to get pH > 7.3 - then proceed with tidal volume reduction Follow ABG's - for sustained PF ratios less than 150 consider proning Continue weight based IV solumedrol at 75 mg q 12 hours Remdesivir Empiric Abx with Vanc, Zosyn; collect and follow cultures and de-escalate Abx as appropriate Monitor fluid balance, prn lasix for goal net even Progress note from 1.17.22: #COVID-19 -uncertain date of symptom onset, tested positive 01/11/2022 -given high-dose methylprednisolone in the emergency department, now on methylprednisolone 60 mg q.12 hours, day 7 of steroids -continuing on remdesivir -maintain enhanced isolation precautions for now # Acute hypoxic respiratory failure with pneumomediastinum -likely secondary to COVID-19 -initial chest x-ray showed bilateral airspace opacities consistent with viral pneumonia -patient emergently intubated in the ER, hard to ventilate, quickly paralyzed and sedated -initial D-dimer 2010, C-reactive protein 65 -currently saturating 92% on AC volume, 65% FiO2, tidal volume 350, rate of 30, peep 8, plateau pressure of 18 -overall net fluid status negative, -1292 mL, continuing on furosemide 40 mg IV q.12 -doing well off paralytics but still encephalopathic, will discontinue fentanyl and utilize Ativan as needed for agitation -if Ativan is not working for agitation, will start dexmedetomidine -will attempt pressure support ventilation today and monitor -appreciate input from Critical Care Service, Dr.  -monitor pneumomediastinum on repeat imaging with use of positive-pressure ventilation # Pneumomediastinum -in the setting of acute hypoxic respiratory failure from COVID-19 -monitor follow-up imaging