Pt w COVID19 PNA. Talking but w refractory hypoxemia 88% on 15 L NRB. RR 22 HR 103. Intubation was planned. No good peripheral IV. I placed a #POCUS guided CVC on right IJ. Pt placed in supine position, performed valsalva to dilate vein. After procedure pt with SUDDEN DISTRESS 1/

As I finished placing the line, pt with severe dyspnea, very heavy work of breathing. RR 48, HR 140. O2 Sat 72% on 15 L NRB. Immediately repositioned the patient (High Fowler's Upright Position). No improvement. #POCUS at right upper quadrant (semi-fowler) good pleural sliding 2/

Chest-X ray w no pneumothorax. Pt did not improve w position. Fortunately intubation was successful and is now doing better. This was just ARDS that deteriorated quickly. I believe supine position precipitated deterioration. Could valsalva maneuver have played a role? 3/3

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