Moderate COPD with Subsequent Bronchospasm

Description

A 62 year-old contractor developed pneumonia while working on a water purification system. He has 90- pack year history of cigarette smoking (2 packs per day x 45 years), has type II diabetes and primary hypertension managed with oral medications. He uses a rescue inhaler (albuterol) and is on a maintenance inhaled corticosteroid. His pre-deployment FEV-1 is 43% of predicted. The patient is 5'9'' tall, weighs 210 lbs and has no known allergies. Chest radiograph demonstrates left-lower lobe consolidation, haziness in the right lower lobe, flattened diaphragms and hyperinflation in the upper lung fields. Heart rate is normal sinus rhythm and occasional PVC's. Patient is sedated and not triggering ventilator.

Figure 1. Chest radiograph demonstrates left-lower lobe consolidation, haziness in the right lower lobe, flattened diaphragms and hyperinflation in the upper lung fields.

Segment Validation

Segment 1

Learning Objectives:

Assess baseline status
Recognize presence of autoPEEP (from flow waveform)
Suspect obstructive lung disease (high minute ventilation requirement but high SpO2 and low Pplat)

Recommended Actions:

None

Ventilator settings are:

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
VC-CMV	0.600	NA	64	NA	0.6	18	5	0.4

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 600 [17]	592.5	1.3%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 24 [381] [270]	23.55	1.9%	Rinsp for moderate COPD
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 36 [381]	37.05	2.9%	Rexp for moderate COPD
RespiratoryCompliance(mL/cmH2O)	EqualTo 68 [229]	65.92	3.1%	C for moderate COPD
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.49 [113]	0.4775	2.6%	VD/VT for moderate COPD
ShuntFraction	EqualTo 0.19 [364]	0.2035	6.9%	QS/QT for moderate COPD

Figure 2. Vitals and ventilator monitors for Segment 1.

Table 2. Data requests for Segment 1.

Property Name	Engine Value
Patient-Height(in)	69
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	23.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	37.1
RespiratoryCompliance(mL/cmH2O)	65.9
PhysiologicDeadSpaceTidalVolumeRatio	0.477
ShuntFraction	0.204
MechanicalVentilator-TidalVolume(L)	0.593
BloodPH	7.39
Aorta-Oxygen-PartialPressure(mmHg)	74.4
Aorta-CarbonDioxide-PartialPressure(mmHg)	43
Aorta-Bicarbonate-Molarity(mEq/L)	26
OxygenSaturation	0.954
HorowitzIndex(mmHg)	186
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	4.44
MechanicalVentilator-RespirationRate(1/min)	18
MechanicalVentilator-MeanAirwayPressure(cmH2O)	11
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	43.3
MechanicalVentilator-PlateauPressure(cmH2O)	16.9
HeartRate(1/min)	79.1
SystolicArterialPressure(mmHg)	112
DiastolicArterialPressure(mmHg)	75.8
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	23.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	37.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	65.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	15.5
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	34
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	266
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.593
MechanicalVentilator-InspiratoryExpiratoryRatio	0.219
MechanicalVentilator-InspiratoryTidalVolume(L)	0.593
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.337
MechanicalVentilator-LeakFraction	8.88E-14
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.93
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	7.93
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.01
TotalPositiveEndExpiratoryPressure(cmH2O)	9.45
EndTidalCarbonDioxidePressure(mmHg)	36.1
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	186
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.209
FractionOfInspiredOxygen	0.4
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	2.4
HeartStrokeVolume(mL)	70.7
HeartEjectionFraction	0.526
BloodVolume(L)	6.57
MeanArterialPressure(mmHg)	94.9
PulsePressure(mmHg)	35.9
CardiacOutput(L/min)	5.59
CarbonDioxideSaturation	0.0526
RespiratoryExchangeRatio	0.816
SystemicVascularResistance(mmHg_s/mL)	0.967
OxygenConsumptionRate(mL/min)	264
CarbonDioxideProductionRate(mL/min)	215
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	5.1
Patient-VitalCapacity(L)	4

Segment 2

Twenty minutes into the transport the patient is slightly agitated and is making inspiratory efforts that are not in sync with the ventilator.

Learning Objectives:

Recognize increased airway resistance (PIP much higher than Pplat)
Recognize autoPEEP (from flow waveform)
Recognize failed trigger efforts due to autoPEEP (examine expiratory flow waveform)
Recognize over-assistance (vent trigger rate higher than patient trigger rate)

Recommended Actions:

Goal shifts to Comfort (improve synchrony) due to failed trigger efforts
Check airway patency (secretions?) suction ETT
Check breath sounds (wheezing?) - suspect bronchospasm and consider bronchodilator

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 600 [17]	590.2	1.7%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment 1 (23.55) [304] [308]	32.55		38.2%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment 1 (37.05) [304] [308]	50.55		36.4%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment 1 (43.33) [304] [308]	56.97		31.5%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment 1 (16.92) [304] [308]	17.03		0.6%	Pplat

Figure 3. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	69
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	32.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	50.5
RespiratoryCompliance(mL/cmH2O)	74.6
PhysiologicDeadSpaceTidalVolumeRatio	0.477
ShuntFraction	0.207
MechanicalVentilator-TidalVolume(L)	0.59
BloodPH	7.38
Aorta-Oxygen-PartialPressure(mmHg)	74.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	43.2
Aorta-Bicarbonate-Molarity(mEq/L)	26
OxygenSaturation	0.954
HorowitzIndex(mmHg)	187
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	9.05
MechanicalVentilator-RespirationRate(1/min)	18
MechanicalVentilator-MeanAirwayPressure(cmH2O)	13.4
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	57
MechanicalVentilator-PlateauPressure(cmH2O)	17
HeartRate(1/min)	77.9
SystolicArterialPressure(mmHg)	112
DiastolicArterialPressure(mmHg)	75.8
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	32.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	50.5
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	72.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	11.4
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	34.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	266
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.578
MechanicalVentilator-InspiratoryExpiratoryRatio	0.219
MechanicalVentilator-InspiratoryTidalVolume(L)	0.59
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.324
MechanicalVentilator-LeakFraction	0.0215
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	3.86
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	8.86
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.02
TotalPositiveEndExpiratoryPressure(cmH2O)	14.1
EndTidalCarbonDioxidePressure(mmHg)	37.4
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	189
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.294
FractionOfInspiredOxygen	0.4
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	2.37
HeartStrokeVolume(mL)	70.9
HeartEjectionFraction	0.526
BloodVolume(L)	6.59
MeanArterialPressure(mmHg)	94.9
PulsePressure(mmHg)	36
CardiacOutput(L/min)	5.53
CarbonDioxideSaturation	0.0647
RespiratoryExchangeRatio	0.815
SystemicVascularResistance(mmHg_s/mL)	0.979
OxygenConsumptionRate(mL/min)	260
CarbonDioxideProductionRate(mL/min)	212
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	5.1
Patient-VitalCapacity(L)	4

Segment 3

Patient suctioned and albuterol administered.

Learning Objectives:

Recognize that treatment reduced airway resistance (lower difference PIP - Pplat)
AutoPEEP reduced
Failed trigger efforts disappeared
Recognize that now discordance problem is early cycle

Recommended Actions:

Goal shifts to Comfort (imprive synchrony) due to cycle dyssychrony
Consider switching mode to PC-CSV (ie Pressure Support)

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 600 [17]	601.7	0.3%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment 2 (32.55) [304] [308]	10.05		-69.1%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment 2 (50.55) [304] [308]	10.05		-80.1%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment 2 (56.97) [304] [308]	23.71		-58.4%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment 2 (17.03) [304] [308]	15.65		-8.1%	Pplat

Figure 4. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	69
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	10.1
ExpiratoryRespiratoryResistance(cmH2O_s/L)	10.1
RespiratoryCompliance(mL/cmH2O)	57.5
PhysiologicDeadSpaceTidalVolumeRatio	0.477
ShuntFraction	0.202
MechanicalVentilator-TidalVolume(L)	0.602
BloodPH	7.39
Aorta-Oxygen-PartialPressure(mmHg)	76.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	42.9
Aorta-Bicarbonate-Molarity(mEq/L)	26
OxygenSaturation	0.957
HorowitzIndex(mmHg)	191
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00235
MechanicalVentilator-RespirationRate(1/min)	19
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.59
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	23.7
MechanicalVentilator-PlateauPressure(cmH2O)	15.6
HeartRate(1/min)	94.6
SystolicArterialPressure(mmHg)	110
DiastolicArterialPressure(mmHg)	79
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.4
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	57.2
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	32.2
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	32.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	269
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.602
MechanicalVentilator-InspiratoryExpiratoryRatio	0.234
MechanicalVentilator-InspiratoryTidalVolume(L)	0.602
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.725
MechanicalVentilator-LeakFraction	0
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.122
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.12
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	5
EndTidalCarbonDioxidePressure(mmHg)	34.1
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	186
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.146
FractionOfInspiredOxygen	0.4
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	2.46
HeartStrokeVolume(mL)	61.6
HeartEjectionFraction	0.489
BloodVolume(L)	6.62
MeanArterialPressure(mmHg)	95.3
PulsePressure(mmHg)	31.3
CardiacOutput(L/min)	5.83
CarbonDioxideSaturation	0.0442
RespiratoryExchangeRatio	0.818
SystemicVascularResistance(mmHg_s/mL)	0.931
OxygenConsumptionRate(mL/min)	260
CarbonDioxideProductionRate(mL/min)	213
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	5.1
Patient-VitalCapacity(L)	4

Scenario Output Plots

Figure 5. Select outputs from the scenario.