Mild ARDS with Right Mainstem Intubation

Description

A 28 year old sailor suffered a crush injury during the transfer of supplies from a fork lift. She suffered an open book pelvic fracture, ruptured bladder and splenic laceration. She required a massive transfusion and intraoperative open reduction and internal fixation of the pelvic fracture. The spleen was removed and the bladder repaired. Blood loss was estimated at 2.5 L. The sailor is 5'5" and weighs 138 lbs.

Figure 1. Chest radiograph demonstrates bilateral infiltrates but no signs of barotrauma.

Segment Validation

Segment 1

Learning Objectives:

Assess baseline status
Recognize mild ARDS

Recommended Actions:

None

Ventilator settings are (VT Target = 6.6 mL/kg (ideal)):

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
VC-CMV	0.376	NA	42	NA	0.6	12	5	0.4

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.72%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.6	3.17%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.6	3.17%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 50 [305]	49.4	1.28%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [230]	0.516	4.57%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [222]	0.223	0.00%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [115]	199	0.325%	PaO2/FiO2 for mild ARDS

Figure 2. Vitals and ventilator monitors for Segment 1.

Table 2. Data requests for Segment 1.

Property Name	Engine Value
Patient-Height(in)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	49.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.455
ClinicalShuntFraction	0.223
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	79.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.961
HorowitzIndex(mmHg)	199
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.102
MechanicalVentilator-RespirationRate(1/min)	26.8
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.07
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.6
MechanicalVentilator-PlateauPressure(cmH2O)	8.67
HeartRate(1/min)	69.5
SystolicArterialPressure(mmHg)	115
DiastolicArterialPressure(mmHg)	73.0
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.53
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	104
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	32.9
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.0
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	268
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.366
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.487
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.454
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.45
PhysiologicDeadSpaceTidalVolumeRatio	0.516
ShuntFraction	0.225
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	58.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.10
EndTidalCarbonDioxidePressure(mmHg)	36.9
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	178
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.154
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0812
VentilationPerfusionRatio	2.51
HeartStrokeVolume(mL)	75.7
HeartEjectionFraction	0.557
BloodVolume(L)	4.47
MeanArterialPressure(mmHg)	95.4
PulsePressure(mmHg)	42.4
CardiacOutput(L/min)	5.26
CarbonDioxideSaturation	0.121
RespiratoryExchangeRatio	0.820
SystemicVascularResistance(mmHg_s/mL)	1.03
OxygenConsumptionRate(mL/min)	204
CarbonDioxideProductionRate(mL/min)	167
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Segment 2

Two hours later the patient is agitated. Both PIP and Pplat have increased. The SpO2 has fallen, and etCO2 has decreased. Learning Objectives:

Recognize right mainstem intubation and recommend repositioning of endotracheal tube

Recommended Actions:

Decreased etCO2, plus greatly increased Pplat and DP, absence of breath sounds on the left side but normal sound to palpation indicate right mainstem intubation
Reposition endotracheal tube and re-assess

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.83%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	LessThan Segment1 (49.4) [305]	28.0		-43.3%	C
Aorta-Oxygen-PartialPressure(mmHg)	LessThan Segment1 (79.5) [186]	44.9		-43.5%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (16.6) [305]	23.6		42.1%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (8.67) [305]	14.6		68.7%	Pplat

Figure 3. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	18.2
ExpiratoryRespiratoryResistance(cmH2O_s/L)	81.9
RespiratoryCompliance(mL/cmH2O)	28.0
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.609
ClinicalShuntFraction	0.555
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	44.9
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.1
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.839
HorowitzIndex(mmHg)	113
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.68
MechanicalVentilator-RespirationRate(1/min)	37.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.16
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	23.6
MechanicalVentilator-PlateauPressure(cmH2O)	14.6
HeartRate(1/min)	153
SystolicArterialPressure(mmHg)	106
DiastolicArterialPressure(mmHg)	85.3
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	14.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.9
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	13.5
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	39.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	20.6
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	24.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	282
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.382
MechanicalVentilator-InspiratoryExpiratoryRatio	0.588
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.710
MechanicalVentilator-LeakFraction	0.00209
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	1.45
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	6.45
PhysiologicDeadSpaceTidalVolumeRatio	0.516
ShuntFraction	0.205
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelCompliance(mL/cmH2O)	59.8
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	7.69
EndTidalCarbonDioxidePressure(mmHg)	26.1
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	116
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.159
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0811
VentilationPerfusionRatio	3.38
HeartStrokeVolume(mL)	34.5
HeartEjectionFraction	0.360
BloodVolume(L)	4.48
MeanArterialPressure(mmHg)	95.3
PulsePressure(mmHg)	20.5
CardiacOutput(L/min)	5.26
CarbonDioxideSaturation	0.125
RespiratoryExchangeRatio	0.805
SystemicVascularResistance(mmHg_s/mL)	1.02
OxygenConsumptionRate(mL/min)	188
CarbonDioxideProductionRate(mL/min)	151
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Segment 3

Endotracheal tube repositioned. Learning Objectives:

Assess effects of tube reposition

Recommended Actions:

None

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.75%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment2 (28.0) [305]	48.3		72.5%	C
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment2 (44.9) [186]	79.6		77.2%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (23.6) [305]	16.6		-29.8%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment2 (14.6) [305]	8.63		-41.0%	Pplat

Figure 4. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	48.3
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.453
ClinicalShuntFraction	0.223
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	79.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.1
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.961
HorowitzIndex(mmHg)	200
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0761
MechanicalVentilator-RespirationRate(1/min)	26.5
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.04
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.6
MechanicalVentilator-PlateauPressure(cmH2O)	8.63
HeartRate(1/min)	67.9
SystolicArterialPressure(mmHg)	116
DiastolicArterialPressure(mmHg)	72.5
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.44
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	105
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	33.0
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.0
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	268
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.361
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.487
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.438
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.44
PhysiologicDeadSpaceTidalVolumeRatio	0.516
ShuntFraction	0.225
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	57.7
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.08
EndTidalCarbonDioxidePressure(mmHg)	36.9
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	175
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.147
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0810
VentilationPerfusionRatio	2.48
HeartStrokeVolume(mL)	77.7
HeartEjectionFraction	0.563
BloodVolume(L)	4.51
MeanArterialPressure(mmHg)	95.4
PulsePressure(mmHg)	43.2
CardiacOutput(L/min)	5.27
CarbonDioxideSaturation	0.120
RespiratoryExchangeRatio	0.821
SystemicVascularResistance(mmHg_s/mL)	1.03
OxygenConsumptionRate(mL/min)	205
CarbonDioxideProductionRate(mL/min)	168
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Scenario Output Plots

Figure 5. Select outputs from the scenario.