Moderate 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

Diagnosis: Moderate ARDS.
Upon arrival to the recovery room she is on mechanical ventilation and remains sedated. Upon arrival to the recovery room she is on mechanical ventilation and remains sedated. 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	20	5	0.4

Vital signs demonstrate the response to injury.

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376 [17]	378	0.5%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	12.38	3.1%	Rinsp for moderate ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	12.38	3.1%	Rexp for moderate ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 35 [229]	29.59	16.8%	C for moderate ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.57 [229]	0.5538	2.9%	VD/VT for moderate ARDS
ShuntFraction	EqualTo 0.3 [229]	0.3963	27.7%	QS/QT for moderate ARDS
HorowitzIndex(mmHg)	[100,200] [115]	161.5	0.0%	PaO2/FiO2

Figure 2. Vitals and ventilator monitors for Segment 1.

Table 2. Data requests for Segment 1.

Property Name	Engine Value
Patient-Height(in)	65
Patient-IdealBodyWeight(kg)	57
InspiratoryRespiratoryResistance(cmH2O_s/L)	12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	12.4
RespiratoryCompliance(mL/cmH2O)	29.6
PhysiologicDeadSpaceTidalVolumeRatio	0.554
ShuntFraction	0.396
MechanicalVentilator-TidalVolume(L)	0.378
BloodPH	7.14
Aorta-Oxygen-PartialPressure(mmHg)	64.3
Aorta-CarbonDioxide-PartialPressure(mmHg)	80.6
Aorta-Bicarbonate-Molarity(mEq/L)	27.5
OxygenSaturation	0.876
HorowitzIndex(mmHg)	162
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0134
MechanicalVentilator-RespirationRate(1/min)	20
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.88
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	25.6
MechanicalVentilator-PlateauPressure(cmH2O)	17
HeartRate(1/min)	154
SystolicArterialPressure(mmHg)	108
DiastolicArterialPressure(mmHg)	83.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	7.56
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.3
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	15.2
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	31.6
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	18.4
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	46.8
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	252
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.378
MechanicalVentilator-InspiratoryExpiratoryRatio	0.25
MechanicalVentilator-InspiratoryTidalVolume(L)	0.378
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.788
MechanicalVentilator-LeakFraction	1.13E-13
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0803
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.08
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	5.01
EndTidalCarbonDioxidePressure(mmHg)	52.5
PhysiologicDeadSpace(mL)	221
AlveolarArterialGradient(mmHg)	170
AlveolarDeadSpace(mL)	107
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0809
FractionOfInspiredOxygen	0.398
LungCompliance(L/cmH2O)	0.0494
VentilationPerfusionRatio	1.98
HeartStrokeVolume(mL)	41.9
HeartEjectionFraction	0.396
BloodVolume(L)	4.61
MeanArterialPressure(mmHg)	96
PulsePressure(mmHg)	24.8
CardiacOutput(L/min)	6.44
CarbonDioxideSaturation	0.175
RespiratoryExchangeRatio	0.83
SystemicVascularResistance(mmHg_s/mL)	0.848
OxygenConsumptionRate(mL/min)	214
CarbonDioxideProductionRate(mL/min)	178
Patient-AlveoliSurfaceArea(m^2)	10.3
Patient-ExpiratoryReserveVolume(L)	0.638
Patient-FunctionalResidualCapacity(L)	0.927
Patient-InspiratoryCapacity(L)	2.28
Patient-InspiratoryReserveVolume(L)	1.83
Patient-ResidualVolume(L)	0.29
Patient-TidalVolumeBaseline(L)	0.442
Patient-TotalLungCapacity(L)	3.2
Patient-VitalCapacity(L)	2.91

Segment 2

Diagnosis: Right Mainstem Intubation.

The patient is agitated and PIP and Pplat have increased, SpO2 has fallen, and ETCO2 has decreased.

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376 [17]	377.9	0.5%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	LessThan Segment 1 (29.59) [304]	26.83		-9.3%	C
Aorta-Oxygen-PartialPressure(mmHg)	LessThan Segment 1 (64.31) [186]	42.79		-33.5%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment 1 (25.57) [304]	30.55		19.4%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment 1 (16.96) [304]	26.33		55.2%	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
Patient-IdealBodyWeight(kg)	57
InspiratoryRespiratoryResistance(cmH2O_s/L)	14.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	250
RespiratoryCompliance(mL/cmH2O)	26.8
PhysiologicDeadSpaceTidalVolumeRatio	0.554
ShuntFraction	0.37
MechanicalVentilator-TidalVolume(L)	0.378
BloodPH	7.11
Aorta-Oxygen-PartialPressure(mmHg)	42.8
Aorta-CarbonDioxide-PartialPressure(mmHg)	85.9
Aorta-Bicarbonate-Molarity(mEq/L)	27.6
OxygenSaturation	0.685
HorowitzIndex(mmHg)	107
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	1.44
MechanicalVentilator-RespirationRate(1/min)	20
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.15
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	30.5
MechanicalVentilator-PlateauPressure(cmH2O)	26.3
HeartRate(1/min)	188
SystolicArterialPressure(mmHg)	106
DiastolicArterialPressure(mmHg)	85.8
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	7.56
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	6.03
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	9.99
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	17.7
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	14.8
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	35.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	265
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.378
MechanicalVentilator-InspiratoryExpiratoryRatio	0.25
MechanicalVentilator-InspiratoryTidalVolume(L)	0.378
MechanicalVentilator-PeakExpiratoryFlow(L/s)	2.13
MechanicalVentilator-LeakFraction	1.03E-11
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.78E-05
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	6.45
EndTidalCarbonDioxidePressure(mmHg)	38.9
PhysiologicDeadSpace(mL)	221
AlveolarArterialGradient(mmHg)	112
AlveolarDeadSpace(mL)	107
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0735
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0452
VentilationPerfusionRatio	2.1
HeartStrokeVolume(mL)	31.5
HeartEjectionFraction	0.327
BloodVolume(L)	4.62
MeanArterialPressure(mmHg)	95.8
PulsePressure(mmHg)	20.4
CardiacOutput(L/min)	5.93
CarbonDioxideSaturation	0.182
RespiratoryExchangeRatio	0.815
SystemicVascularResistance(mmHg_s/mL)	0.911
OxygenConsumptionRate(mL/min)	197
CarbonDioxideProductionRate(mL/min)	161
Patient-AlveoliSurfaceArea(m^2)	10.3
Patient-ExpiratoryReserveVolume(L)	0.638
Patient-FunctionalResidualCapacity(L)	0.927
Patient-InspiratoryCapacity(L)	2.28
Patient-InspiratoryReserveVolume(L)	1.83
Patient-ResidualVolume(L)	0.29
Patient-TidalVolumeBaseline(L)	0.442
Patient-TotalLungCapacity(L)	3.2
Patient-VitalCapacity(L)	2.91

Segment 3

Right mainstem resolution.

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376 [17]	378	0.5%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment 2 (26.83) [304]	29.65		10.5%	C
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment 2 (42.79) [186]	65.01		51.9%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment 2 (30.55) [304]	25.57		-16.3%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment 2 (26.33) [304]	16.96		-35.6%	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
Patient-IdealBodyWeight(kg)	57
InspiratoryRespiratoryResistance(cmH2O_s/L)	12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	12.4
RespiratoryCompliance(mL/cmH2O)	29.7
PhysiologicDeadSpaceTidalVolumeRatio	0.554
ShuntFraction	0.404
MechanicalVentilator-TidalVolume(L)	0.378
BloodPH	7.13
Aorta-Oxygen-PartialPressure(mmHg)	65
Aorta-CarbonDioxide-PartialPressure(mmHg)	82.8
Aorta-Bicarbonate-Molarity(mEq/L)	27.6
OxygenSaturation	0.875
HorowitzIndex(mmHg)	163
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0134
MechanicalVentilator-RespirationRate(1/min)	20
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.88
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	25.6
MechanicalVentilator-PlateauPressure(cmH2O)	17
HeartRate(1/min)	151
SystolicArterialPressure(mmHg)	109
DiastolicArterialPressure(mmHg)	84
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	7.56
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.3
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	15.2
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	31.6
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	18.4
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	48.1
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	251
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.378
MechanicalVentilator-InspiratoryExpiratoryRatio	0.25
MechanicalVentilator-InspiratoryTidalVolume(L)	0.378
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.788
MechanicalVentilator-LeakFraction	7.06E-14
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0803
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.08
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	5.01
EndTidalCarbonDioxidePressure(mmHg)	53.9
PhysiologicDeadSpace(mL)	221
AlveolarArterialGradient(mmHg)	170
AlveolarDeadSpace(mL)	107
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0818
FractionOfInspiredOxygen	0.398
LungCompliance(L/cmH2O)	0.0494
VentilationPerfusionRatio	1.98
HeartStrokeVolume(mL)	42.6
HeartEjectionFraction	0.398
BloodVolume(L)	4.65
MeanArterialPressure(mmHg)	96.6
PulsePressure(mmHg)	25.2
CardiacOutput(L/min)	6.43
CarbonDioxideSaturation	0.173
RespiratoryExchangeRatio	0.83
SystemicVascularResistance(mmHg_s/mL)	0.854
OxygenConsumptionRate(mL/min)	214
CarbonDioxideProductionRate(mL/min)	177
Patient-AlveoliSurfaceArea(m^2)	10.3
Patient-ExpiratoryReserveVolume(L)	0.638
Patient-FunctionalResidualCapacity(L)	0.927
Patient-InspiratoryCapacity(L)	2.28
Patient-InspiratoryReserveVolume(L)	1.83
Patient-ResidualVolume(L)	0.29
Patient-TidalVolumeBaseline(L)	0.442
Patient-TotalLungCapacity(L)	3.2
Patient-VitalCapacity(L)	2.91

Scenario Output Plots

Figure 5. Select outputs from the scenario.