Hypoxemic Respiratory Failure - Pneumonia
Description
A 23 year old soldier suffered developed shortness of breath, substernal chest pain and a productive cough following burn pit exposure. He was started on broad spectrum antibiotics and steroids for a suspected respiratory tract infection. Initial chest x-ray demonstrated some minor hilar infiltrates. On day 5 of his antibiotic course he developed worsening dyspnea, was febrile to 39.5 C, a breathing frequency of 32 bpm and his SpO2 was 91%. He was placed on high flow nasal cannula at 50% and 40 L/min. After 12 hours he was intubated.After intubation he is on mechanical ventilation and remains sedated with a RASS of -2.
The soldier is 6'3'' and weighs 215 lbs. Suctioning reveals thick, tenacious, brownish-yellow secretions. Therapeutic bronchoscopy is performed and 15-20 mL secretions removed and sent for culture and sensitivity. Initial gram stain suggests acinetobacter baumanni. Antibiotics are changed to a carbapenem. He is scheduled for CCATT to definitive care in the morning.
Segment Validation
Segment 1
Learning Objectives:
- Assess baseline status
- Recognize moderate ARDS
Recommended Actions:
- None
Ventilator settings are:
Mode | VT (L) | PIP (cmH2O) | Flow (L/min) | I:E | TI (s) | RR (bpm) | PEEP (cmH2O) | FiO2 |
---|---|---|---|---|---|---|---|---|
PC-CMV | NA | 20 | NA | NA | 0.6 | 10 | 10 | 0.60 |
Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
---|---|---|---|---|---|
InspiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [17] | 12.4 | 3.08% | Rinsp for moderate ARDS | |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [17] | 12.4 | 3.16% | Rexp for moderate ARDS | |
RespiratoryCompliance(mL/cmH2O) | EqualTo 40 [305] | 42.6 | 6.37% | C requested by SME for moderate ARDS | |
PhysiologicDeadSpaceTidalVolumeRatio | EqualTo 0.57 [230] | 0.553 | 3.03% | VD/VT for moderate ARDS | |
ClinicalShuntFraction | [0.300,0.500] [222] | 0.301 | 0.00% | QS/QT for moderate ARDS (determined from blood gas values) | |
HorowitzIndex(mmHg) | [100,200] [115] | 118 | 0.00% | PaO2/FiO2 for moderate ARDS |
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Property Name | Engine Value |
---|---|
Patient-Height(in) | 75.0 |
Patient-IdealBodyWeight(kg) | 84.5 |
InspiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
RespiratoryCompliance(mL/cmH2O) | 42.6 |
ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.598 |
ClinicalShuntFraction | 0.301 |
MechanicalVentilator-TidalVolume(L) | 0.411 |
BloodPH | 7.28 |
Aorta-Oxygen-PartialPressure(mmHg) | 70.4 |
Aorta-CarbonDioxide-PartialPressure(mmHg) | 55.6 |
Aorta-Bicarbonate-Molarity(mEq/L) | 26.6 |
OxygenSaturation | 0.930 |
HorowitzIndex(mmHg) | 118 |
IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.128 |
MechanicalVentilator-RespirationRate(1/min) | 34.9 |
MechanicalVentilator-MeanAirwayPressure(cmH2O) | 13.3 |
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 20.0 |
MechanicalVentilator-PlateauPressure(cmH2O) | 20.8 |
HeartRate(1/min) | 69.6 |
SystolicArterialPressure(mmHg) | 116 |
DiastolicArterialPressure(mmHg) | 72.8 |
MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 14.3 |
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 12.3 |
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 12.4 |
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 42.6 |
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 41.3 |
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 33.7 |
MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 423 |
MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.411 |
MechanicalVentilator-InspiratoryExpiratoryRatio | 0.536 |
MechanicalVentilator-InspiratoryTidalVolume(L) | 0.411 |
MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.678 |
MechanicalVentilator-LeakFraction | 2.64e-05 |
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 1.16 |
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 11.2 |
PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
ShuntFraction | 0.304 |
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
TotalRespiratoryModelCompliance(mL/cmH2O) | 46.9 |
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
TotalPositiveEndExpiratoryPressure(cmH2O) | 10.1 |
EndTidalCarbonDioxidePressure(mmHg) | 38.0 |
PhysiologicDeadSpace(mL) | 327 |
AlveolarArterialGradient(mmHg) | 334 |
AlveolarDeadSpace(mL) | 158 |
AnatomicDeadSpace(mL) | 169 |
ChestWallCompliance(L/cmH2O) | 0.196 |
FractionOfInspiredOxygen | 0.599 |
LungCompliance(L/cmH2O) | 0.0590 |
VentilationPerfusionRatio | 3.37 |
HeartStrokeVolume(mL) | 87.8 |
HeartEjectionFraction | 0.570 |
BloodVolume(L) | 7.09 |
MeanArterialPressure(mmHg) | 95.6 |
PulsePressure(mmHg) | 42.9 |
CardiacOutput(L/min) | 6.10 |
CarbonDioxideSaturation | 0.460 |
RespiratoryExchangeRatio | 0.818 |
SystemicVascularResistance(mmHg_s/mL) | 0.892 |
OxygenConsumptionRate(mL/min) | 309 |
CarbonDioxideProductionRate(mL/min) | 253 |
Patient-AlveoliSurfaceArea(m^2) | 15.3 |
Patient-ExpiratoryReserveVolume(L) | 0.969 |
Patient-FunctionalResidualCapacity(L) | 1.43 |
Patient-InspiratoryCapacity(L) | 3.46 |
Patient-InspiratoryReserveVolume(L) | 2.84 |
Patient-ResidualVolume(L) | 0.457 |
Patient-TidalVolumeBaseline(L) | 0.622 |
Patient-TotalLungCapacity(L) | 4.89 |
Patient-VitalCapacity(L) | 4.43 |
Segment 2
The patient is loaded onto the aircraft for transfer to Level III care. During transport the patient becomes agitated and respiratory rate increases and SpO2 has fallen. Learning Objectives:
- Recognize hypoventilation due to increased secretions
- Recognize gas trapping due to high respiratory rate (expiratory flow does not return to zero)
Recommended Actions:
- Check for pneumothorax
- Suction
Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
---|---|---|---|---|---|
MechanicalVentilator-TidalVolume(mL) | LessThan Segment1 (411) | 199 | -51.6% | VT (measured) | |
InspiratoryRespiratoryResistance(cmH2O_s/L) | GreaterThan Segment1 (12.4) [305] [309] | 20.5 | 65.8% | Rinsp | |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | GreaterThan Segment1 (12.4) [305] [309] | 20.5 | 65.7% | Rexp |
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Property Name | Engine Value |
---|---|
Patient-Height(in) | 75.0 |
Patient-IdealBodyWeight(kg) | 84.5 |
InspiratoryRespiratoryResistance(cmH2O_s/L) | 20.5 |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | 20.5 |
RespiratoryCompliance(mL/cmH2O) | 43.9 |
ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.572 |
ClinicalShuntFraction | 0.286 |
MechanicalVentilator-TidalVolume(L) | 0.199 |
BloodPH | 7.19 |
Aorta-Oxygen-PartialPressure(mmHg) | 78.1 |
Aorta-CarbonDioxide-PartialPressure(mmHg) | 69.7 |
Aorta-Bicarbonate-Molarity(mEq/L) | 27.1 |
OxygenSaturation | 0.931 |
HorowitzIndex(mmHg) | 135 |
IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.0526 |
MechanicalVentilator-RespirationRate(1/min) | 46.2 |
MechanicalVentilator-MeanAirwayPressure(cmH2O) | 14.4 |
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 20.0 |
MechanicalVentilator-PlateauPressure(cmH2O) | 16.7 |
HeartRate(1/min) | 113 |
SystolicArterialPressure(mmHg) | 111 |
DiastolicArterialPressure(mmHg) | 80.2 |
MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 9.19 |
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 20.5 |
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 20.5 |
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 43.6 |
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 19.9 |
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 35.0 |
MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 410 |
MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.199 |
MechanicalVentilator-InspiratoryExpiratoryRatio | 0.857 |
MechanicalVentilator-InspiratoryTidalVolume(L) | 0.199 |
MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.462 |
MechanicalVentilator-LeakFraction | 0.00196 |
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 2.09 |
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 12.1 |
PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
ShuntFraction | 0.280 |
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 20.5 |
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 20.5 |
TotalRespiratoryModelCompliance(mL/cmH2O) | 47.8 |
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
TotalPositiveEndExpiratoryPressure(cmH2O) | 10.1 |
EndTidalCarbonDioxidePressure(mmHg) | 43.2 |
PhysiologicDeadSpace(mL) | 327 |
AlveolarArterialGradient(mmHg) | 290 |
AlveolarDeadSpace(mL) | 158 |
AnatomicDeadSpace(mL) | 169 |
ChestWallCompliance(L/cmH2O) | 0.182 |
FractionOfInspiredOxygen | 0.579 |
LungCompliance(L/cmH2O) | 0.0590 |
VentilationPerfusionRatio | 1.87 |
HeartStrokeVolume(mL) | 61.4 |
HeartEjectionFraction | 0.475 |
BloodVolume(L) | 7.10 |
MeanArterialPressure(mmHg) | 96.1 |
PulsePressure(mmHg) | 30.9 |
CardiacOutput(L/min) | 6.95 |
CarbonDioxideSaturation | 0.607 |
RespiratoryExchangeRatio | 0.827 |
SystemicVascularResistance(mmHg_s/mL) | 0.787 |
OxygenConsumptionRate(mL/min) | 322 |
CarbonDioxideProductionRate(mL/min) | 266 |
Patient-AlveoliSurfaceArea(m^2) | 15.3 |
Patient-ExpiratoryReserveVolume(L) | 0.969 |
Patient-FunctionalResidualCapacity(L) | 1.43 |
Patient-InspiratoryCapacity(L) | 3.46 |
Patient-InspiratoryReserveVolume(L) | 2.84 |
Patient-ResidualVolume(L) | 0.457 |
Patient-TidalVolumeBaseline(L) | 0.622 |
Patient-TotalLungCapacity(L) | 4.89 |
Patient-VitalCapacity(L) | 4.43 |
Segment 3
Patient is suctioned for large volume of thick secretions. Learning Objectives:
- Recognize that suctioning decreased airway resistance and restored tidal volume)
Recommended Actions:
- None
Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
---|---|---|---|---|---|
MechanicalVentilator-TidalVolume(mL) | GreaterThan Segment2 (199) | 418 | 110% | VT (measured) | |
InspiratoryRespiratoryResistance(cmH2O_s/L) | LessThan Segment2 (20.5) [305] [309] | 12.4 | -39.7% | Rinsp | |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | LessThan Segment2 (20.5) [305] [309] | 12.4 | -39.7% | Rexp |
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Property Name | Engine Value |
---|---|
Patient-Height(in) | 75.0 |
Patient-IdealBodyWeight(kg) | 84.5 |
InspiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
ExpiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
RespiratoryCompliance(mL/cmH2O) | 43.2 |
ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.604 |
ClinicalShuntFraction | 0.297 |
MechanicalVentilator-TidalVolume(L) | 0.418 |
BloodPH | 7.27 |
Aorta-Oxygen-PartialPressure(mmHg) | 72.1 |
Aorta-CarbonDioxide-PartialPressure(mmHg) | 57.9 |
Aorta-Bicarbonate-Molarity(mEq/L) | 26.7 |
OxygenSaturation | 0.930 |
HorowitzIndex(mmHg) | 120 |
IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.146 |
MechanicalVentilator-RespirationRate(1/min) | 35.3 |
MechanicalVentilator-MeanAirwayPressure(cmH2O) | 13.4 |
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 20.0 |
MechanicalVentilator-PlateauPressure(cmH2O) | 21.0 |
HeartRate(1/min) | 68.8 |
SystolicArterialPressure(mmHg) | 116 |
DiastolicArterialPressure(mmHg) | 72.3 |
MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 14.8 |
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 12.3 |
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 12.4 |
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 42.7 |
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 42.0 |
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 35.0 |
MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 423 |
MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.418 |
MechanicalVentilator-InspiratoryExpiratoryRatio | 0.545 |
MechanicalVentilator-InspiratoryTidalVolume(L) | 0.418 |
MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.701 |
MechanicalVentilator-LeakFraction | 0.00 |
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 1.22 |
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 11.2 |
PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
ShuntFraction | 0.297 |
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
TotalRespiratoryModelCompliance(mL/cmH2O) | 46.8 |
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
TotalPositiveEndExpiratoryPressure(cmH2O) | 10.1 |
EndTidalCarbonDioxidePressure(mmHg) | 39.3 |
PhysiologicDeadSpace(mL) | 327 |
AlveolarArterialGradient(mmHg) | 335 |
AlveolarDeadSpace(mL) | 158 |
AnatomicDeadSpace(mL) | 169 |
ChestWallCompliance(L/cmH2O) | 0.190 |
FractionOfInspiredOxygen | 0.599 |
LungCompliance(L/cmH2O) | 0.0591 |
VentilationPerfusionRatio | 3.40 |
HeartStrokeVolume(mL) | 90.2 |
HeartEjectionFraction | 0.577 |
BloodVolume(L) | 7.13 |
MeanArterialPressure(mmHg) | 95.6 |
PulsePressure(mmHg) | 43.9 |
CardiacOutput(L/min) | 6.20 |
CarbonDioxideSaturation | 0.493 |
RespiratoryExchangeRatio | 0.821 |
SystemicVascularResistance(mmHg_s/mL) | 0.878 |
OxygenConsumptionRate(mL/min) | 313 |
CarbonDioxideProductionRate(mL/min) | 257 |
Patient-AlveoliSurfaceArea(m^2) | 15.3 |
Patient-ExpiratoryReserveVolume(L) | 0.969 |
Patient-FunctionalResidualCapacity(L) | 1.43 |
Patient-InspiratoryCapacity(L) | 3.46 |
Patient-InspiratoryReserveVolume(L) | 2.84 |
Patient-ResidualVolume(L) | 0.457 |
Patient-TidalVolumeBaseline(L) | 0.622 |
Patient-TotalLungCapacity(L) | 4.89 |
Patient-VitalCapacity(L) | 4.43 |
Scenario Output Plots
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