CSTARS Scenario 6

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.

Figure 1. Chest radiograph demonstrates bilateral infiltrates with right middle and lower lobe consolidation, but no signs of barotrauma.

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
Table 1. Data request validation results for Segment 1.
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


Figure 2. Vitals and ventilator monitors for Segment 1.


Table 2. Data requests for Segment 1.
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


Table 3. Data request validation results for Segment 2.
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


Figure 3. Vitals and ventilator monitors for Segment 2.


Table 4. Data requests for Segment 2.
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


Table 5. Data request validation results for Segment 3.
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


Figure 4. Vitals and ventilator monitors for Segment 3.


Table 6. Data requests for Segment 3.
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


Figure 5. Select outputs from the scenario.


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