Hypoxemic Respiratory Failure Plugged ETT

Description

A 54-year-old, Black contractor was injured in a motor vehicle accident sustaining multiple rib fractures and pulmonary contusion. He lost consciousness at the scene, sustained a complex jaw fracture, near transection of the tongue with significant blood loss and noted to have blood in the trachea at intubation. After intubation he is on mechanical ventilation and remains sedated with a RASS of -2

His initial chest x-ray demonstrated right middle lobe consolidation and some evidence of hyperinflation. The patient has a smoking history of 2 packs per day for 35 years and has primary hypertension managed with drug therapy. He is 5'8'' and weighs 235 lbs. Suctioning reveals a moderate amount of old blood. Gram stain of secretions shows no bacteria. He is scheduled for CCATT to definitive care that night.

Figure 1. Chest radiograph demonstrates with right middle lobe consolidation, flattened diaphragms and hyperinflation in the upper lobes bilaterally, but no signs of barotrauma.

Segment Validation

Segment 1

Learning Objectives:

Assess baseline status

Recommended Actions:

None

Ventilator settings are (delivered VT of 460 ml):

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
PC-CMV	NA	14.2	NA	NA	0.8	10	5	0.40

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 460	464	0.857%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.4	4.80%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.4	4.79%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 50 [305]	50.4	0.728%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [230]	0.515	4.65%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [222]	0.224	0.00%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [115]	196	2.24%	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)	68.0
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.4
RespiratoryCompliance(mL/cmH2O)	50.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.502
ClinicalShuntFraction	0.224
MechanicalVentilator-TidalVolume(L)	0.464
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	78.1
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.959
HorowitzIndex(mmHg)	196
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.191
MechanicalVentilator-RespirationRate(1/min)	25.4
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.04
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	14.9
HeartRate(1/min)	99.6
SystolicArterialPressure(mmHg)	131
DiastolicArterialPressure(mmHg)	72.5
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.8
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	49.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	50.6
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.464
MechanicalVentilator-InspiratoryExpiratoryRatio	0.513
MechanicalVentilator-InspiratoryTidalVolume(L)	0.464
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.664
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.601
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.60
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.225
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	56.8
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.19
EndTidalCarbonDioxidePressure(mmHg)	36.8
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	178
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.146
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	2.52
HeartStrokeVolume(mL)	60.6
HeartEjectionFraction	0.455
BloodVolume(L)	6.37
MeanArterialPressure(mmHg)	102
PulsePressure(mmHg)	58.5
CardiacOutput(L/min)	6.04
CarbonDioxideSaturation	0.124
RespiratoryExchangeRatio	0.818
SystemicVascularResistance(mmHg_s/mL)	0.973
OxygenConsumptionRate(mL/min)	255
CarbonDioxideProductionRate(mL/min)	209
Patient-AlveoliSurfaceArea(m^2)	31.0
Patient-ExpiratoryReserveVolume(L)	0.819
Patient-FunctionalResidualCapacity(L)	1.54
Patient-InspiratoryCapacity(L)	2.93
Patient-InspiratoryReserveVolume(L)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	4.46
Patient-VitalCapacity(L)	3.74

Segment 2

The patient is loaded onto the aircraft for transfer to Level III care. During transport the patient is heavily sedated. Immediately after take-off multiple ventilator alarms sound, tidal volume falls, respiratory rate increases, and SpO2 has fallen. The patient is growing agitated. Attempting to manually ventilate the patient meets extreme resistance and no air movement. Learning Objectives:

Recognize plugged ET tube

Recommended Actions:

Suction ET tube to remove obstruction

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	LessThan Segment1 (464)	7.05	-98.5%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (11.4) [305] [309]	1.00e+03	8.66e+03%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (11.4) [305] [309]	1.00e+03	8.66e+03%	Rexp

Figure 3. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	68.0
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	1.00e+03
ExpiratoryRespiratoryResistance(cmH2O_s/L)	1.00e+03
RespiratoryCompliance(mL/cmH2O)	47.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.502
ClinicalShuntFraction	0.236
MechanicalVentilator-TidalVolume(L)	0.00705
BloodPH	7.33
Aorta-Oxygen-PartialPressure(mmHg)	71.2
Aorta-CarbonDioxide-PartialPressure(mmHg)	49.3
Aorta-Bicarbonate-Molarity(mEq/L)	26.3
OxygenSaturation	0.941
HorowitzIndex(mmHg)	196
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
MechanicalVentilator-RespirationRate(1/min)	9.97
MechanicalVentilator-MeanAirwayPressure(cmH2O)	6.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	5.27
HeartRate(1/min)	101
SystolicArterialPressure(mmHg)	131
DiastolicArterialPressure(mmHg)	72.4
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	0.0667
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	1.00e+03
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	1.00e+03
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	47.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	0.728
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	17.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	285
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.00286
MechanicalVentilator-InspiratoryExpiratoryRatio	0.153
MechanicalVentilator-InspiratoryTidalVolume(L)	0.00705
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.00264
MechanicalVentilator-LeakFraction	0.572
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.125
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.13
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.237
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	1.00e+03
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	1.00e+03
TotalRespiratoryModelCompliance(mL/cmH2O)	57.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
TotalPositiveEndExpiratoryPressure(cmH2O)	0.00
EndTidalCarbonDioxidePressure(mmHg)	0.00
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	101
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.123
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0788
VentilationPerfusionRatio	2.52
HeartStrokeVolume(mL)	61.0
HeartEjectionFraction	0.455
BloodVolume(L)	6.37
MeanArterialPressure(mmHg)	103
PulsePressure(mmHg)	58.9
CardiacOutput(L/min)	6.16
CarbonDioxideSaturation	0.323
RespiratoryExchangeRatio	0.819
SystemicVascularResistance(mmHg_s/mL)	0.955
OxygenConsumptionRate(mL/min)	256
CarbonDioxideProductionRate(mL/min)	209
Patient-AlveoliSurfaceArea(m^2)	31.0
Patient-ExpiratoryReserveVolume(L)	0.819
Patient-FunctionalResidualCapacity(L)	1.54
Patient-InspiratoryCapacity(L)	2.93
Patient-InspiratoryReserveVolume(L)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	4.46
Patient-VitalCapacity(L)	3.74

Segment 3

Patient suctioned and ET tube obstruction removed. Learning Objectives:

Recognize success of suctioning

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 Segment1 (464)	438	5.70%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (1.00e+03) [305] [309]	11.4		-98.9%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (1.00e+03) [305] [309]	11.4		-98.9%	Rexp

Figure 4. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	68.0
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.4
RespiratoryCompliance(mL/cmH2O)	50.6
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.532
ClinicalShuntFraction	0.219
MechanicalVentilator-TidalVolume(L)	0.438
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	79.9
Aorta-CarbonDioxide-PartialPressure(mmHg)	45.7
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.959
HorowitzIndex(mmHg)	200
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0180
MechanicalVentilator-RespirationRate(1/min)	28.3
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.38
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	14.6
HeartRate(1/min)	98.8
SystolicArterialPressure(mmHg)	131
DiastolicArterialPressure(mmHg)	72.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	12.4
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	50.0
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	47.7
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.8
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.438
MechanicalVentilator-InspiratoryExpiratoryRatio	0.606
MechanicalVentilator-InspiratoryTidalVolume(L)	0.438
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.695
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.872
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.87
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.221
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	56.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.02
EndTidalCarbonDioxidePressure(mmHg)	37.3
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	176
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.164
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	2.65
HeartStrokeVolume(mL)	60.6
HeartEjectionFraction	0.454
BloodVolume(L)	6.39
MeanArterialPressure(mmHg)	103
PulsePressure(mmHg)	58.5
CardiacOutput(L/min)	5.99
CarbonDioxideSaturation	0.196
RespiratoryExchangeRatio	0.822
SystemicVascularResistance(mmHg_s/mL)	0.982
OxygenConsumptionRate(mL/min)	259
CarbonDioxideProductionRate(mL/min)	213
Patient-AlveoliSurfaceArea(m^2)	31.0
Patient-ExpiratoryReserveVolume(L)	0.819
Patient-FunctionalResidualCapacity(L)	1.54
Patient-InspiratoryCapacity(L)	2.93
Patient-InspiratoryReserveVolume(L)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	4.46
Patient-VitalCapacity(L)	3.74

Scenario Output Plots

Figure 5. Select outputs from the scenario.