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. 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

Diagnosis: Mild ARDS.
After intubation he is on mechanical ventilation and remains sedated with a RASS of -2.
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	20	NA	NA	0.5	10	5	0.40

Vital signs demonstrate an appropriate response to illness. Blood gases suggests mild ARDS.

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 460 [17]	461.2	0.3%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.62	3.2%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.63	3.2%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 40 [229]	37.72	5.9%	C for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [229]	0.5155	4.6%	VD/VT for mild ARDS
ShuntFraction	EqualTo 0.2 [229]	0.276	31.9%	QS/QT for mild ARDS
HorowitzIndex(mmHg)	[200,300] [115]	181.7	9.6%	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
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	37.7
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.276
MechanicalVentilator-TidalVolume(L)	0.461
BloodPH	7.26
Aorta-Oxygen-PartialPressure(mmHg)	72.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	58.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.7
OxygenSaturation	0.933
HorowitzIndex(mmHg)	182
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.189
MechanicalVentilator-RespirationRate(1/min)	23.4
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.79
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	19.9
MechanicalVentilator-PlateauPressure(cmH2O)	17.5
HeartRate(1/min)	70.6
SystolicArterialPressure(mmHg)	116
DiastolicArterialPressure(mmHg)	73
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.8
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	37.1
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	30.9
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	38
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	261
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.461
MechanicalVentilator-InspiratoryExpiratoryRatio	0.243
MechanicalVentilator-InspiratoryTidalVolume(L)	0.461
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.548
MechanicalVentilator-LeakFraction	2.02E-07
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.105
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.11
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	5.19
EndTidalCarbonDioxidePressure(mmHg)	41.7
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	176
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.111
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0583
VentilationPerfusionRatio	2.49
HeartStrokeVolume(mL)	84.9
HeartEjectionFraction	0.567
BloodVolume(L)	6.43
MeanArterialPressure(mmHg)	95.9
PulsePressure(mmHg)	43.2
CardiacOutput(L/min)	6
CarbonDioxideSaturation	0.198
RespiratoryExchangeRatio	0.831
SystemicVascularResistance(mmHg_s/mL)	0.911
OxygenConsumptionRate(mL/min)	274
CarbonDioxideProductionRate(mL/min)	227
Patient-AlveoliSurfaceArea(m^2)	31
Patient-ExpiratoryReserveVolume(L)	0.783
Patient-FunctionalResidualCapacity(L)	1.46
Patient-InspiratoryCapacity(L)	2.8
Patient-InspiratoryReserveVolume(L)	2.26
Patient-ResidualVolume(L)	0.677
Patient-TidalVolumeBaseline(L)	0.531
Patient-TotalLungCapacity(L)	4.26
Patient-VitalCapacity(L)	3.58

Segment 2

Diagnosis: ETT plug.
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, SpO2 has fallen, and ETCO2 has increased. The patient is growing agitated. Attempting to manually ventilate the patient meets extreme resistance and no air movement.

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	LessThan Segment 1 (461.2) [17]	5.152	-98.9%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment 1 (11.62) [304] [308]	1002	8517.5%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment 1 (11.63) [304] [308]	1002	8515.7%	Rexp

Figure 3. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	68
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	1E+03
ExpiratoryRespiratoryResistance(cmH2O_s/L)	1E+03
RespiratoryCompliance(mL/cmH2O)	39.1
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.265
MechanicalVentilator-TidalVolume(L)	0.00515
BloodPH	7.01
Aorta-Oxygen-PartialPressure(mmHg)	40.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	110
Aorta-Bicarbonate-Molarity(mEq/L)	28.2
OxygenSaturation	0.58
HorowitzIndex(mmHg)	182
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0
MechanicalVentilator-RespirationRate(1/min)	23.1
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.55
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	20
MechanicalVentilator-PlateauPressure(cmH2O)	5.26
HeartRate(1/min)	170
SystolicArterialPressure(mmHg)	108
DiastolicArterialPressure(mmHg)	84.8
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	0.122
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	1E+03
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	1E+03
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	38.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	0.352
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	9.62
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	292
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.00383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.238
MechanicalVentilator-InspiratoryTidalVolume(L)	0.00515
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.00575
MechanicalVentilator-LeakFraction	0.275
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.129
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.13
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	0
TotalPositiveEndExpiratoryPressure(cmH2O)	0
EndTidalCarbonDioxidePressure(mmHg)	0
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	4.97
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.117
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0585
VentilationPerfusionRatio	1.98
HeartStrokeVolume(mL)	41.8
HeartEjectionFraction	0.378
BloodVolume(L)	6.44
MeanArterialPressure(mmHg)	96.5
PulsePressure(mmHg)	23.4
CardiacOutput(L/min)	7.11
CarbonDioxideSaturation	0.168
RespiratoryExchangeRatio	0.817
SystemicVascularResistance(mmHg_s/mL)	0.774
OxygenConsumptionRate(mL/min)	253
CarbonDioxideProductionRate(mL/min)	207
Patient-AlveoliSurfaceArea(m^2)	31
Patient-ExpiratoryReserveVolume(L)	0.783
Patient-FunctionalResidualCapacity(L)	1.46
Patient-InspiratoryCapacity(L)	2.8
Patient-InspiratoryReserveVolume(L)	2.26
Patient-ResidualVolume(L)	0.677
Patient-TidalVolumeBaseline(L)	0.531
Patient-TotalLungCapacity(L)	4.26
Patient-VitalCapacity(L)	3.58

Segment 3

Remove plug.

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 460 [17]	461.5	0.3%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment 2 (1002) [304] [308]	11.63		-98.8%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment 2 (1002) [304] [308]	11.63		-98.8%	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
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	37
PhysiologicDeadSpaceTidalVolumeRatio	0.515
ShuntFraction	0.274
MechanicalVentilator-TidalVolume(L)	0.462
BloodPH	7.25
Aorta-Oxygen-PartialPressure(mmHg)	74.3
Aorta-CarbonDioxide-PartialPressure(mmHg)	60.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.8
OxygenSaturation	0.934
HorowitzIndex(mmHg)	186
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.25
MechanicalVentilator-RespirationRate(1/min)	24.6
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.93
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	19.9
MechanicalVentilator-PlateauPressure(cmH2O)	17.8
HeartRate(1/min)	70.8
SystolicArterialPressure(mmHg)	116
DiastolicArterialPressure(mmHg)	72.8
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	36.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	30.9
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	39
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	262
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.462
MechanicalVentilator-InspiratoryExpiratoryRatio	0.258
MechanicalVentilator-InspiratoryTidalVolume(L)	0.462
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.555
MechanicalVentilator-LeakFraction	0
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.131
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.13
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5
TotalPositiveEndExpiratoryPressure(cmH2O)	5.25
EndTidalCarbonDioxidePressure(mmHg)	42.7
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	178
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.106
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0585
VentilationPerfusionRatio	2.59
HeartStrokeVolume(mL)	85.1
HeartEjectionFraction	0.568
BloodVolume(L)	6.46
MeanArterialPressure(mmHg)	95.7
PulsePressure(mmHg)	43.3
CardiacOutput(L/min)	6.03
CarbonDioxideSaturation	0.195
RespiratoryExchangeRatio	0.831
SystemicVascularResistance(mmHg_s/mL)	0.905
OxygenConsumptionRate(mL/min)	273
CarbonDioxideProductionRate(mL/min)	227
Patient-AlveoliSurfaceArea(m^2)	31
Patient-ExpiratoryReserveVolume(L)	0.783
Patient-FunctionalResidualCapacity(L)	1.46
Patient-InspiratoryCapacity(L)	2.8
Patient-InspiratoryReserveVolume(L)	2.26
Patient-ResidualVolume(L)	0.677
Patient-TidalVolumeBaseline(L)	0.531
Patient-TotalLungCapacity(L)	4.26
Patient-VitalCapacity(L)	3.58

Scenario Output Plots

Figure 5. Select outputs from the scenario.