Mild ARDS with Progressive Fall in Oxygenation

Description

A 22 year-old patient was involved in a motor vehicle crash with rollover and ejection from the vehicle. He suffered multiple rib fractures, a right femur fracture, multiple lacerations and pulmonary contusion. He underwent internal fixation of the femur fracture, received 4 units of whole blood, had a chest tube placed for a small hemothorax and returned from the operating room on mechanical ventilation. The patient is sedated and is not currently triggering the ventilator. Intraoperatively 3 L of crystalloids were administered. The patient is 6'2'' tall, weighs 200 lbs and has no known comorbidities or allergies. Chest radiograph demonstrates bi-basilar early consolidation, presence of the chest tube and pulmonary contusion.

Segment Validation

Segment 1

Learning Objectives:

Identify severity of ARDS
Recognize acceptable ventilator settings

Recommended Actions:

None

Ventilator settings are (VT Target = 7.1 mL/kg (ideal)):

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
VC-AC	0.584	NA	60	NA	0.62	24	5	0.4

Ventilator alarm settings are:

High PIP = 38 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
Low MVe = 10.4 L/min (~25% below the initial value)
Low VT = 438 mL (~25% below the initial value)
High RR = 34 bpm (~10 bpm above the initial value or a max of 40 bpm)

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 584	578	-0.98%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [18]	11.6	-3.12%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [18]	11.6	-3.12%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 50 [316]	50.8	1.67%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [238]	0.515	-4.61%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [229]	0.216	0.00%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [119]	185	-7.60%	PaO2/FiO2 for mild ARDS

Figure 1. Vitals and ventilator monitors for Segment 1.

Table 2. Data requests for Segment 1.

Property Name	Engine Value
Patient-Height(in)	74.0
Patient-IdealBodyWeight(kg)	82.2
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	50.8
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.432
ClinicalShuntFraction	0.216
MechanicalVentilator-TidalVolume(L)	0.578
BloodPH	7.38
Aorta-Oxygen-PartialPressure(mmHg)	73.9
Aorta-CarbonDioxide-PartialPressure(mmHg)	40.9
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.953
HorowitzIndex(mmHg)	185
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.503
MechanicalVentilator-RespirationRate(1/min)	24.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.37
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	28.1
MechanicalVentilator-PlateauPressure(cmH2O)	17.0
HeartRate(1/min)	73.5
SystolicArterialPressure(mmHg)	114
DiastolicArterialPressure(mmHg)	73.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	13.9
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	50.0
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	25.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	30.5
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	270
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.578
MechanicalVentilator-InspiratoryExpiratoryRatio	0.330
MechanicalVentilator-InspiratoryTidalVolume(L)	0.578
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.843
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.456
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.46
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.218
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	58.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.51
EndTidalCarbonDioxidePressure(mmHg)	32.5
PhysiologicDeadSpace(mL)	296
AlveolarArterialGradient(mmHg)	194
AlveolarDeadSpace(mL)	132
AnatomicDeadSpace(mL)	164
ChestWallCompliance(L/cmH2O)	0.151
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	1.18
HeartStrokeVolume(mL)	80.4
HeartEjectionFraction	0.555
BloodVolume(L)	6.50
MeanArterialPressure(mmHg)	95.2
PulsePressure(mmHg)	40.0
CardiacOutput(L/min)	5.91
CarbonDioxideSaturation	0.0258
RespiratoryExchangeRatio	0.799
SystemicVascularResistance(mmHg_s/mL)	0.919
OxygenConsumptionRate(mL/min)	291
CarbonDioxideProductionRate(mL/min)	232
Patient-AlveoliSurfaceArea(m^2)	37.3
Patient-ExpiratoryReserveVolume(L)	0.984
Patient-FunctionalResidualCapacity(L)	1.85
Patient-InspiratoryCapacity(L)	3.52
Patient-InspiratoryReserveVolume(L)	2.94
Patient-ResidualVolume(L)	0.863
Patient-TidalVolumeBaseline(L)	0.578
Patient-TotalLungCapacity(L)	5.36
Patient-VitalCapacity(L)	4.50

Segment 2

The patient is loaded in the aircraft for transport to trauma center care. Twenty minutes into the transport, SpO2 falls and both PIP and Pplat are increased. The patient is triggering the ventilator.

Learning Objectives:

Recognize worsening ARDS
Adjust vent settings for safety

Recommended Actions:

Increase FiO2 to 0.5
Decrease VT to 490 mL to get acceptable DP

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 567	585	3.11%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [18]	12.4	3.13%		Rinsp for moderate ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [18]	12.4	3.13%		Rexp for moderate ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 40 [316]	39.8	-0.45%		C requested by SME for moderate ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.57 [238]	0.553	-2.97%		VD/VT for moderate ARDS
ClinicalShuntFraction	[0.300,0.500] [229]	0.357	0.00%		QS/QT for moderate ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[100,200] [119]	137	0.00%		PaO2/FiO2 for moderate ARDS
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (28.1) [316]	28.1	-0.03%		PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (17.0) [316]	20.8		22.28%	Pplat
OxygenSaturation	LessThan Segment1 (0.953) [316] [320]	0.899		-5.76%	SpO2

Figure 2. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	74.0
Patient-IdealBodyWeight(kg)	82.2
InspiratoryRespiratoryResistance(cmH2O_s/L)	12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	12.4
RespiratoryCompliance(mL/cmH2O)	39.8
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.578
ClinicalShuntFraction	0.357
MechanicalVentilator-TidalVolume(L)	0.585
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	54.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	42.0
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.899
HorowitzIndex(mmHg)	137
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.324
MechanicalVentilator-RespirationRate(1/min)	30.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.79
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	28.1
MechanicalVentilator-PlateauPressure(cmH2O)	20.8
HeartRate(1/min)	122
SystolicArterialPressure(mmHg)	109
DiastolicArterialPressure(mmHg)	81.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	17.5
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	39.1
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	25.4
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	25.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	278
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.585
MechanicalVentilator-InspiratoryExpiratoryRatio	0.449
MechanicalVentilator-InspiratoryTidalVolume(L)	0.585
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.875
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.865
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.86
PhysiologicDeadSpaceTidalVolumeRatio	0.553
PhysiologicShuntFraction	0.359
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelCompliance(mL/cmH2O)	45.3
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.33
EndTidalCarbonDioxidePressure(mmHg)	27.2
PhysiologicDeadSpace(mL)	318
AlveolarArterialGradient(mmHg)	219
AlveolarDeadSpace(mL)	154
AnatomicDeadSpace(mL)	164
ChestWallCompliance(L/cmH2O)	0.138
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0591
VentilationPerfusionRatio	1.26
HeartStrokeVolume(mL)	53.4
HeartEjectionFraction	0.446
BloodVolume(L)	6.51
MeanArterialPressure(mmHg)	95.8
PulsePressure(mmHg)	27.5
CardiacOutput(L/min)	6.50
CarbonDioxideSaturation	0.0260
RespiratoryExchangeRatio	0.795
SystemicVascularResistance(mmHg_s/mL)	0.839
OxygenConsumptionRate(mL/min)	279
CarbonDioxideProductionRate(mL/min)	222
Patient-AlveoliSurfaceArea(m^2)	14.9
Patient-ExpiratoryReserveVolume(L)	0.943
Patient-FunctionalResidualCapacity(L)	1.39
Patient-InspiratoryCapacity(L)	3.37
Patient-InspiratoryReserveVolume(L)	2.79
Patient-ResidualVolume(L)	0.444
Patient-TidalVolumeBaseline(L)	0.578
Patient-TotalLungCapacity(L)	4.75
Patient-VitalCapacity(L)	4.31

Segment 3

Patient transport continues.

Learning Objectives:

Recognize need to increase PEEP to keep on PEEP matrix

Recommended Actions:

Increase PEEP to 10 to keep on PEEP matrix

Ventilator settings are updated to:

FiO2: 0.4 -> 0.5
VT: 567 -> 490 mL
Flow: 59 -> 50 L/min

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 490	488	-0.50%		VT (measured)
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment2 (54.7) [316] [320]	56.7		3.61%	PaO2
ClinicalShuntFraction	EqualTo Segment2 (0.357) [316] [320]	0.366	2.47%		QS/QT

Figure 3. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	74.0
Patient-IdealBodyWeight(kg)	82.2
InspiratoryRespiratoryResistance(cmH2O_s/L)	12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	12.4
RespiratoryCompliance(mL/cmH2O)	39.2
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.529
ClinicalShuntFraction	0.366
MechanicalVentilator-TidalVolume(L)	0.488
BloodPH	7.35
Aorta-Oxygen-PartialPressure(mmHg)	56.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	43.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.904
HorowitzIndex(mmHg)	114
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.275
MechanicalVentilator-RespirationRate(1/min)	32.3
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.34
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	24.9
MechanicalVentilator-PlateauPressure(cmH2O)	18.5
HeartRate(1/min)	113
SystolicArterialPressure(mmHg)	110
DiastolicArterialPressure(mmHg)	81.4
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	15.7
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	38.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	24.5
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	28.0
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	350
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.488
MechanicalVentilator-InspiratoryExpiratoryRatio	0.500
MechanicalVentilator-InspiratoryTidalVolume(L)	0.488
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.799
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.950
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.95
PhysiologicDeadSpaceTidalVolumeRatio	0.553
PhysiologicShuntFraction	0.370
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelCompliance(mL/cmH2O)	47.3
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.28
EndTidalCarbonDioxidePressure(mmHg)	31.3
PhysiologicDeadSpace(mL)	318
AlveolarArterialGradient(mmHg)	289
AlveolarDeadSpace(mL)	154
AnatomicDeadSpace(mL)	164
ChestWallCompliance(L/cmH2O)	0.132
FractionOfInspiredOxygen	0.499
LungCompliance(L/cmH2O)	0.0587
VentilationPerfusionRatio	0.891
HeartStrokeVolume(mL)	55.4
HeartEjectionFraction	0.458
BloodVolume(L)	6.52
MeanArterialPressure(mmHg)	95.8
PulsePressure(mmHg)	28.1
CardiacOutput(L/min)	6.28
CarbonDioxideSaturation	0.0630
RespiratoryExchangeRatio	0.796
SystemicVascularResistance(mmHg_s/mL)	0.868
OxygenConsumptionRate(mL/min)	282
CarbonDioxideProductionRate(mL/min)	224
Patient-AlveoliSurfaceArea(m^2)	14.9
Patient-ExpiratoryReserveVolume(L)	0.943
Patient-FunctionalResidualCapacity(L)	1.39
Patient-InspiratoryCapacity(L)	3.37
Patient-InspiratoryReserveVolume(L)	2.79
Patient-ResidualVolume(L)	0.444
Patient-TidalVolumeBaseline(L)	0.578
Patient-TotalLungCapacity(L)	4.75
Patient-VitalCapacity(L)	4.31

Segment 4

Patient transport has ended.

Learning Objectives:

Recognize improvement due to change in vent settings
Consider changing mode to address work shifting

Recommended Actions:

None

Ventilator settings are updated to:

PEEP: 5 -> 10 cmH2O

Table 7. Data request validation results for Segment 4.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 490	489	-0.25%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment3 (39.2) [238]	42.0		7.27%	C
Aorta-CarbonDioxide-PartialPressure(mmHg)	EqualTo Segment3 (43.2) [264]	44.1	2.10%		PaCO2
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment3 (56.7) [193]	62.6		10.42%	PaO2
HorowitzIndex(mmHg)	GreaterThan Segment3 (114) [193]	125		10.45%	PaO2/FiO2
ClinicalShuntFraction	LessThan Segment3 (0.366) [193]	0.312		-14.63%	QS/QT (determined from blood gas values)

Figure 4. Vitals and ventilator monitors for Segment 4.

Table 8. Data requests for Segment 4.

Property Name	Engine Value
Patient-Height(in)	74.0
Patient-IdealBodyWeight(kg)	82.2
InspiratoryRespiratoryResistance(cmH2O_s/L)	12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	12.4
RespiratoryCompliance(mL/cmH2O)	42.0
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.450
ClinicalShuntFraction	0.312
MechanicalVentilator-TidalVolume(L)	0.489
BloodPH	7.35
Aorta-Oxygen-PartialPressure(mmHg)	62.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.1
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.924
HorowitzIndex(mmHg)	125
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.276
MechanicalVentilator-RespirationRate(1/min)	28.3
MechanicalVentilator-MeanAirwayPressure(cmH2O)	13.2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	26.9
MechanicalVentilator-PlateauPressure(cmH2O)	22.3
HeartRate(1/min)	90.0
SystolicArterialPressure(mmHg)	112
DiastolicArterialPressure(mmHg)	78.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	13.8
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	12.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	41.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	28.9
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	32.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	346
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.489
MechanicalVentilator-InspiratoryExpiratoryRatio	0.413
MechanicalVentilator-InspiratoryTidalVolume(L)	0.489
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.683
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.646
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	10.0
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	10.6
PhysiologicDeadSpaceTidalVolumeRatio	0.553
PhysiologicShuntFraction	0.319
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	12.4
TotalRespiratoryModelCompliance(mL/cmH2O)	47.4
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	10.0
TotalPositiveEndExpiratoryPressure(cmH2O)	10.3
EndTidalCarbonDioxidePressure(mmHg)	36.7
PhysiologicDeadSpace(mL)	318
AlveolarArterialGradient(mmHg)	275
AlveolarDeadSpace(mL)	154
AnatomicDeadSpace(mL)	164
ChestWallCompliance(L/cmH2O)	0.158
FractionOfInspiredOxygen	0.499
LungCompliance(L/cmH2O)	0.0591
VentilationPerfusionRatio	0.811
HeartStrokeVolume(mL)	67.8
HeartEjectionFraction	0.511
BloodVolume(L)	6.51
MeanArterialPressure(mmHg)	95.5
PulsePressure(mmHg)	33.6
CardiacOutput(L/min)	6.10
CarbonDioxideSaturation	0.111
RespiratoryExchangeRatio	0.798
SystemicVascularResistance(mmHg_s/mL)	0.892
OxygenConsumptionRate(mL/min)	285
CarbonDioxideProductionRate(mL/min)	228
Patient-AlveoliSurfaceArea(m^2)	14.9
Patient-ExpiratoryReserveVolume(L)	0.943
Patient-FunctionalResidualCapacity(L)	1.39
Patient-InspiratoryCapacity(L)	3.37
Patient-InspiratoryReserveVolume(L)	2.79
Patient-ResidualVolume(L)	0.444
Patient-TidalVolumeBaseline(L)	0.578
Patient-TotalLungCapacity(L)	4.75
Patient-VitalCapacity(L)	4.31

Scenario Output Plots

Figure 5. Select outputs from the scenario.