Moderate COPD with Subsequent Bronchospasm

Description

A 62 year-old contractor developed pneumonia while working on a water purification system. He has 90- pack year history of cigarette smoking (2 packs per day x 45 years), has type II diabetes and primary hypertension managed with oral medications. He uses a rescue inhaler (albuterol) and is on a maintenance inhaled corticosteroid. His pre-deployment FEV-1 is 43% of predicted. The patient is 5'9" tall, weighs 210 lbs and has no known allergies.

Chest radiograph demonstrates left-lower lobe consolidation, haziness in the right lower lobe, flattened diaphragms and hyperinflation in the upper lung fields. Heart rate is normal sinus rhythm and occasional PVC's. Patient is sedated and not triggering ventilator.

Figure 1. Chest radiograph demonstrates left-lower lobe consolidation, haziness in the right lower lobe, flattened diaphragms and hyperinflation in the upper lung fields.

Segment Validation

Segment 1

Learning Objectives:

Assess baseline status
Recognize presence of autoPEEP (from flow waveform)
Suspect obstructive lung disease (high minute ventilation requirement but high SpO2 and low Pplat)

Recommended Actions:

None

Ventilator settings are:

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
VC-CMV	0.650	NA	70	NA	0.6	14	5	0.4

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 650	650	0.0590%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 24 [382] [271]	24.0	0.196%	Rinsp for moderate COPD
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 36 [382]	36.9	2.45%	Rexp for moderate COPD
RespiratoryCompliance(mL/cmH2O)	EqualTo 68 [230]	64.5	5.22%	C for moderate COPD
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.49 [113]	0.477	2.59%	VD/VT for moderate COPD
ClinicalShuntFraction	EqualTo 0.19 [365]	0.187	1.79%	QS/QT for moderate COPD (determined from blood gas values)

Figure 2. Vitals and ventilator monitors for Segment 1.

Table 2. Data requests for Segment 1.

Property Name	Engine Value
Patient-Height(in)	69.0
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	24.0
ExpiratoryRespiratoryResistance(cmH2O_s/L)	36.9
RespiratoryCompliance(mL/cmH2O)	64.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.410
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.650
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	77.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	45.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.956
HorowitzIndex(mmHg)	194
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.73
MechanicalVentilator-RespirationRate(1/min)	14.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.82
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	45.0
MechanicalVentilator-PlateauPressure(cmH2O)	17.3
HeartRate(1/min)	79.9
SystolicArterialPressure(mmHg)	110
DiastolicArterialPressure(mmHg)	75.7
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.08
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	24.0
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	37.0
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	63.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	16.2
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	38.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	261
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.650
MechanicalVentilator-InspiratoryExpiratoryRatio	0.162
MechanicalVentilator-InspiratoryTidalVolume(L)	0.650
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.321
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.13
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	7.13
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.193
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	23.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	37.0
TotalRespiratoryModelCompliance(mL/cmH2O)	73.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.01
TotalPositiveEndExpiratoryPressure(cmH2O)	7.74
EndTidalCarbonDioxidePressure(mmHg)	40.3
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	184
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.201
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	1.73
HeartStrokeVolume(mL)	68.2
HeartEjectionFraction	0.519
BloodVolume(L)	6.61
MeanArterialPressure(mmHg)	94.1
PulsePressure(mmHg)	34.6
CardiacOutput(L/min)	5.45
CarbonDioxideSaturation	0.173
RespiratoryExchangeRatio	0.814
SystemicVascularResistance(mmHg_s/mL)	0.982
OxygenConsumptionRate(mL/min)	263
CarbonDioxideProductionRate(mL/min)	214
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.540
Patient-TotalLungCapacity(L)	5.10
Patient-VitalCapacity(L)	4.00

Segment 2

Twenty minutes into the transport the patient is slightly agitated and is making inspiratory efforts that are not in sync with the ventilator.

Learning Objectives:

Recognize increased airway resistance (PIP much higher than Pplat)
Recognize autoPEEP (from flow waveform)
Recognize failed trigger efforts due to autoPEEP (examine expiratory flow waveform)

Recommended Actions:

Goal shifts to Comfort (improve synchrony) due to failed trigger efforts
Check airway patency (secretions?) suction ETT
Check breath sounds (wheezing?) - suspect bronchospasm and consider bronchodilator

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 650	651	0.174%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (24.0) [305] [309]	33.1		38.1%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (36.9) [305] [309]	50.5		37.0%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (45.0) [305] [309]	51.0		13.2%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (17.3) [305] [309]	17.5		1.19%	Pplat

Figure 3. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	69.0
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	33.1
ExpiratoryRespiratoryResistance(cmH2O_s/L)	50.5
RespiratoryCompliance(mL/cmH2O)	69.9
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.441
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.651
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	77.9
Aorta-CarbonDioxide-PartialPressure(mmHg)	45.5
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.956
HorowitzIndex(mmHg)	195
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.78
MechanicalVentilator-RespirationRate(1/min)	14.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	11.8
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	51.0
MechanicalVentilator-PlateauPressure(cmH2O)	17.5
HeartRate(1/min)	79.7
SystolicArterialPressure(mmHg)	111
DiastolicArterialPressure(mmHg)	76.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.04
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	33.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	50.5
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	69.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	11.9
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	39.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	260
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.675
MechanicalVentilator-InspiratoryExpiratoryRatio	0.162
MechanicalVentilator-InspiratoryTidalVolume(L)	0.651
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.312
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	3.25
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	8.25
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.184
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	32.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	50.5
TotalRespiratoryModelCompliance(mL/cmH2O)	71.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.01
TotalPositiveEndExpiratoryPressure(cmH2O)	7.78
EndTidalCarbonDioxidePressure(mmHg)	37.5
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	179
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.255
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	1.80
HeartStrokeVolume(mL)	69.2
HeartEjectionFraction	0.521
BloodVolume(L)	6.62
MeanArterialPressure(mmHg)	94.9
PulsePressure(mmHg)	35.3
CardiacOutput(L/min)	5.52
CarbonDioxideSaturation	0.187
RespiratoryExchangeRatio	0.816
SystemicVascularResistance(mmHg_s/mL)	0.980
OxygenConsumptionRate(mL/min)	266
CarbonDioxideProductionRate(mL/min)	217
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.540
Patient-TotalLungCapacity(L)	5.10
Patient-VitalCapacity(L)	4.00

Segment 3

Patient suctioned and albuterol administered.

Learning Objectives:

Recognize that treatment reduced airway resistance (lower difference PIP - Pplat)
AutoPEEP reduced
Failed trigger efforts disappeared
Recognize that now discordance problem is early cycle

Recommended Actions:

Goal shifts to Comfort (imprive synchrony) due to cycle dyssychrony
Decrease FiO2
Consider switching mode to PC-CSV (ie Pressure Support)

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 650	658	1.29%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (33.1) [305] [309]	10.1		-69.6%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (50.5) [305] [309]	10.1		-80.1%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (51.0) [305] [309]	22.3		-56.3%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment2 (17.5) [305] [309]	16.3		-6.62%	Pplat

Figure 4. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	69.0
Patient-IdealBodyWeight(kg)	70.7
InspiratoryRespiratoryResistance(cmH2O_s/L)	10.1
ExpiratoryRespiratoryResistance(cmH2O_s/L)	10.1
RespiratoryCompliance(mL/cmH2O)	60.3
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.441
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.658
BloodPH	7.42
Aorta-Oxygen-PartialPressure(mmHg)	78.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	39.7
Aorta-Bicarbonate-Molarity(mEq/L)	25.8
OxygenSaturation	0.962
HorowitzIndex(mmHg)	197
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.174
MechanicalVentilator-RespirationRate(1/min)	17.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.31
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	22.3
MechanicalVentilator-PlateauPressure(cmH2O)	16.3
HeartRate(1/min)	96.1
SystolicArterialPressure(mmHg)	109
DiastolicArterialPressure(mmHg)	79.7
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.8
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	58.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	38.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	29.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	272
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.658
MechanicalVentilator-InspiratoryExpiratoryRatio	0.217
MechanicalVentilator-InspiratoryTidalVolume(L)	0.658
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.628
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.103
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.10
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.191
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelCompliance(mL/cmH2O)	67.7
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.18
EndTidalCarbonDioxidePressure(mmHg)	30.8
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	191
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.170
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	2.19
HeartStrokeVolume(mL)	58.3
HeartEjectionFraction	0.477
BloodVolume(L)	6.66
MeanArterialPressure(mmHg)	95.1
PulsePressure(mmHg)	29.8
CardiacOutput(L/min)	5.61
CarbonDioxideSaturation	0.0288
RespiratoryExchangeRatio	0.815
SystemicVascularResistance(mmHg_s/mL)	0.966
OxygenConsumptionRate(mL/min)	257
CarbonDioxideProductionRate(mL/min)	209
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.59
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.540
Patient-TotalLungCapacity(L)	5.10
Patient-VitalCapacity(L)	4.00

Scenario Output Plots

Figure 5. Select outputs from the scenario.