Moderate COPD with Subsequent Bronchospasm

Description

A 62 year-old patient 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. @subsection autotoc_md718 Segment Validation @subsubsection autotoc_md719 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 <br> Ventilator settings are: <table class="markdownTable"> <tr class="markdownTableHead"> <th class="markdownTableHeadNone"> Mode

VT (L)

PIP (cmH2O)

Flow (L/min)

I:E

TI (s)

RR (bpm)

PEEP (cmH2O)

FiO2

VC-AC

0.650

NA

70

NA

0.6

14

5

0.4

Ventilator alarm settings are:

High PIP = 50 cmH2O (~10 cmH2O above the initial value or a max of 50 cmH2O)
Low MVe = 6.8 L/min (~25% below the initial value)
Low VT = 490 mL (~25% below the initial value)
High RR = 24 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 650	650	0.06%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 24 [401] [280]	24.0	-0.20%	Rinsp for moderate COPD
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 36 [401]	37.0	2.80%	Rexp for moderate COPD
RespiratoryCompliance(mL/cmH2O)	EqualTo 68 [238]	64.8	-4.65%	C for moderate COPD
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.49 [117]	0.477	-2.56%	VD/VT for moderate COPD
ClinicalShuntFraction	EqualTo 0.19 [382]	0.187	-1.46%	QS/QT for moderate COPD (determined from blood gas values)

Figure 1. 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)	37.0
RespiratoryCompliance(mL/cmH2O)	64.8
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.369
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.650
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	77.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	42.8
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.957
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)	82.0
SystolicArterialPressure(mmHg)	110
DiastolicArterialPressure(mmHg)	76.3
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)	35.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	264
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	0.185
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	23.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	37.0
TotalRespiratoryModelCompliance(mL/cmH2O)	68.8
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.01
TotalPositiveEndExpiratoryPressure(cmH2O)	7.74
EndTidalCarbonDioxidePressure(mmHg)	37.2
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	1.13
HeartStrokeVolume(mL)	66.5
HeartEjectionFraction	0.513
BloodVolume(L)	6.57
MeanArterialPressure(mmHg)	94.2
PulsePressure(mmHg)	33.8
CardiacOutput(L/min)	5.45
CarbonDioxideSaturation	0.0383
RespiratoryExchangeRatio	0.801
SystemicVascularResistance(mmHg_s/mL)	0.983
OxygenConsumptionRate(mL/min)	266
CarbonDioxideProductionRate(mL/min)	213
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.61
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.513
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 Change	Notes
MechanicalVentilator-TidalVolume(mL)	LessThan Segment1 (650)	562	-13.64%	VT for PIP alarm cycling
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (24.0) [316] [320]	33.1	38.04%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (37.0) [316] [320]	50.6	36.59%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (45.0) [316] [320]	50.2	11.37%	PIP

Figure 2. 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)	50.6
RespiratoryCompliance(mL/cmH2O)	67.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.152
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.562
BloodPH	7.32
Aorta-Oxygen-PartialPressure(mmHg)	77.1
Aorta-CarbonDioxide-PartialPressure(mmHg)	46.8
Aorta-Bicarbonate-Molarity(mEq/L)	26.4
OxygenSaturation	0.952
HorowitzIndex(mmHg)	193
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.000968
MechanicalVentilator-RespirationRate(1/min)	21.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	6.84
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	50.2
MechanicalVentilator-PlateauPressure(cmH2O)	7.43
HeartRate(1/min)	82.2
SystolicArterialPressure(mmHg)	111
DiastolicArterialPressure(mmHg)	76.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	2.35
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	33.2
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	50.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	66.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	2.46
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	40.0
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	250
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.221
MechanicalVentilator-InspiratoryExpiratoryRatio	0.0515
MechanicalVentilator-InspiratoryTidalVolume(L)	0.562
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.156
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.745
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.75
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.184
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	32.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	50.5
TotalRespiratoryModelCompliance(mL/cmH2O)	71.5
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.00
EndTidalCarbonDioxidePressure(mmHg)	43.6
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	167
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.228
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0966
VentilationPerfusionRatio	0.00
HeartStrokeVolume(mL)	66.8
HeartEjectionFraction	0.514
BloodVolume(L)	6.58
MeanArterialPressure(mmHg)	94.7
PulsePressure(mmHg)	34.2
CardiacOutput(L/min)	5.49
CarbonDioxideSaturation	0.222
RespiratoryExchangeRatio	0.804
SystemicVascularResistance(mmHg_s/mL)	0.983
OxygenConsumptionRate(mL/min)	270
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)	2.61
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.513
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 (improve 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	1.30%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (33.1) [316] [320]	10.1		-69.60%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (50.6) [316] [320]	10.1		-80.12%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (50.2) [316] [320]	22.2		-55.68%	PIP

Figure 3. 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)	60.1
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.388
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.658
BloodPH	7.41
Aorta-Oxygen-PartialPressure(mmHg)	77.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	37.8
Aorta-Bicarbonate-Molarity(mEq/L)	25.9
OxygenSaturation	0.962
HorowitzIndex(mmHg)	194
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.137
MechanicalVentilator-RespirationRate(1/min)	17.1
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.23
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	22.2
MechanicalVentilator-PlateauPressure(cmH2O)	16.4
HeartRate(1/min)	99.6
SystolicArterialPressure(mmHg)	109
DiastolicArterialPressure(mmHg)	80.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	58.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	38.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	29.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	272
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.658
MechanicalVentilator-InspiratoryExpiratoryRatio	0.207
MechanicalVentilator-InspiratoryTidalVolume(L)	0.658
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.615
MechanicalVentilator-LeakFraction	1.85e-06
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0799
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.08
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.186
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelCompliance(mL/cmH2O)	69.8
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.14
EndTidalCarbonDioxidePressure(mmHg)	30.1
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	196
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.171
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	1.36
HeartStrokeVolume(mL)	56.1
HeartEjectionFraction	0.467
BloodVolume(L)	6.58
MeanArterialPressure(mmHg)	94.9
PulsePressure(mmHg)	28.8
CardiacOutput(L/min)	5.58
CarbonDioxideSaturation	0.0267
RespiratoryExchangeRatio	0.804
SystemicVascularResistance(mmHg_s/mL)	0.968
OxygenConsumptionRate(mL/min)	264
CarbonDioxideProductionRate(mL/min)	213
Patient-AlveoliSurfaceArea(m^2)	12.8
Patient-ExpiratoryReserveVolume(L)	0.876
Patient-FunctionalResidualCapacity(L)	1.97
Patient-InspiratoryCapacity(L)	3.13
Patient-InspiratoryReserveVolume(L)	2.61
Patient-ResidualVolume(L)	1.09
Patient-TidalVolumeBaseline(L)	0.513
Patient-TotalLungCapacity(L)	5.10
Patient-VitalCapacity(L)	4.00

Scenario Output Plots

Figure 4. Select outputs from the scenario.