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En Route Care Scenario 2

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.

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-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 Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 650 650 0.0590%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 24 [381] [270] 24.0 0.196%   Rinsp for moderate COPD
ExpiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 36 [381] 36.9 2.45%   Rexp for moderate COPD
RespiratoryCompliance(mL/cmH2O) EqualTo 68 [229] 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 [364] 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) LessThan Segment1 (650) 650   -0.0685% VT for PIP alarm cycling
InspiratoryRespiratoryResistance(cmH2O_s/L) GreaterThan Segment1 (24.0) [304] [308] 33.3   38.9% Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L) GreaterThan Segment1 (36.9) [304] [308] 50.6   37.0% Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) GreaterThan Segment1 (45.0) [304] [308] 49.6   10.1% PIP



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) 33.3
ExpiratoryRespiratoryResistance(cmH2O_s/L) 50.6
RespiratoryCompliance(mL/cmH2O) 68.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.462
ClinicalShuntFraction 0.188
MechanicalVentilator-TidalVolume(L) 0.650
BloodPH 7.33
Aorta-Oxygen-PartialPressure(mmHg) 77.3
Aorta-CarbonDioxide-PartialPressure(mmHg) 50.0
Aorta-Bicarbonate-Molarity(mEq/L) 26.4
OxygenSaturation 0.951
HorowitzIndex(mmHg) 193
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 4.29
MechanicalVentilator-RespirationRate(1/min) 14.0
MechanicalVentilator-MeanAirwayPressure(cmH2O) 10.6
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 49.6
MechanicalVentilator-PlateauPressure(cmH2O) 17.7
HeartRate(1/min) 79.9
SystolicArterialPressure(mmHg) 111
DiastolicArterialPressure(mmHg) 76.3
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 9.07
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 33.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 50.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 68.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 14.6
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 41.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 248
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.596
MechanicalVentilator-InspiratoryExpiratoryRatio 0.162
MechanicalVentilator-InspiratoryTidalVolume(L) 0.650
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.279
MechanicalVentilator-LeakFraction 0.0825
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 3.25
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 8.25
PhysiologicDeadSpaceTidalVolumeRatio 0.477
PhysiologicShuntFraction 0.193
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 32.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 50.5
TotalRespiratoryModelCompliance(mL/cmH2O) 70.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.01
TotalPositiveEndExpiratoryPressure(cmH2O) 9.30
EndTidalCarbonDioxidePressure(mmHg) 44.2
PhysiologicDeadSpace(mL) 236
AlveolarArterialGradient(mmHg) 163
AlveolarDeadSpace(mL) 94.9
AnatomicDeadSpace(mL) 141
ChestWallCompliance(L/cmH2O) 0.237
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0971
VentilationPerfusionRatio 1.42
HeartStrokeVolume(mL) 68.8
HeartEjectionFraction 0.520
BloodVolume(L) 6.62
MeanArterialPressure(mmHg) 94.9
PulsePressure(mmHg) 35.0
CardiacOutput(L/min) 5.50
CarbonDioxideSaturation 0.341
RespiratoryExchangeRatio 0.818
SystemicVascularResistance(mmHg_s/mL) 0.983
OxygenConsumptionRate(mL/min) 268
CarbonDioxideProductionRate(mL/min) 219
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 (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 (33.3) [304] [308] 10.1   -69.8% Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (50.6) [304] [308] 10.1   -80.1% Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) LessThan Segment2 (49.6) [304] [308] 22.2   -55.1% PIP



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) 59.1
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.442
ClinicalShuntFraction 0.187
MechanicalVentilator-TidalVolume(L) 0.658
BloodPH 7.42
Aorta-Oxygen-PartialPressure(mmHg) 78.6
Aorta-CarbonDioxide-PartialPressure(mmHg) 39.6
Aorta-Bicarbonate-Molarity(mEq/L) 25.8
OxygenSaturation 0.963
HorowitzIndex(mmHg) 197
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.180
MechanicalVentilator-RespirationRate(1/min) 18.0
MechanicalVentilator-MeanAirwayPressure(cmH2O) 7.33
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 22.2
MechanicalVentilator-PlateauPressure(cmH2O) 16.3
HeartRate(1/min) 96.1
SystolicArterialPressure(mmHg) 110
DiastolicArterialPressure(mmHg) 79.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 11.8
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 10.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 10.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 58.6
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 38.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 29.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 272
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.658
MechanicalVentilator-InspiratoryExpiratoryRatio 0.219
MechanicalVentilator-InspiratoryTidalVolume(L) 0.658
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.628
MechanicalVentilator-LeakFraction 0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.107
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.11
PhysiologicDeadSpaceTidalVolumeRatio 0.477
PhysiologicShuntFraction 0.191
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 10.1
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 10.1
TotalRespiratoryModelCompliance(mL/cmH2O) 66.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.18
EndTidalCarbonDioxidePressure(mmHg) 30.7
PhysiologicDeadSpace(mL) 236
AlveolarArterialGradient(mmHg) 189
AlveolarDeadSpace(mL) 94.9
AnatomicDeadSpace(mL) 141
ChestWallCompliance(L/cmH2O) 0.161
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0972
VentilationPerfusionRatio 2.20
HeartStrokeVolume(mL) 58.5
HeartEjectionFraction 0.478
BloodVolume(L) 6.66
MeanArterialPressure(mmHg) 95.1
PulsePressure(mmHg) 29.9
CardiacOutput(L/min) 5.62
CarbonDioxideSaturation 0.0288
RespiratoryExchangeRatio 0.815
SystemicVascularResistance(mmHg_s/mL) 0.964
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.


Distributed under the Apache License, Version 2.0.

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