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_md725 Segment Validation @subsubsection autotoc_md726 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 ventilator begins alarming.

Learning Objectives:

Identify alarms
Recognize increased airway resistance (PIP much higher than Pplat)
Recognize autoPEEP (from flow waveform)

Recommended Actions:

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)	302	-53.64%	VT for PIP alarm cycling
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (24.0) [316] [320]	33.7	40.79%	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]	50.1	11.23%	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)	33.7
ExpiratoryRespiratoryResistance(cmH2O_s/L)	50.6
RespiratoryCompliance(mL/cmH2O)	61.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.359
ClinicalShuntFraction	0.190
MechanicalVentilator-TidalVolume(L)	0.302
BloodPH	7.27
Aorta-Oxygen-PartialPressure(mmHg)	68.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	54.0
Aorta-Bicarbonate-Molarity(mEq/L)	26.7
OxygenSaturation	0.926
HorowitzIndex(mmHg)	179
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.31
MechanicalVentilator-RespirationRate(1/min)	14.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	50.1
MechanicalVentilator-PlateauPressure(cmH2O)	11.9
HeartRate(1/min)	88.1
SystolicArterialPressure(mmHg)	110
DiastolicArterialPressure(mmHg)	77.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	4.85
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	33.7
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	50.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	60.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	7.17
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	40.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	205
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.318
MechanicalVentilator-InspiratoryExpiratoryRatio	0.0865
MechanicalVentilator-InspiratoryTidalVolume(L)	0.302
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.140
MechanicalVentilator-LeakFraction	0.0207
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	1.60
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	6.60
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.189
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	32.5
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	50.5
TotalRespiratoryModelCompliance(mL/cmH2O)	68.4
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	7.32
EndTidalCarbonDioxidePressure(mmHg)	49.0
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	104
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.171
FractionOfInspiredOxygen	0.383
LungCompliance(L/cmH2O)	0.0972
VentilationPerfusionRatio	0.237
HeartStrokeVolume(mL)	62.4
HeartEjectionFraction	0.495
BloodVolume(L)	6.58
MeanArterialPressure(mmHg)	94.8
PulsePressure(mmHg)	32.2
CardiacOutput(L/min)	5.50
CarbonDioxideSaturation	0.407
RespiratoryExchangeRatio	0.803
SystemicVascularResistance(mmHg_s/mL)	0.981
OxygenConsumptionRate(mL/min)	265
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 3

Patient suctioned and albuterol administered.

Learning Objectives:

Recognize that treatment reduced airway resistance (lower difference PIP - Pplat)
AutoPEEP reduced

Recommended Actions:

Decrease FiO2

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 650	653	0.50%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (33.7) [316] [320]	10.1		-70.20%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (50.6) [316] [320]	10.1		-80.12%	Rexp
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (50.1) [316] [320]	27.1		-45.82%	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)	56.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.259
ClinicalShuntFraction	0.187
MechanicalVentilator-TidalVolume(L)	0.653
BloodPH	7.34
Aorta-Oxygen-PartialPressure(mmHg)	79.4
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.5
Aorta-Bicarbonate-Molarity(mEq/L)	26.3
OxygenSaturation	0.958
HorowitzIndex(mmHg)	199
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0186
MechanicalVentilator-RespirationRate(1/min)	14.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.37
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	27.1
MechanicalVentilator-PlateauPressure(cmH2O)	16.7
HeartRate(1/min)	99.6
SystolicArterialPressure(mmHg)	109
DiastolicArterialPressure(mmHg)	80.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.12
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	10.1
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	56.1
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	29.5
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	38.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	263
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.653
MechanicalVentilator-InspiratoryExpiratoryRatio	0.162
MechanicalVentilator-InspiratoryTidalVolume(L)	0.653
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.889
MechanicalVentilator-LeakFraction	1.10e-11
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0165
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.02
PhysiologicDeadSpaceTidalVolumeRatio	0.477
PhysiologicShuntFraction	0.186
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	10.1
TotalRespiratoryModelCompliance(mL/cmH2O)	66.0
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.02
EndTidalCarbonDioxidePressure(mmHg)	39.1
PhysiologicDeadSpace(mL)	236
AlveolarArterialGradient(mmHg)	179
AlveolarDeadSpace(mL)	94.9
AnatomicDeadSpace(mL)	141
ChestWallCompliance(L/cmH2O)	0.141
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0970
VentilationPerfusionRatio	1.09
HeartStrokeVolume(mL)	55.9
HeartEjectionFraction	0.467
BloodVolume(L)	6.56
MeanArterialPressure(mmHg)	94.9
PulsePressure(mmHg)	28.7
CardiacOutput(L/min)	5.56
CarbonDioxideSaturation	0.125
RespiratoryExchangeRatio	0.804
SystemicVascularResistance(mmHg_s/mL)	0.972
OxygenConsumptionRate(mL/min)	265
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.