Mild ARDS with Right Mainstem Intubation

Description

A 28 year old patient suffered a crush injury during the transfer of supplies from a fork lift. She suffered an open book pelvic fracture, ruptured bladder and splenic laceration. She required a massive transfusion and intraoperative open reduction and internal fixation of the pelvic fracture. The spleen was removed and the bladder repaired. Blood loss was estimated at 2.5 L. The patient is 5'5" and weighs 138 lbs. @subsection autotoc_md753 Segment Validation @subsubsection autotoc_md754 Segment 1 Learning Objectives: - Assess baseline status - Recognize mild ARDS Recommended Actions: - None <br> Ventilator settings are (VT Target = 6.6 mL/kg (ideal)): <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

0.376

NA

42

NA

0.6

12

5

0.4

Ventilator alarm settings are:

High PIP = 26 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
Low MVe = 7.5 L/min (~25% below the initial value)
Low VT = 290 mL (~25% below the initial value)
High RR = 36 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 376	383	1.76%	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]	48.9	-2.20%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [238]	0.516	-4.47%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [229]	0.212	0.00%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [119]	203	0.00%	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)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	48.9
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.412
ClinicalShuntFraction	0.212
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	81.0
Aorta-CarbonDioxide-PartialPressure(mmHg)	42.9
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.962
HorowitzIndex(mmHg)	203
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.113
MechanicalVentilator-RespirationRate(1/min)	27.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.07
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.6
MechanicalVentilator-PlateauPressure(cmH2O)	8.63
HeartRate(1/min)	71.7
SystolicArterialPressure(mmHg)	114
DiastolicArterialPressure(mmHg)	73.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.42
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	105
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	33.0
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.370
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.489
MechanicalVentilator-LeakFraction	9.35e-07
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.457
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.46
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.221
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	57.8
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.11
EndTidalCarbonDioxidePressure(mmHg)	36.7
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	180
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.148
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0813
VentilationPerfusionRatio	0.942
HeartStrokeVolume(mL)	72.5
HeartEjectionFraction	0.548
BloodVolume(L)	4.47
MeanArterialPressure(mmHg)	95.2
PulsePressure(mmHg)	40.8
CardiacOutput(L/min)	5.20
CarbonDioxideSaturation	0.0409
RespiratoryExchangeRatio	0.805
SystemicVascularResistance(mmHg_s/mL)	1.04
OxygenConsumptionRate(mL/min)	203
CarbonDioxideProductionRate(mL/min)	163
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.04
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.416
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Segment 2

Two hours later the patient is agitated. Both PIP and Pplat have increased. The SpO2 has fallen, and etCO2 has decreased.

Learning Objectives:

Recognize right mainstem intubation by observing loss of breath sounds on the left

Recommended Actions:

Decreased etCO2, plus greatly increased Pplat and DP, absence of breath sounds on the left side but normal sound to palpation indicate right mainstem intubation
Reposition endotracheal tube and re-assess

Table 3. Data request validation results for Segment 2.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.95%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	LessThan Segment1 (48.9) [316]	28.1		-42.49%	C
Aorta-Oxygen-PartialPressure(mmHg)	LessThan Segment1 (81.0) [193]	38.5		-52.42%	PaO2
OxygenSaturation	LessThan Segment1 (0.962) [316] [320]	0.772		-19.75%	SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (16.6) [316]	26.3		58.62%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (8.63) [316]	16.8		94.44%	Pplat
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	LessThan Segment1 (33.3) [316]	18.1		-45.73%	EtCO2

Figure 2. Vitals and ventilator monitors for Segment 2.

Table 4. Data requests for Segment 2.

Property Name	Engine Value
Patient-Height(in)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	13.3
ExpiratoryRespiratoryResistance(cmH2O_s/L)	13.4
RespiratoryCompliance(mL/cmH2O)	28.1
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.703
ClinicalShuntFraction	0.625
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	38.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	43.1
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.772
HorowitzIndex(mmHg)	96.6
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	-0.561
MechanicalVentilator-RespirationRate(1/min)	42.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	10.2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	26.3
MechanicalVentilator-PlateauPressure(cmH2O)	16.8
HeartRate(1/min)	184
SystolicArterialPressure(mmHg)	101
DiastolicArterialPressure(mmHg)	86.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	16.4
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.7
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	13.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	32.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	18.5
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	18.1
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	289
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.379
MechanicalVentilator-InspiratoryExpiratoryRatio	0.750
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.880
MechanicalVentilator-LeakFraction	0.00962
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	1.87
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	6.87
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.222
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelCompliance(mL/cmH2O)	58.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	4.44
EndTidalCarbonDioxidePressure(mmHg)	19.1
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	120
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0970
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0409
VentilationPerfusionRatio	1.77
HeartStrokeVolume(mL)	23.2
HeartEjectionFraction	0.281
BloodVolume(L)	4.48
MeanArterialPressure(mmHg)	93.4
PulsePressure(mmHg)	15.3
CardiacOutput(L/min)	4.27
CarbonDioxideSaturation	0.0552
RespiratoryExchangeRatio	0.782
SystemicVascularResistance(mmHg_s/mL)	1.21
OxygenConsumptionRate(mL/min)	188
CarbonDioxideProductionRate(mL/min)	147
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.04
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.416
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Segment 3

Endotracheal tube repositioned.

Learning Objectives:

Assess effects of tube reposition

Recommended Actions:

None

Table 5. Data request validation results for Segment 3.

Property Name	Validation	Engine Value	Percent Error	Percent Change	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.77%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment2 (28.1) [316]	49.1		74.52%	C
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment2 (38.5) [193]	81.1		110.34%	PaO2
OxygenSaturation	GreaterThan Segment2 (0.772) [316] [320]	0.962		24.65%	SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (26.3) [316]	16.6		-37.11%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment2 (16.8) [316]	8.59		-48.81%	Pplat

Figure 3. Vitals and ventilator monitors for Segment 3.

Table 6. Data requests for Segment 3.

Property Name	Engine Value
Patient-Height(in)	65.0
Patient-IdealBodyWeight(kg)	57.0
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.6
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.6
RespiratoryCompliance(mL/cmH2O)	49.1
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.413
ClinicalShuntFraction	0.208
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	81.1
Aorta-CarbonDioxide-PartialPressure(mmHg)	42.9
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.962
HorowitzIndex(mmHg)	203
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.113
MechanicalVentilator-RespirationRate(1/min)	27.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.06
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.6
MechanicalVentilator-PlateauPressure(cmH2O)	8.59
HeartRate(1/min)	71.1
SystolicArterialPressure(mmHg)	115
DiastolicArterialPressure(mmHg)	73.5
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.33
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	107
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	33.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.370
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.489
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.452
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.45
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.219
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	61.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.11
EndTidalCarbonDioxidePressure(mmHg)	36.6
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	183
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.160
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0811
VentilationPerfusionRatio	0.945
HeartStrokeVolume(mL)	72.9
HeartEjectionFraction	0.549
BloodVolume(L)	4.49
MeanArterialPressure(mmHg)	95.2
PulsePressure(mmHg)	41.0
CardiacOutput(L/min)	5.19
CarbonDioxideSaturation	0.0400
RespiratoryExchangeRatio	0.808
SystemicVascularResistance(mmHg_s/mL)	1.05
OxygenConsumptionRate(mL/min)	206
CarbonDioxideProductionRate(mL/min)	166
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.04
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.416
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Scenario Output Plots

Figure 4. Select outputs from the scenario.