Mild ARDS with Right Mainstem Intubation

Description

A 28 year old sailor 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 sailor is 5'5" and weighs 138 lbs.

Figure 1. Chest radiograph demonstrates bilateral infiltrates but no signs of barotrauma.

Segment Validation

Segment 1

Learning Objectives:

Assess baseline status
Recognize mild ARDS

Recommended Actions:

None

Ventilator settings are (VT Target = 6.6 mL/kg (ideal)):

Mode	VT (L)	PIP (cmH2O)	Flow (L/min)	I:E	TI (s)	RR (bpm)	PEEP (cmH2O)	FiO2
VC-CMV	0.376	NA	42	NA	0.6	12	5	0.4

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 376	383	1.79%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.6	3.17%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.6	3.17%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 50 [305]	48.9	2.22%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [230]	0.516	4.57%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [222]	0.184	8.20%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [115]	216	0.00%	PaO2/FiO2 for mild ARDS

Figure 2. 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	0.449
ClinicalShuntFraction	0.184
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	86.0
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.7
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.968
HorowitzIndex(mmHg)	216
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0300
MechanicalVentilator-RespirationRate(1/min)	26.1
MechanicalVentilator-MeanAirwayPressure(cmH2O)	6.98
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.5
MechanicalVentilator-PlateauPressure(cmH2O)	8.52
HeartRate(1/min)	70.9
SystolicArterialPressure(mmHg)	115
DiastolicArterialPressure(mmHg)	73.7
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.99
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.31
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	109
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	33.3
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.5
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.353
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.482
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.414
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.41
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.194
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	61.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.03
EndTidalCarbonDioxidePressure(mmHg)	37.4
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	171
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.151
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0811
VentilationPerfusionRatio	1.99
HeartStrokeVolume(mL)	72.6
HeartEjectionFraction	0.548
BloodVolume(L)	4.47
MeanArterialPressure(mmHg)	95.3
PulsePressure(mmHg)	40.8
CardiacOutput(L/min)	5.15
CarbonDioxideSaturation	0.148
RespiratoryExchangeRatio	0.822
SystemicVascularResistance(mmHg_s/mL)	1.05
OxygenConsumptionRate(mL/min)	207
CarbonDioxideProductionRate(mL/min)	170
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
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 and recommend repositioning of endotracheal tube

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	382	1.67%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	LessThan Segment1 (48.9) [305]	27.3		-44.2%	C
Aorta-Oxygen-PartialPressure(mmHg)	LessThan Segment1 (86.0) [186]	41.6		-51.6%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (16.5) [305]	23.0		39.4%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (8.52) [305]	14.0		64.1%	Pplat

Figure 3. 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)	13.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	13.4
RespiratoryCompliance(mL/cmH2O)	27.3
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.613
ClinicalShuntFraction	0.610
MechanicalVentilator-TidalVolume(L)	0.382
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	41.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.3
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.808
HorowitzIndex(mmHg)	104
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	3.75
MechanicalVentilator-RespirationRate(1/min)	38.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.10
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	23.0
MechanicalVentilator-PlateauPressure(cmH2O)	14.0
HeartRate(1/min)	156
SystolicArterialPressure(mmHg)	105
DiastolicArterialPressure(mmHg)	85.5
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	14.5
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	12.9
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	12.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	42.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	21.3
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	25.0
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	283
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.382
MechanicalVentilator-InspiratoryExpiratoryRatio	0.612
MechanicalVentilator-InspiratoryTidalVolume(L)	0.382
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.713
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	1.44
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	6.44
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.195
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelCompliance(mL/cmH2O)	62.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	8.75
EndTidalCarbonDioxidePressure(mmHg)	26.7
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	116
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0878
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0410
VentilationPerfusionRatio	2.92
HeartStrokeVolume(mL)	32.6
HeartEjectionFraction	0.346
BloodVolume(L)	4.48
MeanArterialPressure(mmHg)	95.2
PulsePressure(mmHg)	19.5
CardiacOutput(L/min)	5.09
CarbonDioxideSaturation	0.136
RespiratoryExchangeRatio	0.804
SystemicVascularResistance(mmHg_s/mL)	1.06
OxygenConsumptionRate(mL/min)	188
CarbonDioxideProductionRate(mL/min)	151
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
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	1.74%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment2 (27.3) [305]	48.6		78.1%	C
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment2 (41.6) [186]	86.6		108%	PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (23.0) [305]	16.6		-27.8%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment2 (14.0) [305]	8.64		-38.2%	Pplat

Figure 4. 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)	48.6
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.453
ClinicalShuntFraction	0.186
MechanicalVentilator-TidalVolume(L)	0.383
BloodPH	7.37
Aorta-Oxygen-PartialPressure(mmHg)	86.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.9
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.968
HorowitzIndex(mmHg)	217
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.0760
MechanicalVentilator-RespirationRate(1/min)	26.5
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.04
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	16.6
MechanicalVentilator-PlateauPressure(cmH2O)	8.64
HeartRate(1/min)	69.0
SystolicArterialPressure(mmHg)	116
DiastolicArterialPressure(mmHg)	72.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	10.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	7.47
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	105
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	33.0
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	33.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.383
MechanicalVentilator-InspiratoryExpiratoryRatio	0.361
MechanicalVentilator-InspiratoryTidalVolume(L)	0.383
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.487
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.440
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.44
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.197
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	57.7
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.08
EndTidalCarbonDioxidePressure(mmHg)	37.6
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	168
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.147
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0814
VentilationPerfusionRatio	1.98
HeartStrokeVolume(mL)	76.3
HeartEjectionFraction	0.560
BloodVolume(L)	4.53
MeanArterialPressure(mmHg)	95.5
PulsePressure(mmHg)	42.6
CardiacOutput(L/min)	5.26
CarbonDioxideSaturation	0.160
RespiratoryExchangeRatio	0.822
SystemicVascularResistance(mmHg_s/mL)	1.03
OxygenConsumptionRate(mL/min)	206
CarbonDioxideProductionRate(mL/min)	169
Patient-AlveoliSurfaceArea(m^2)	25.9
Patient-ExpiratoryReserveVolume(L)	0.687
Patient-FunctionalResidualCapacity(L)	1.29
Patient-InspiratoryCapacity(L)	2.45
Patient-InspiratoryReserveVolume(L)	2.01
Patient-ResidualVolume(L)	0.603
Patient-TidalVolumeBaseline(L)	0.443
Patient-TotalLungCapacity(L)	3.74
Patient-VitalCapacity(L)	3.14

Scenario Output Plots

Figure 5. Select outputs from the scenario.