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_md760 Segment Validation @subsubsection autotoc_md761 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

26

5

0.4

Ventilator alarm settings are:

High PIP = 31 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
Low MVe = 7.3 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	377	0.19%	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]	47.9	-4.28%	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]	0.209	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)	47.9
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.351
ClinicalShuntFraction	0.209
MechanicalVentilator-TidalVolume(L)	0.377
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	80.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	43.2
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.961
HorowitzIndex(mmHg)	203
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.375
MechanicalVentilator-RespirationRate(1/min)	25.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.05
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	20.9
MechanicalVentilator-PlateauPressure(cmH2O)	12.8
HeartRate(1/min)	71.8
SystolicArterialPressure(mmHg)	114
DiastolicArterialPressure(mmHg)	73.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.74
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	13.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	48.2
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	23.7
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	34.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	265
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.377
MechanicalVentilator-InspiratoryExpiratoryRatio	0.349
MechanicalVentilator-InspiratoryTidalVolume(L)	0.377
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.575
MechanicalVentilator-LeakFraction	2.18e-14
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.567
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.57
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.221
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	59.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.38
EndTidalCarbonDioxidePressure(mmHg)	38.3
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	178
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.123
FractionOfInspiredOxygen	0.398
LungCompliance(L/cmH2O)	0.0819
VentilationPerfusionRatio	0.874
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	0.0594
RespiratoryExchangeRatio	0.808
SystemicVascularResistance(mmHg_s/mL)	1.04
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

Segment 2

Two hours later 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	378	0.47%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	LessThan Segment1 (47.9) [316]	25.4		-46.98%	C
Aorta-Oxygen-PartialPressure(mmHg)	LessThan Segment1 (80.7) [193]	40.5		-49.85%	PaO2
OxygenSaturation	LessThan Segment1 (0.961) [316] [320]	0.790		-17.84%	SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	GreaterThan Segment1 (20.9) [316]	28.3		34.98%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	GreaterThan Segment1 (12.8) [316]	18.9		47.62%	Pplat
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	LessThan Segment1 (34.6) [316]	27.2		-21.48%	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)	13.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	13.3
RespiratoryCompliance(mL/cmH2O)	25.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.482
ClinicalShuntFraction	0.616
MechanicalVentilator-TidalVolume(L)	0.378
BloodPH	7.35
Aorta-Oxygen-PartialPressure(mmHg)	40.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.3
Aorta-Bicarbonate-Molarity(mEq/L)	26.3
OxygenSaturation	0.790
HorowitzIndex(mmHg)	102
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	2.48
MechanicalVentilator-RespirationRate(1/min)	25.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	28.3
MechanicalVentilator-PlateauPressure(cmH2O)	18.9
HeartRate(1/min)	167
SystolicArterialPressure(mmHg)	104
DiastolicArterialPressure(mmHg)	86.2
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.77
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	13.3
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	16.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	27.1
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	16.2
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	27.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	278
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.378
MechanicalVentilator-InspiratoryExpiratoryRatio	0.349
MechanicalVentilator-InspiratoryTidalVolume(L)	0.378
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.836
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.309
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.31
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.201
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	13.3
TotalRespiratoryModelCompliance(mL/cmH2O)	60.3
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	7.48
EndTidalCarbonDioxidePressure(mmHg)	28.7
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	114
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.0725
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0409
VentilationPerfusionRatio	0.941
HeartStrokeVolume(mL)	28.4
HeartEjectionFraction	0.319
BloodVolume(L)	4.48
MeanArterialPressure(mmHg)	94.7
PulsePressure(mmHg)	17.5
CardiacOutput(L/min)	4.73
CarbonDioxideSaturation	0.122
RespiratoryExchangeRatio	0.786
SystemicVascularResistance(mmHg_s/mL)	1.12
OxygenConsumptionRate(mL/min)	184
CarbonDioxideProductionRate(mL/min)	145
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	377	0.19%		VT (measured)
RespiratoryCompliance(mL/cmH2O)	GreaterThan Segment2 (25.4) [316]	47.8		88.43%	C
Aorta-Oxygen-PartialPressure(mmHg)	GreaterThan Segment2 (40.5) [193]	81.0		100.18%	PaO2
OxygenSaturation	GreaterThan Segment2 (0.790) [316] [320]	0.961		21.70%	SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	LessThan Segment2 (28.3) [316]	20.9		-25.92%	PIP
MechanicalVentilator-PlateauPressure(cmH2O)	LessThan Segment2 (18.9) [316]	12.8		-32.26%	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)	47.8
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.337
ClinicalShuntFraction	0.209
MechanicalVentilator-TidalVolume(L)	0.377
BloodPH	7.35
Aorta-Oxygen-PartialPressure(mmHg)	81.0
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.0
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.961
HorowitzIndex(mmHg)	203
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.375
MechanicalVentilator-RespirationRate(1/min)	25.9
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.05
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	20.9
MechanicalVentilator-PlateauPressure(cmH2O)	12.8
HeartRate(1/min)	71.1
SystolicArterialPressure(mmHg)	115
DiastolicArterialPressure(mmHg)	73.5
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.74
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	13.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	48.2
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	23.7
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	36.1
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	265
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.377
MechanicalVentilator-InspiratoryExpiratoryRatio	0.349
MechanicalVentilator-InspiratoryTidalVolume(L)	0.377
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.575
MechanicalVentilator-LeakFraction	2.65e-14
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.567
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.57
PhysiologicDeadSpaceTidalVolumeRatio	0.516
PhysiologicShuntFraction	0.218
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.6
TotalRespiratoryModelCompliance(mL/cmH2O)	58.5
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.38
EndTidalCarbonDioxidePressure(mmHg)	39.9
PhysiologicDeadSpace(mL)	206
AlveolarArterialGradient(mmHg)	176
AlveolarDeadSpace(mL)	91.8
AnatomicDeadSpace(mL)	114
ChestWallCompliance(L/cmH2O)	0.123
FractionOfInspiredOxygen	0.398
LungCompliance(L/cmH2O)	0.0819
VentilationPerfusionRatio	0.877
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	0.102
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.