Building Medical Digital Twins with Pulse: Open Source Simulation Tools for Developers and Researchers
Webinar
×
En Route Care Scenario 5 - NoSpontaneous

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.

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-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 Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 376 377 0.189%   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 [304] 48.3 3.37%   C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio EqualTo 0.54 [229] 0.516 4.57%   VD/VT for mild ARDS
ClinicalShuntFraction [0.200,0.400] [221] 0.188 6.33%   QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg) [200,300] [115] 219 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) 48.3
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.427
ClinicalShuntFraction 0.188
MechanicalVentilator-TidalVolume(L) 0.377
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 87.4
Aorta-CarbonDioxide-PartialPressure(mmHg) 47.3
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.967
HorowitzIndex(mmHg) 219
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) 68.0
SystolicArterialPressure(mmHg) 116
DiastolicArterialPressure(mmHg) 72.7
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) 34.8
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 6.04e-15
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.567
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.57
PhysiologicDeadSpaceTidalVolumeRatio 0.516
PhysiologicShuntFraction 0.197
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.6
TotalRespiratoryModelCompliance(mL/cmH2O) 58.0
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.38
EndTidalCarbonDioxidePressure(mmHg) 38.9
PhysiologicDeadSpace(mL) 206
AlveolarArterialGradient(mmHg) 166
AlveolarDeadSpace(mL) 91.8
AnatomicDeadSpace(mL) 114
ChestWallCompliance(L/cmH2O) 0.127
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0819
VentilationPerfusionRatio 1.91
HeartStrokeVolume(mL) 76.9
HeartEjectionFraction 0.561
BloodVolume(L) 4.56
MeanArterialPressure(mmHg) 95.4
PulsePressure(mmHg) 42.8
CardiacOutput(L/min) 5.22
CarbonDioxideSaturation 0.257
RespiratoryExchangeRatio 0.822
SystemicVascularResistance(mmHg_s/mL) 1.04
OxygenConsumptionRate(mL/min) 205
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

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 0.471%   VT (measured)
RespiratoryCompliance(mL/cmH2O) LessThan Segment1 (48.3) [304] 24.6   -49.1% C
Aorta-Oxygen-PartialPressure(mmHg) LessThan Segment1 (87.4) [185] 40.9   -53.2% PaO2
OxygenSaturation LessThan Segment1 (0.967) [304] [308] 0.793   -17.9% SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) GreaterThan Segment1 (20.9) [304] 28.3   35.0% PIP
MechanicalVentilator-PlateauPressure(cmH2O) GreaterThan Segment1 (12.8) [304] 18.9   47.6% Pplat
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) LessThan Segment1 (34.8) [304] 33.5   -3.83% EtCO2



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) 24.6
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.400
ClinicalShuntFraction 0.617
MechanicalVentilator-TidalVolume(L) 0.378
BloodPH 7.36
Aorta-Oxygen-PartialPressure(mmHg) 40.9
Aorta-CarbonDioxide-PartialPressure(mmHg) 45.8
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.793
HorowitzIndex(mmHg) 103
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.596
MechanicalVentilator-RespirationRate(1/min) 25.9
MechanicalVentilator-MeanAirwayPressure(cmH2O) 9.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 28.3
MechanicalVentilator-PlateauPressure(cmH2O) 18.9
HeartRate(1/min) 154
SystolicArterialPressure(mmHg) 105
DiastolicArterialPressure(mmHg) 84.6
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) 33.5
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 274
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 0.221
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 13.3
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 13.3
TotalRespiratoryModelCompliance(mL/cmH2O) 58.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.60
EndTidalCarbonDioxidePressure(mmHg) 35.8
PhysiologicDeadSpace(mL) 206
AlveolarArterialGradient(mmHg) 109
AlveolarDeadSpace(mL) 91.8
AnatomicDeadSpace(mL) 114
ChestWallCompliance(L/cmH2O) 0.0664
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0409
VentilationPerfusionRatio 1.88
HeartStrokeVolume(mL) 34.5
HeartEjectionFraction 0.361
BloodVolume(L) 4.57
MeanArterialPressure(mmHg) 94.8
PulsePressure(mmHg) 20.7
CardiacOutput(L/min) 5.31
CarbonDioxideSaturation 0.211
RespiratoryExchangeRatio 0.803
SystemicVascularResistance(mmHg_s/mL) 1.01
OxygenConsumptionRate(mL/min) 186
CarbonDioxideProductionRate(mL/min) 149
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 376 377 0.189%   VT (measured)
RespiratoryCompliance(mL/cmH2O) GreaterThan Segment2 (24.6) [304] 48.5   97.0% C
Aorta-Oxygen-PartialPressure(mmHg) GreaterThan Segment2 (40.9) [185] 87.5   114% PaO2
OxygenSaturation GreaterThan Segment2 (0.793) [304] [308] 0.967   21.9% SpO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) LessThan Segment2 (28.3) [304] 20.9   -25.9% PIP
MechanicalVentilator-PlateauPressure(cmH2O) LessThan Segment2 (18.9) [304] 12.8   -32.3% 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) 48.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.426
ClinicalShuntFraction 0.184
MechanicalVentilator-TidalVolume(L) 0.377
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 87.5
Aorta-CarbonDioxide-PartialPressure(mmHg) 47.0
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.967
HorowitzIndex(mmHg) 220
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) 67.1
SystolicArterialPressure(mmHg) 116
DiastolicArterialPressure(mmHg) 72.1
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) 34.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 266
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.377
MechanicalVentilator-InspiratoryExpiratoryRatio 0.349
MechanicalVentilator-InspiratoryTidalVolume(L) 0.377
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.575
MechanicalVentilator-LeakFraction 6.78e-15
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.567
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.57
PhysiologicDeadSpaceTidalVolumeRatio 0.516
PhysiologicShuntFraction 0.195
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.6
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.6
TotalRespiratoryModelCompliance(mL/cmH2O) 58.4
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.38
EndTidalCarbonDioxidePressure(mmHg) 38.7
PhysiologicDeadSpace(mL) 206
AlveolarArterialGradient(mmHg) 166
AlveolarDeadSpace(mL) 91.8
AnatomicDeadSpace(mL) 114
ChestWallCompliance(L/cmH2O) 0.128
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0819
VentilationPerfusionRatio 1.88
HeartStrokeVolume(mL) 79.3
HeartEjectionFraction 0.567
BloodVolume(L) 4.60
MeanArterialPressure(mmHg) 95.5
PulsePressure(mmHg) 44.2
CardiacOutput(L/min) 5.32
CarbonDioxideSaturation 0.249
RespiratoryExchangeRatio 0.824
SystemicVascularResistance(mmHg_s/mL) 1.02
OxygenConsumptionRate(mL/min) 208
CarbonDioxideProductionRate(mL/min) 171
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.


Distributed under the Apache License, Version 2.0.

See accompanying NOTICE file for details.