En Route Care Scenario 6
Hypoxemic Respiratory Failure - Pneumonia
Description
A 23 year old patient suffered developed shortness of breath, substernal chest pain and a productive cough following burn pit exposure. He was started on broad spectrum antibiotics and steroids for a suspected respiratory tract infection. Initial chest x-ray demonstrated some minor hilar infiltrates. On day 5 of his antibiotic course he developed worsening dyspnea, was febrile to 39.5 C, and his SpO2 was 91%. He was placed on high flow nasal cannula at 50% and 40 L/min. After 12 hours he was intubated.After intubation he is on mechanical ventilation and remains sedated with a RASS of -2.
The patient is 6'3'' and weighs 215 lbs. Suctioning reveals thick, tenacious, brownish-yellow secretions. Therapeutic bronchoscopy is performed and 15-20 mL secretions removed and sent for culture and sensitivity. Initial gram stain suggests acinetobacter baumanni. Antibiotics are changed to a carbapenem. He is scheduled for transport to definitive care in the morning.
Segment Validation
Segment 1
Learning Objectives:
- Assess baseline status
- Recognize moderate ARDS
Recommended Actions:
- None
Ventilator settings are:
| Mode | VT (L) | PIP (cmH2O) | Flow (L/min) | I:E | TI (s) | RR (bpm) | PEEP (cmH2O) | FiO2 |
|---|---|---|---|---|---|---|---|---|
| PC-AC | NA | 25 | NA | NA | 0.6 | 10 | 10 | 0.50 |
Ventilator alarm settings are:
- High PIP = 35 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
- Low MVe = 11 L/min (~25% below the initial value)
- Low VT = 310 mL (~25% below the initial value)
- High RR = 40 bpm (~10 bpm above the initial value or a max of 40 bpm)
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| InspiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [18] | 12.4 | 3.13% | Rinsp for moderate ARDS | |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [18] | 12.4 | 3.13% | Rexp for moderate ARDS | |
| RespiratoryCompliance(mL/cmH2O) | EqualTo 40 [316] | 42.6 | 6.54% | C requested by SME for moderate ARDS | |
| PhysiologicDeadSpaceTidalVolumeRatio | EqualTo 0.57 [238] | 0.553 | -2.98% | VD/VT for moderate ARDS | |
| ClinicalShuntFraction | [0.300,0.500] [229] | 0.306 | 0.00% | QS/QT for moderate ARDS (determined from blood gas values) | |
| HorowitzIndex(mmHg) | [100,200] [119] | 125 | 0.00% | PaO2/FiO2 for moderate ARDS |
| Property Name | Engine Value |
|---|---|
| Patient-Height(in) | 75.0 |
| Patient-IdealBodyWeight(kg) | 84.5 |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
| RespiratoryCompliance(mL/cmH2O) | 42.6 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.501 |
| ClinicalShuntFraction | 0.306 |
| MechanicalVentilator-TidalVolume(L) | 0.590 |
| BloodPH | 7.36 |
| Aorta-Oxygen-PartialPressure(mmHg) | 62.5 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 43.1 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.2 |
| OxygenSaturation | 0.925 |
| HorowitzIndex(mmHg) | 125 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.324 |
| MechanicalVentilator-RespirationRate(1/min) | 25.0 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 13.6 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 24.9 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 24.5 |
| HeartRate(1/min) | 89.6 |
| SystolicArterialPressure(mmHg) | 112 |
| DiastolicArterialPressure(mmHg) | 78.1 |
| MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 14.7 |
| MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 42.1 |
| MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 39.5 |
| MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 29.9 |
| MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 350 |
| MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.590 |
| MechanicalVentilator-InspiratoryExpiratoryRatio | 0.333 |
| MechanicalVentilator-InspiratoryTidalVolume(L) | 0.590 |
| MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.731 |
| MechanicalVentilator-LeakFraction | 1.25e-05 |
| MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.443 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 10.4 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.309 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 46.3 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 10.3 |
| EndTidalCarbonDioxidePressure(mmHg) | 32.2 |
| PhysiologicDeadSpace(mL) | 327 |
| AlveolarArterialGradient(mmHg) | 283 |
| AlveolarDeadSpace(mL) | 158 |
| AnatomicDeadSpace(mL) | 169 |
| ChestWallCompliance(L/cmH2O) | 0.164 |
| FractionOfInspiredOxygen | 0.500 |
| LungCompliance(L/cmH2O) | 0.0589 |
| VentilationPerfusionRatio | 1.11 |
| HeartStrokeVolume(mL) | 68.0 |
| HeartEjectionFraction | 0.508 |
| BloodVolume(L) | 7.00 |
| MeanArterialPressure(mmHg) | 95.5 |
| PulsePressure(mmHg) | 33.6 |
| CardiacOutput(L/min) | 6.09 |
| CarbonDioxideSaturation | 0.0522 |
| RespiratoryExchangeRatio | 0.797 |
| SystemicVascularResistance(mmHg_s/mL) | 0.893 |
| OxygenConsumptionRate(mL/min) | 298 |
| CarbonDioxideProductionRate(mL/min) | 237 |
| Patient-AlveoliSurfaceArea(m^2) | 15.3 |
| Patient-ExpiratoryReserveVolume(L) | 0.969 |
| Patient-FunctionalResidualCapacity(L) | 1.43 |
| Patient-InspiratoryCapacity(L) | 3.46 |
| Patient-InspiratoryReserveVolume(L) | 2.86 |
| Patient-ResidualVolume(L) | 0.457 |
| Patient-TidalVolumeBaseline(L) | 0.597 |
| Patient-TotalLungCapacity(L) | 4.89 |
| Patient-VitalCapacity(L) | 4.43 |
Segment 2
The patient is loaded onto the aircraft for transfer to trauma center care. During transport the patient becomes agitated and respiratory rate increases and SpO2 has fallen.
Learning Objectives:
- Recognize hypoventilation due to increased secretions
- Recognize oscillation of expiratory flow indicaint secretions
Recommended Actions:
- Check for pneumothorax
- Suction
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| MechanicalVentilator-TidalVolume(mL) | LessThan Segment1 (590) | 392 | -33.65% | VT (measured) | |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | GreaterThan Segment1 (12.4) [316] [320] | 20.5 | 65.80% | Rinsp | |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | GreaterThan Segment1 (12.4) [316] [320] | 20.3 | 63.99% | Rexp | |
| OxygenSaturation | LessThan Segment1 (0.925) [316] [320] | 0.922 | -0.33% | SpO2 |
| Property Name | Engine Value |
|---|---|
| Patient-Height(in) | 75.0 |
| Patient-IdealBodyWeight(kg) | 84.5 |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | 20.5 |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | 20.3 |
| RespiratoryCompliance(mL/cmH2O) | 43.0 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.474 |
| ClinicalShuntFraction | 0.298 |
| MechanicalVentilator-TidalVolume(L) | 0.392 |
| BloodPH | 7.32 |
| Aorta-Oxygen-PartialPressure(mmHg) | 63.9 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 47.5 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.4 |
| OxygenSaturation | 0.922 |
| HorowitzIndex(mmHg) | 129 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.460 |
| MechanicalVentilator-RespirationRate(1/min) | 30.0 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 14.3 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 25.0 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 21.0 |
| HeartRate(1/min) | 86.2 |
| SystolicArterialPressure(mmHg) | 112 |
| DiastolicArterialPressure(mmHg) | 77.0 |
| MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 11.7 |
| MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 20.5 |
| MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 20.1 |
| MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 42.6 |
| MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 26.1 |
| MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 32.9 |
| MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 337 |
| MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.392 |
| MechanicalVentilator-InspiratoryExpiratoryRatio | 0.429 |
| MechanicalVentilator-InspiratoryTidalVolume(L) | 0.392 |
| MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.725 |
| MechanicalVentilator-LeakFraction | 0.00 |
| MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 1.79 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 11.8 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.300 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 20.5 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 21.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 46.8 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 10.5 |
| EndTidalCarbonDioxidePressure(mmHg) | 39.0 |
| PhysiologicDeadSpace(mL) | 327 |
| AlveolarArterialGradient(mmHg) | 258 |
| AlveolarDeadSpace(mL) | 158 |
| AnatomicDeadSpace(mL) | 169 |
| ChestWallCompliance(L/cmH2O) | 0.171 |
| FractionOfInspiredOxygen | 0.497 |
| LungCompliance(L/cmH2O) | 0.0591 |
| VentilationPerfusionRatio | 0.330 |
| HeartStrokeVolume(mL) | 71.4 |
| HeartEjectionFraction | 0.520 |
| BloodVolume(L) | 7.01 |
| MeanArterialPressure(mmHg) | 95.5 |
| PulsePressure(mmHg) | 35.3 |
| CardiacOutput(L/min) | 6.16 |
| CarbonDioxideSaturation | 0.248 |
| RespiratoryExchangeRatio | 0.799 |
| SystemicVascularResistance(mmHg_s/mL) | 0.884 |
| OxygenConsumptionRate(mL/min) | 301 |
| CarbonDioxideProductionRate(mL/min) | 240 |
| Patient-AlveoliSurfaceArea(m^2) | 15.3 |
| Patient-ExpiratoryReserveVolume(L) | 0.969 |
| Patient-FunctionalResidualCapacity(L) | 1.43 |
| Patient-InspiratoryCapacity(L) | 3.46 |
| Patient-InspiratoryReserveVolume(L) | 2.86 |
| Patient-ResidualVolume(L) | 0.457 |
| Patient-TidalVolumeBaseline(L) | 0.597 |
| Patient-TotalLungCapacity(L) | 4.89 |
| Patient-VitalCapacity(L) | 4.43 |
Segment 3
Patient is suctioned for large volume of thick secretions.
Learning Objectives:
- Recognize that suctioning decreased airway resistance and restored tidal volume)
Recommended Actions:
- None
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| MechanicalVentilator-TidalVolume(mL) | GreaterThan Segment2 (392) | 589 | 50.43% | VT (measured) | |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | LessThan Segment2 (20.5) [316] [320] | 12.4 | -39.69% | Rinsp | |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | LessThan Segment2 (20.3) [316] [320] | 12.4 | -39.02% | Rexp | |
| OxygenSaturation | GreaterThan Segment2 (0.922) [316] [320] | 0.925 | 0.32% | SpO2 |
| Property Name | Engine Value |
|---|---|
| Patient-Height(in) | 75.0 |
| Patient-IdealBodyWeight(kg) | 84.5 |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | 12.4 |
| RespiratoryCompliance(mL/cmH2O) | 42.5 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.488 |
| ClinicalShuntFraction | 0.304 |
| MechanicalVentilator-TidalVolume(L) | 0.589 |
| BloodPH | 7.35 |
| Aorta-Oxygen-PartialPressure(mmHg) | 62.7 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 43.4 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.2 |
| OxygenSaturation | 0.925 |
| HorowitzIndex(mmHg) | 125 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.378 |
| MechanicalVentilator-RespirationRate(1/min) | 25.4 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 13.7 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 24.9 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 24.4 |
| HeartRate(1/min) | 89.3 |
| SystolicArterialPressure(mmHg) | 112 |
| DiastolicArterialPressure(mmHg) | 77.5 |
| MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 15.0 |
| MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 42.2 |
| MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 39.4 |
| MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 31.1 |
| MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 350 |
| MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.589 |
| MechanicalVentilator-InspiratoryExpiratoryRatio | 0.341 |
| MechanicalVentilator-InspiratoryTidalVolume(L) | 0.589 |
| MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.730 |
| MechanicalVentilator-LeakFraction | 3.65e-06 |
| MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.479 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 10.5 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.309 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 46.1 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 10.0 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 10.4 |
| EndTidalCarbonDioxidePressure(mmHg) | 33.5 |
| PhysiologicDeadSpace(mL) | 327 |
| AlveolarArterialGradient(mmHg) | 281 |
| AlveolarDeadSpace(mL) | 158 |
| AnatomicDeadSpace(mL) | 169 |
| ChestWallCompliance(L/cmH2O) | 0.163 |
| FractionOfInspiredOxygen | 0.500 |
| LungCompliance(L/cmH2O) | 0.0590 |
| VentilationPerfusionRatio | 1.10 |
| HeartStrokeVolume(mL) | 69.8 |
| HeartEjectionFraction | 0.513 |
| BloodVolume(L) | 7.01 |
| MeanArterialPressure(mmHg) | 95.5 |
| PulsePressure(mmHg) | 34.7 |
| CardiacOutput(L/min) | 6.23 |
| CarbonDioxideSaturation | 0.0691 |
| RespiratoryExchangeRatio | 0.797 |
| SystemicVascularResistance(mmHg_s/mL) | 0.873 |
| OxygenConsumptionRate(mL/min) | 298 |
| CarbonDioxideProductionRate(mL/min) | 238 |
| Patient-AlveoliSurfaceArea(m^2) | 15.3 |
| Patient-ExpiratoryReserveVolume(L) | 0.969 |
| Patient-FunctionalResidualCapacity(L) | 1.43 |
| Patient-InspiratoryCapacity(L) | 3.46 |
| Patient-InspiratoryReserveVolume(L) | 2.86 |
| Patient-ResidualVolume(L) | 0.457 |
| Patient-TidalVolumeBaseline(L) | 0.597 |
| Patient-TotalLungCapacity(L) | 4.89 |
| Patient-VitalCapacity(L) | 4.43 |
Scenario Output Plots
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