What’s New in the Pulse Physiology Engine 4.4.0
Webinar
×
En Route Care Scenario 7

Hypoxemic Respiratory Failure Plugged ETT

Description

A 54-year-old, patient was injured in a motor vehicle accident sustaining multiple rib fractures and pulmonary contusion. He lost consciousness at the scene, sustained a complex jaw fracture, near transection of the tongue with significant blood loss and noted to have blood in the trachea at intubation. After intubation he is on mechanical ventilation and remains sedated with a RASS of -3

His initial chest x-ray demonstrated right middle lobe consolidation and some evidence of hyperinflation. The patient has a smoking history of 2 packs per day for 35 years and has primary hypertension managed with drug therapy. He is 5'8'' and weighs 235 lbs. Suctioning reveals a moderate amount of old blood. Gram stain of secretions shows no bacteria. He is scheduled for transport to definitive care that night.

Segment Validation

Segment 1

Learning Objectives:

  • Assess baseline status

Recommended Actions:

  • None


Ventilator settings are (delivered VT of 460 ml):

Mode VT (L) PIP (cmH2O) Flow (L/min) I:E TI (s) RR (bpm) PEEP (cmH2O) FiO2
PC-AC NA 14.2 NA NA 0.8 10 5 0.40

Ventilator alarm settings are:

  • High PIP = 24 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
  • Low MVe = 8.4 L/min (~25% below the initial value)
  • Low VT = 365 mL (~25% below the initial value)
  • High RR = 33 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 460 479 4.13%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [18] 11.4 -4.68%   Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [18] 11.4 -4.68%   Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O) EqualTo 50 [316] 49.7 -0.58%   C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio EqualTo 0.54 [238] 0.515 -4.54%   VD/VT for mild ARDS
ClinicalShuntFraction [0.200,0.400] [229] 0.196 -2.12%   QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg) [200,300] [119] 214 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) 68.0
Patient-IdealBodyWeight(kg) 68.4
InspiratoryRespiratoryResistance(cmH2O_s/L) 11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L) 11.4
RespiratoryCompliance(mL/cmH2O) 49.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.431
ClinicalShuntFraction 0.196
MechanicalVentilator-TidalVolume(L) 0.479
BloodPH 7.36
Aorta-Oxygen-PartialPressure(mmHg) 85.4
Aorta-CarbonDioxide-PartialPressure(mmHg) 43.0
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.967
HorowitzIndex(mmHg) 214
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.0256
MechanicalVentilator-RespirationRate(1/min) 24.2
MechanicalVentilator-MeanAirwayPressure(cmH2O) 7.89
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 14.2
MechanicalVentilator-PlateauPressure(cmH2O) 15.2
HeartRate(1/min) 97.3
SystolicArterialPressure(mmHg) 132
DiastolicArterialPressure(mmHg) 70.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 11.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 49.4
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 52.2
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 34.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 265
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.479
MechanicalVentilator-InspiratoryExpiratoryRatio 0.476
MechanicalVentilator-InspiratoryTidalVolume(L) 0.479
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.647
MechanicalVentilator-LeakFraction 7.19e-08
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.496
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.50
PhysiologicDeadSpaceTidalVolumeRatio 0.515
PhysiologicShuntFraction 0.204
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelCompliance(mL/cmH2O) 60.0
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.03
EndTidalCarbonDioxidePressure(mmHg) 37.6
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 177
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.149
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 0.906
HeartStrokeVolume(mL) 64.2
HeartEjectionFraction 0.467
BloodVolume(L) 6.37
MeanArterialPressure(mmHg) 102
PulsePressure(mmHg) 61.4
CardiacOutput(L/min) 6.24
CarbonDioxideSaturation 0.0455
RespiratoryExchangeRatio 0.808
SystemicVascularResistance(mmHg_s/mL) 0.942
OxygenConsumptionRate(mL/min) 259
CarbonDioxideProductionRate(mL/min) 209
Patient-AlveoliSurfaceArea(m^2) 31.0
Patient-ExpiratoryReserveVolume(L) 0.819
Patient-FunctionalResidualCapacity(L) 1.54
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.41
Patient-ResidualVolume(L) 0.718
Patient-TidalVolumeBaseline(L) 0.513
Patient-TotalLungCapacity(L) 4.46
Patient-VitalCapacity(L) 3.74

Segment 2

The patient is loaded onto the aircraft for transfer to trauma center care. During transport the patient is heavily sedated. Immediately after take-off multiple ventilator alarms sound and SpO2 has fallen. The patient is growing agitated. Attempting to manually ventilate the patient meets extreme resistance and no air movement.

Learning Objectives:

  • Recognize plugged ET tube

Recommended Actions:

  • Suction ET tube to remove obstruction
Table 3. Data request validation results for Segment 2.
Property Name Validation Engine Value Percent Error Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 0 3.32e-91 0.00%   VT fully plugged
OxygenSaturation LessThan Segment1 (0.967) [316] [320] 0.814   -15.82% SpO2



Figure 2. Vitals and ventilator monitors for Segment 2.


Table 4. Data requests for Segment 2.
Property Name Engine Value
Patient-Height(in) 68.0
Patient-IdealBodyWeight(kg) 68.4
InspiratoryRespiratoryResistance(cmH2O_s/L) 11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L) 11.4
RespiratoryCompliance(mL/cmH2O) 48.2
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.431
ClinicalShuntFraction 0.155
MechanicalVentilator-TidalVolume(L) 3.32e-94
BloodPH 7.26
Aorta-Oxygen-PartialPressure(mmHg) 46.6
Aorta-CarbonDioxide-PartialPressure(mmHg) 54.7
Aorta-Bicarbonate-Molarity(mEq/L) 26.7
OxygenSaturation 0.814
HorowitzIndex(mmHg) 214
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
MechanicalVentilator-RespirationRate(1/min) 9.97
MechanicalVentilator-MeanAirwayPressure(cmH2O) 6.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 14.2
MechanicalVentilator-PlateauPressure(cmH2O) 14.2
HeartRate(1/min) 160
SystolicArterialPressure(mmHg) 126
DiastolicArterialPressure(mmHg) 81.6
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 3.31e-93
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 3.61e-92
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 3.61e-92
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 0.442
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 305
MechanicalVentilator-ExpiratoryTidalVolume(L) -6.83e-94
MechanicalVentilator-InspiratoryExpiratoryRatio 0.153
MechanicalVentilator-InspiratoryTidalVolume(L) 4.40e-94
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.00
MechanicalVentilator-LeakFraction 1.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.00
PhysiologicDeadSpaceTidalVolumeRatio 0.515
PhysiologicShuntFraction 0.203
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelCompliance(mL/cmH2O) 60.1
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
TotalPositiveEndExpiratoryPressure(cmH2O) 0.00
EndTidalCarbonDioxidePressure(mmHg) 0.00
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 11.8
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.148
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 0.906
HeartStrokeVolume(mL) 43.6
HeartEjectionFraction 0.368
BloodVolume(L) 6.38
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 44.0
CardiacOutput(L/min) 6.96
CarbonDioxideSaturation 0.431
RespiratoryExchangeRatio 0.804
SystemicVascularResistance(mmHg_s/mL) 0.849
OxygenConsumptionRate(mL/min) 254
CarbonDioxideProductionRate(mL/min) 204
Patient-AlveoliSurfaceArea(m^2) 31.0
Patient-ExpiratoryReserveVolume(L) 0.819
Patient-FunctionalResidualCapacity(L) 1.54
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.41
Patient-ResidualVolume(L) 0.718
Patient-TidalVolumeBaseline(L) 0.513
Patient-TotalLungCapacity(L) 4.46
Patient-VitalCapacity(L) 3.74

Segment 3

Patient suctioned and ET tube obstruction removed.

Learning Objectives:

  • Recognize success of suctioning

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 Segment1 (479) 455 -5.11%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [316] [320] 11.4   -0.01% Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [316] [320] 11.4   -0.01% Rexp
OxygenSaturation GreaterThan Segment2 (0.814) [316] [320] 0.966   18.71% SpO2



Figure 3. Vitals and ventilator monitors for Segment 3.


Table 6. Data requests for Segment 3.
Property Name Engine Value
Patient-Height(in) 68.0
Patient-IdealBodyWeight(kg) 68.4
InspiratoryRespiratoryResistance(cmH2O_s/L) 11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L) 11.4
RespiratoryCompliance(mL/cmH2O) 49.9
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.431
ClinicalShuntFraction 0.196
MechanicalVentilator-TidalVolume(L) 0.455
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 85.4
Aorta-CarbonDioxide-PartialPressure(mmHg) 43.8
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.966
HorowitzIndex(mmHg) 214
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.0684
MechanicalVentilator-RespirationRate(1/min) 26.8
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.20
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 14.2
MechanicalVentilator-PlateauPressure(cmH2O) 14.9
HeartRate(1/min) 97.6
SystolicArterialPressure(mmHg) 132
DiastolicArterialPressure(mmHg) 71.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 12.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 49.7
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 49.5
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 36.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 265
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.455
MechanicalVentilator-InspiratoryExpiratoryRatio 0.556
MechanicalVentilator-InspiratoryTidalVolume(L) 0.455
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.673
MechanicalVentilator-LeakFraction 1.02e-05
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.726
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.73
PhysiologicDeadSpaceTidalVolumeRatio 0.515
PhysiologicShuntFraction 0.204
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelCompliance(mL/cmH2O) 59.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.07
EndTidalCarbonDioxidePressure(mmHg) 39.9
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 175
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.143
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 0.895
HeartStrokeVolume(mL) 64.1
HeartEjectionFraction 0.467
BloodVolume(L) 6.38
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 61.3
CardiacOutput(L/min) 6.26
CarbonDioxideSaturation 0.0946
RespiratoryExchangeRatio 0.806
SystemicVascularResistance(mmHg_s/mL) 0.941
OxygenConsumptionRate(mL/min) 256
CarbonDioxideProductionRate(mL/min) 207
Patient-AlveoliSurfaceArea(m^2) 31.0
Patient-ExpiratoryReserveVolume(L) 0.819
Patient-FunctionalResidualCapacity(L) 1.54
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.41
Patient-ResidualVolume(L) 0.718
Patient-TidalVolumeBaseline(L) 0.513
Patient-TotalLungCapacity(L) 4.46
Patient-VitalCapacity(L) 3.74

Scenario Output Plots


Figure 4. Select outputs from the scenario.


Distributed under the Apache License, Version 2.0.

See accompanying NOTICE file for details.