Hypoxemic Respiratory Failure Plugged ETT

Description

A 54-year-old, Black contractor 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 -2

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 CCATT to definitive care that night.

Figure 1. Chest radiograph demonstrates with right middle lobe consolidation, flattened diaphragms and hyperinflation in the upper lobes bilaterally, but no signs of barotrauma.

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-CMV	NA	14.2	NA	NA	0.8	10	5	0.40

Table 1. Data request validation results for Segment 1.

Property Name	Validation	Engine Value	Percent Error	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 460	487	5.73%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.4	4.79%	Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L)	EqualTo 12 [17]	11.4	4.79%	Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O)	EqualTo 50 [305]	50.3	0.547%	C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio	EqualTo 0.54 [230]	0.515	4.65%	VD/VT for mild ARDS
ClinicalShuntFraction	[0.200,0.400] [222]	0.193	3.36%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [115]	210	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)	68.0
Patient-IdealBodyWeight(kg)	68.4
InspiratoryRespiratoryResistance(cmH2O_s/L)	11.4
ExpiratoryRespiratoryResistance(cmH2O_s/L)	11.4
RespiratoryCompliance(mL/cmH2O)	50.3
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.475
ClinicalShuntFraction	0.193
MechanicalVentilator-TidalVolume(L)	0.487
BloodPH	7.38
Aorta-Oxygen-PartialPressure(mmHg)	84.1
Aorta-CarbonDioxide-PartialPressure(mmHg)	44.0
Aorta-Bicarbonate-Molarity(mEq/L)	26.1
OxygenSaturation	0.966
HorowitzIndex(mmHg)	210
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.217
MechanicalVentilator-RespirationRate(1/min)	23.1
MechanicalVentilator-MeanAirwayPressure(cmH2O)	7.76
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	15.3
HeartRate(1/min)	102
SystolicArterialPressure(mmHg)	130
DiastolicArterialPressure(mmHg)	72.7
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.2
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	49.4
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	53.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	34.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	265
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.487
MechanicalVentilator-InspiratoryExpiratoryRatio	0.444
MechanicalVentilator-InspiratoryTidalVolume(L)	0.487
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.636
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.408
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.41
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.196
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	57.0
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.22
EndTidalCarbonDioxidePressure(mmHg)	37.2
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	172
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.147
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	1.91
HeartStrokeVolume(mL)	59.2
HeartEjectionFraction	0.450
BloodVolume(L)	6.36
MeanArterialPressure(mmHg)	102
PulsePressure(mmHg)	57.3
CardiacOutput(L/min)	6.01
CarbonDioxideSaturation	0.113
RespiratoryExchangeRatio	0.817
SystemicVascularResistance(mmHg_s/mL)	0.973
OxygenConsumptionRate(mL/min)	253
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)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	4.46
Patient-VitalCapacity(L)	3.74

Segment 2

The patient is loaded onto the aircraft for transfer to Level III care. During transport the patient is heavily sedated. Immediately after take-off multiple ventilator alarms sound, tidal volume falls, respiratory rate increases, 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 Change	Notes
MechanicalVentilator-TidalVolume(mL)	LessThan Segment1 (487)	4.83	-99.0%	VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (11.4) [305] [309]	11.4	0.00%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	GreaterThan Segment1 (11.4) [305] [309]	11.4	0.00%	Rexp

Figure 3. 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)	48.0
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.475
ClinicalShuntFraction	0.206
MechanicalVentilator-TidalVolume(L)	0.00483
BloodPH	7.33
Aorta-Oxygen-PartialPressure(mmHg)	74.6
Aorta-CarbonDioxide-PartialPressure(mmHg)	48.9
Aorta-Bicarbonate-Molarity(mEq/L)	26.3
OxygenSaturation	0.949
HorowitzIndex(mmHg)	210
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
MechanicalVentilator-RespirationRate(1/min)	9.97
MechanicalVentilator-MeanAirwayPressure(cmH2O)	6.19
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	5.11
HeartRate(1/min)	102
SystolicArterialPressure(mmHg)	130
DiastolicArterialPressure(mmHg)	73.4
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	0.0508
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	47.8
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	0.554
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	18.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	283
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.00129
MechanicalVentilator-InspiratoryExpiratoryRatio	0.153
MechanicalVentilator-InspiratoryTidalVolume(L)	0.00483
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.00270
MechanicalVentilator-LeakFraction	0.747
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	7.74e-06
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.00
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.215
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	1.00e+03
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	1.00e+03
TotalRespiratoryModelCompliance(mL/cmH2O)	57.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
TotalPositiveEndExpiratoryPressure(cmH2O)	0.00
EndTidalCarbonDioxidePressure(mmHg)	0.00
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	96.3
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.125
FractionOfInspiredOxygen	0.400
LungCompliance(L/cmH2O)	0.0789
VentilationPerfusionRatio	1.91
HeartStrokeVolume(mL)	58.0
HeartEjectionFraction	0.445
BloodVolume(L)	6.36
MeanArterialPressure(mmHg)	102
PulsePressure(mmHg)	56.6
CardiacOutput(L/min)	5.91
CarbonDioxideSaturation	0.312
RespiratoryExchangeRatio	0.821
SystemicVascularResistance(mmHg_s/mL)	0.993
OxygenConsumptionRate(mL/min)	259
CarbonDioxideProductionRate(mL/min)	213
Patient-AlveoliSurfaceArea(m^2)	31.0
Patient-ExpiratoryReserveVolume(L)	0.819
Patient-FunctionalResidualCapacity(L)	1.54
Patient-InspiratoryCapacity(L)	2.93
Patient-InspiratoryReserveVolume(L)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
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 (487)	448	8.37%		VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (11.4) [305] [309]	11.4		-0.0107%	Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L)	LessThan Segment2 (11.4) [305] [309]	11.4		-0.0105%	Rexp

Figure 4. 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)	50.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.518
ClinicalShuntFraction	0.193
MechanicalVentilator-TidalVolume(L)	0.448
BloodPH	7.36
Aorta-Oxygen-PartialPressure(mmHg)	84.7
Aorta-CarbonDioxide-PartialPressure(mmHg)	45.6
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.965
HorowitzIndex(mmHg)	212
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.130
MechanicalVentilator-RespirationRate(1/min)	27.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	8.23
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	14.2
MechanicalVentilator-PlateauPressure(cmH2O)	14.7
HeartRate(1/min)	101
SystolicArterialPressure(mmHg)	131
DiastolicArterialPressure(mmHg)	73.0
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	12.1
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	49.9
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	48.8
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	34.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	267
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.448
MechanicalVentilator-InspiratoryExpiratoryRatio	0.563
MechanicalVentilator-InspiratoryTidalVolume(L)	0.448
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.687
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.746
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.75
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.196
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	59.7
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.13
EndTidalCarbonDioxidePressure(mmHg)	37.6
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	174
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.149
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	2.07
HeartStrokeVolume(mL)	59.3
HeartEjectionFraction	0.450
BloodVolume(L)	6.38
MeanArterialPressure(mmHg)	102
PulsePressure(mmHg)	57.5
CardiacOutput(L/min)	6.02
CarbonDioxideSaturation	0.192
RespiratoryExchangeRatio	0.819
SystemicVascularResistance(mmHg_s/mL)	0.976
OxygenConsumptionRate(mL/min)	255
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)	2.39
Patient-ResidualVolume(L)	0.718
Patient-TidalVolumeBaseline(L)	0.535
Patient-TotalLungCapacity(L)	4.46
Patient-VitalCapacity(L)	3.74

Scenario Output Plots

Figure 5. Select outputs from the scenario.