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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.

Figure 1. Chest radiograph demonstrates 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-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 460 487 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 [304] 50.3 0.547%   C requested by SME for mild ARDS
PhysiologicDeadSpaceTidalVolumeRatio EqualTo 0.54 [229] 0.515 4.65%   VD/VT for mild ARDS
ClinicalShuntFraction [0.200,0.400] [221] 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 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 3.55e-91 0.00%   VT fully plugged
OxygenSaturation LessThan Segment1 (0.966) [304] [308] 0.689   -28.7% SpO2



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) 48.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.475
ClinicalShuntFraction 0.0906
MechanicalVentilator-TidalVolume(L) 3.55e-94
BloodPH 7.29
Aorta-Oxygen-PartialPressure(mmHg) 35.7
Aorta-CarbonDioxide-PartialPressure(mmHg) 55.0
Aorta-Bicarbonate-Molarity(mEq/L) 26.6
OxygenSaturation 0.689
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) 14.2
HeartRate(1/min) 170
SystolicArterialPressure(mmHg) 123
DiastolicArterialPressure(mmHg) 83.2
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 3.09e-93
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 3.37e-92
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 3.37e-92
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 30.5
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 270
MechanicalVentilator-ExpiratoryTidalVolume(L) -1.13e-93
MechanicalVentilator-InspiratoryExpiratoryRatio 0.153
MechanicalVentilator-InspiratoryTidalVolume(L) 4.62e-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 0.228
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelCompliance(mL/cmH2O) 56.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
TotalPositiveEndExpiratoryPressure(cmH2O) 0.00
EndTidalCarbonDioxidePressure(mmHg) 0.00
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 3.46
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.146
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 1.91
HeartStrokeVolume(mL) 38.2
HeartEjectionFraction 0.343
BloodVolume(L) 6.37
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 39.8
CardiacOutput(L/min) 6.49
CarbonDioxideSaturation 0.475
RespiratoryExchangeRatio 0.806
SystemicVascularResistance(mmHg_s/mL) 0.908
OxygenConsumptionRate(mL/min) 240
CarbonDioxideProductionRate(mL/min) 194
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) 442 9.71%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [304] [308] 11.4   -0.0118% Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [304] [308] 11.4   -0.0116% Rexp
OxygenSaturation GreaterThan Segment2 (0.689) [304] [308] 0.965   40.1% SpO2



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) 51.0
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.526
ClinicalShuntFraction 0.193
MechanicalVentilator-TidalVolume(L) 0.442
BloodPH 7.36
Aorta-Oxygen-PartialPressure(mmHg) 84.9
Aorta-CarbonDioxide-PartialPressure(mmHg) 46.1
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.965
HorowitzIndex(mmHg) 213
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.234
MechanicalVentilator-RespirationRate(1/min) 27.8
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.32
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 14.2
MechanicalVentilator-PlateauPressure(cmH2O) 14.6
HeartRate(1/min) 101
SystolicArterialPressure(mmHg) 131
DiastolicArterialPressure(mmHg) 73.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 12.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 50.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 48.1
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 34.2
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 267
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.442
MechanicalVentilator-InspiratoryExpiratoryRatio 0.588
MechanicalVentilator-InspiratoryTidalVolume(L) 0.442
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.696
MechanicalVentilator-LeakFraction 4.52e-06
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.826
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.83
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) 5.24
EndTidalCarbonDioxidePressure(mmHg) 37.8
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 174
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.152
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 2.10
HeartStrokeVolume(mL) 59.3
HeartEjectionFraction 0.450
BloodVolume(L) 6.38
MeanArterialPressure(mmHg) 102
PulsePressure(mmHg) 57.5
CardiacOutput(L/min) 6.00
CarbonDioxideSaturation 0.211
RespiratoryExchangeRatio 0.819
SystemicVascularResistance(mmHg_s/mL) 0.979
OxygenConsumptionRate(mL/min) 256
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.


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