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	18	NA	NA	0.8	25	5	0.40

Ventilator alarm settings are:

High PIP = 28 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
Low MVe = 7.9 L/min (~25% below the initial value)
Low VT = 365 mL (~25% below the initial value)
High RR = 35 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	Notes
MechanicalVentilator-TidalVolume(mL)	EqualTo 460	451	-1.89%	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]	49.5	-1.09%	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	-2.03%	QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg)	[200,300] [119]	213	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)	49.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.412
ClinicalShuntFraction	0.196
MechanicalVentilator-TidalVolume(L)	0.451
BloodPH	7.35
Aorta-Oxygen-PartialPressure(mmHg)	85.1
Aorta-CarbonDioxide-PartialPressure(mmHg)	43.6
Aorta-Bicarbonate-Molarity(mEq/L)	26.2
OxygenSaturation	0.966
HorowitzIndex(mmHg)	213
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.567
MechanicalVentilator-RespirationRate(1/min)	25.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.23
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	18.0
MechanicalVentilator-PlateauPressure(cmH2O)	14.7
HeartRate(1/min)	97.3
SystolicArterialPressure(mmHg)	132
DiastolicArterialPressure(mmHg)	70.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	49.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	34.8
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	36.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	263
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.451
MechanicalVentilator-InspiratoryExpiratoryRatio	0.500
MechanicalVentilator-InspiratoryTidalVolume(L)	0.451
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.700
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.535
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.54
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.203
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	56.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.57
EndTidalCarbonDioxidePressure(mmHg)	39.5
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	171
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.139
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	0.827
HeartStrokeVolume(mL)	64.2
HeartEjectionFraction	0.467
BloodVolume(L)	6.37
MeanArterialPressure(mmHg)	102
PulsePressure(mmHg)	61.4
CardiacOutput(L/min)	6.24
CarbonDioxideSaturation	0.0831
RespiratoryExchangeRatio	0.806
SystemicVascularResistance(mmHg_s/mL)	0.942
OxygenConsumptionRate(mL/min)	256
CarbonDioxideProductionRate(mL/min)	206
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. 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	3.63e-91	0.00%		VT fully plugged
OxygenSaturation	LessThan Segment1 (0.966) [316] [320]	0.689		-28.63%	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)	48.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.412
ClinicalShuntFraction	0.123
MechanicalVentilator-TidalVolume(L)	3.63e-94
BloodPH	7.26
Aorta-Oxygen-PartialPressure(mmHg)	36.5
Aorta-CarbonDioxide-PartialPressure(mmHg)	55.5
Aorta-Bicarbonate-Molarity(mEq/L)	26.8
OxygenSaturation	0.689
HorowitzIndex(mmHg)	213
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
MechanicalVentilator-RespirationRate(1/min)	25.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.22
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	18.0
MechanicalVentilator-PlateauPressure(cmH2O)	18.0
HeartRate(1/min)	170
SystolicArterialPressure(mmHg)	124
DiastolicArterialPressure(mmHg)	83.0
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	9.07e-93
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	0.00
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	0.00
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	2.79e-92
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	2.79e-92
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	35.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	264
MechanicalVentilator-ExpiratoryTidalVolume(L)	-2.33e-94
MechanicalVentilator-InspiratoryExpiratoryRatio	0.500
MechanicalVentilator-InspiratoryTidalVolume(L)	4.99e-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	0.252
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	1.02e+95
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	1.02e+95
TotalRespiratoryModelCompliance(mL/cmH2O)	56.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	0.00
TotalPositiveEndExpiratoryPressure(cmH2O)	0.00
EndTidalCarbonDioxidePressure(mmHg)	0.00
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	3.29
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.138
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	0.827
HeartStrokeVolume(mL)	40.9
HeartEjectionFraction	0.354
BloodVolume(L)	6.38
MeanArterialPressure(mmHg)	103
PulsePressure(mmHg)	41.4
CardiacOutput(L/min)	6.95
CarbonDioxideSaturation	0.458
RespiratoryExchangeRatio	0.791
SystemicVascularResistance(mmHg_s/mL)	0.852
OxygenConsumptionRate(mL/min)	238
CarbonDioxideProductionRate(mL/min)	188
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 (451)	451	0.01%		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 (0.689) [316] [320]	0.964		39.86%	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)	49.4
ClinicalPhysiologicDeadSpaceTidalVolumeRatio	0.414
ClinicalShuntFraction	0.196
MechanicalVentilator-TidalVolume(L)	0.451
BloodPH	7.32
Aorta-Oxygen-PartialPressure(mmHg)	86.4
Aorta-CarbonDioxide-PartialPressure(mmHg)	47.7
Aorta-Bicarbonate-Molarity(mEq/L)	26.4
OxygenSaturation	0.964
HorowitzIndex(mmHg)	216
IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.567
MechanicalVentilator-RespirationRate(1/min)	25.0
MechanicalVentilator-MeanAirwayPressure(cmH2O)	9.23
MechanicalVentilator-PeakInspiratoryPressure(cmH2O)	18.0
MechanicalVentilator-PlateauPressure(cmH2O)	14.7
HeartRate(1/min)	97.7
SystolicArterialPressure(mmHg)	132
DiastolicArterialPressure(mmHg)	71.1
MechanicalVentilator-TotalPulmonaryVentilation(L/min)	11.3
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L)	11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O)	49.3
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O)	34.8
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg)	39.6
MechanicalVentilator-EndTidalOxygenPressure(mmHg)	262
MechanicalVentilator-ExpiratoryTidalVolume(L)	0.451
MechanicalVentilator-InspiratoryExpiratoryRatio	0.500
MechanicalVentilator-InspiratoryTidalVolume(L)	0.451
MechanicalVentilator-PeakExpiratoryFlow(L/s)	0.700
MechanicalVentilator-LeakFraction	0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O)	0.535
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O)	5.54
PhysiologicDeadSpaceTidalVolumeRatio	0.515
PhysiologicShuntFraction	0.204
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L)	11.4
TotalRespiratoryModelCompliance(mL/cmH2O)	59.4
ExtrinsicPositiveEndExpiratoryPressure(cmH2O)	5.00
TotalPositiveEndExpiratoryPressure(cmH2O)	5.57
EndTidalCarbonDioxidePressure(mmHg)	43.1
PhysiologicDeadSpace(mL)	247
AlveolarArterialGradient(mmHg)	171
AlveolarDeadSpace(mL)	110
AnatomicDeadSpace(mL)	137
ChestWallCompliance(L/cmH2O)	0.138
FractionOfInspiredOxygen	0.399
LungCompliance(L/cmH2O)	0.0790
VentilationPerfusionRatio	0.825
HeartStrokeVolume(mL)	64.0
HeartEjectionFraction	0.467
BloodVolume(L)	6.37
MeanArterialPressure(mmHg)	103
PulsePressure(mmHg)	61.3
CardiacOutput(L/min)	6.26
CarbonDioxideSaturation	0.252
RespiratoryExchangeRatio	0.808
SystemicVascularResistance(mmHg_s/mL)	0.941
OxygenConsumptionRate(mL/min)	260
CarbonDioxideProductionRate(mL/min)	210
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.