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En Route Care Scenario 7 - NoSpontaneous

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 18 NA NA 0.8 23 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 = 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 460 458 0.412%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [17] 11.4 4.81%   Rinsp for mild ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [17] 11.4 4.81%   Rexp for mild ARDS
RespiratoryCompliance(mL/cmH2O) EqualTo 50 [304] 48.7 2.73%   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 3.55%   QS/QT for mild ARDS (determined from blood gas values)
HorowitzIndex(mmHg) [200,300] [115] 217 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) 48.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.480
ClinicalShuntFraction 0.193
MechanicalVentilator-TidalVolume(L) 0.458
BloodPH 7.30
Aorta-Oxygen-PartialPressure(mmHg) 86.8
Aorta-CarbonDioxide-PartialPressure(mmHg) 52.6
Aorta-Bicarbonate-Molarity(mEq/L) 26.5
OxygenSaturation 0.961
HorowitzIndex(mmHg) 217
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.370
MechanicalVentilator-RespirationRate(1/min) 22.9
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.87
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 18.0
MechanicalVentilator-PlateauPressure(cmH2O) 14.8
HeartRate(1/min) 99.9
SystolicArterialPressure(mmHg) 131
DiastolicArterialPressure(mmHg) 73.0
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 10.5
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 48.6
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 35.3
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 39.4
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 260
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.458
MechanicalVentilator-InspiratoryExpiratoryRatio 0.440
MechanicalVentilator-InspiratoryTidalVolume(L) 0.458
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.697
MechanicalVentilator-LeakFraction 0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.357
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.36
PhysiologicDeadSpaceTidalVolumeRatio 0.515
PhysiologicShuntFraction 0.195
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelCompliance(mL/cmH2O) 57.6
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.37
EndTidalCarbonDioxidePressure(mmHg) 42.9
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 160
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.133
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 1.81
HeartStrokeVolume(mL) 59.8
HeartEjectionFraction 0.451
BloodVolume(L) 6.43
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 57.9
CardiacOutput(L/min) 5.97
CarbonDioxideSaturation 0.403
RespiratoryExchangeRatio 0.824
SystemicVascularResistance(mmHg_s/mL) 0.985
OxygenConsumptionRate(mL/min) 263
CarbonDioxideProductionRate(mL/min) 216
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. 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 3.36e-91 0.00%   VT fully plugged
OxygenSaturation LessThan Segment1 (0.961) [304] [308] 0.653   -32.1% 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) 46.5
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.480
ClinicalShuntFraction 0.0337
MechanicalVentilator-TidalVolume(L) 3.36e-94
BloodPH 7.17
Aorta-Oxygen-PartialPressure(mmHg) 38.3
Aorta-CarbonDioxide-PartialPressure(mmHg) 73.8
Aorta-Bicarbonate-Molarity(mEq/L) 27.3
OxygenSaturation 0.653
HorowitzIndex(mmHg) 217
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
MechanicalVentilator-RespirationRate(1/min) 22.9
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.87
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 18.0
MechanicalVentilator-PlateauPressure(cmH2O) 18.0
HeartRate(1/min) 170
SystolicArterialPressure(mmHg) 123
DiastolicArterialPressure(mmHg) 83.4
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 7.70e-93
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 0.00
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 2.59e-92
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 2.59e-92
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 6.29
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 299
MechanicalVentilator-ExpiratoryTidalVolume(L) -2.03e-94
MechanicalVentilator-InspiratoryExpiratoryRatio 0.440
MechanicalVentilator-InspiratoryTidalVolume(L) 4.72e-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 0.196
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 1.02e+95
TotalRespiratoryModelCompliance(mL/cmH2O) 57.9
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 0.00
TotalPositiveEndExpiratoryPressure(cmH2O) 0.00
EndTidalCarbonDioxidePressure(mmHg) 0.00
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 3.47
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.131
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 1.81
HeartStrokeVolume(mL) 38.3
HeartEjectionFraction 0.342
BloodVolume(L) 6.43
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 39.9
CardiacOutput(L/min) 6.51
CarbonDioxideSaturation 0.659
RespiratoryExchangeRatio 0.812
SystemicVascularResistance(mmHg_s/mL) 0.907
OxygenConsumptionRate(mL/min) 247
CarbonDioxideProductionRate(mL/min) 200
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 (458) 458 0.000411%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [304] [308] 11.4   -0.000721% Rinsp
ExpiratoryRespiratoryResistance(cmH2O_s/L) LessThan Segment2 (11.4) [304] [308] 11.4   -0.000893% Rexp
OxygenSaturation GreaterThan Segment2 (0.653) [304] [308] 0.960   47.1% 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) 49.7
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.484
ClinicalShuntFraction 0.193
MechanicalVentilator-TidalVolume(L) 0.458
BloodPH 7.27
Aorta-Oxygen-PartialPressure(mmHg) 88.8
Aorta-CarbonDioxide-PartialPressure(mmHg) 57.5
Aorta-Bicarbonate-Molarity(mEq/L) 26.7
OxygenSaturation 0.960
HorowitzIndex(mmHg) 222
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.370
MechanicalVentilator-RespirationRate(1/min) 22.9
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.87
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 18.0
MechanicalVentilator-PlateauPressure(cmH2O) 14.8
HeartRate(1/min) 100
SystolicArterialPressure(mmHg) 131
DiastolicArterialPressure(mmHg) 72.9
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 10.5
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 11.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 48.6
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 35.3
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 42.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 258
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.458
MechanicalVentilator-InspiratoryExpiratoryRatio 0.440
MechanicalVentilator-InspiratoryTidalVolume(L) 0.458
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.697
MechanicalVentilator-LeakFraction 0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.357
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.36
PhysiologicDeadSpaceTidalVolumeRatio 0.515
PhysiologicShuntFraction 0.194
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 11.4
TotalRespiratoryModelCompliance(mL/cmH2O) 58.0
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.37
EndTidalCarbonDioxidePressure(mmHg) 46.5
PhysiologicDeadSpace(mL) 247
AlveolarArterialGradient(mmHg) 158
AlveolarDeadSpace(mL) 110
AnatomicDeadSpace(mL) 137
ChestWallCompliance(L/cmH2O) 0.141
FractionOfInspiredOxygen 0.399
LungCompliance(L/cmH2O) 0.0790
VentilationPerfusionRatio 1.79
HeartStrokeVolume(mL) 60.1
HeartEjectionFraction 0.452
BloodVolume(L) 6.46
MeanArterialPressure(mmHg) 103
PulsePressure(mmHg) 58.1
CardiacOutput(L/min) 6.02
CarbonDioxideSaturation 0.485
RespiratoryExchangeRatio 0.828
SystemicVascularResistance(mmHg_s/mL) 0.976
OxygenConsumptionRate(mL/min) 268
CarbonDioxideProductionRate(mL/min) 222
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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