SimCase 001

Start at 10 – titrate as per PEEP/FiO₂ scale; aim SpO₂ >95%

Start at 50; titrate as per PEEP/FiO₂ scale; aim SpO₂ >95%

Start at 10 and ensure TV> 520ml (>6ml/kg). If he was to remain on NIV then assess RR in 15 mins; if >25, increase TV to 8ml/kg and then reassess in another 15 going to a max of 10ml/kg

CXR: bilateral pneumonia

VBG: This gas shows a patient who is severely hypoxic with a mixed acidosis: predominantly respiratory (high CO₂) but also a metabolic component (low HCO₃⁻ and base excess)

• pH 7.29 (low): Acidaemia.
• pCO₂ 56 mmHg (high): Respiratory acidosis.
• HCO₃⁻ 18 mmol/L (low) + Base excess –10: Metabolic acidosis component

Bilateral pneumonia and VBG shows he’s tiring -> patient needs intubation

VAPOX: Ventilator-assisted preoxygenation – ramping pillow should be inserted and positioning checked so that ear is above sternal notch and face parallel to ceiling

• PEEP = 20 as likely OSA
• FiO₂ = 100%
• Rate = 6 so that it’s obvious when Ketamine kicks in
• Ketamine 0.5 mg/kg IBW; so likely 50mg over 90s (avoid bolus as will be become trsansiently apnoeic, and if OSA with obstruct)

• RR = 16
• Titrate later depending on gases  

• Start at initial NIV settings
• Use PEEP/FiO₂ scale aiming for SpO₂ >95%

• Press Alarms
• Increase upper limit of Pressure (max 70) while trouble shooting to allow TV
• If still going off, touch Graphics then Dynamic lung – make diagnosis of restrictive lung disease

Now that the patient is stablised…switch to ASV so they see what it does

• 110% MinVol
• PEEP 10
• FiO₂ 50%
• Gives RR 20 and TV 420mL

Use the card to show how the ‘safety window’ can be used diagnostically

• Tall rectangle = obstructive lung
• Long rectangle = restrictive lung

The small square of the mixed lung disease is the T1 threading the small needle of a COPD with pneumonia, balancing the degree of obstruction/restriction

Facilitator Notes (for running the sim):

Once stabilised, switch to ASV: set 110% MinVol, PEEP 10, FiO₂ 50%. Show how the ASV safety window changes shape with restrictive vs obstructive patterns.

SimMon: manually set RR to 40 at start

At 30 min, show bilateral pneumonia on CXR, VBG with fatigue → force decision to intubate

After intubation, drop compliance to trigger pressure-limitation alarms → guide learners to raise alarm limits, then use Dynamic Lung to identify restrictive physiology