Authors: Dominic Pappas, Amrita Vempati
Categories: Simulation
Source: Journal of Education & Teaching in Emergency Medicine
Doi: 10.21980/J8V070
Authors: Dominic Pappas, Amrita Vempati
This case is targeted to emergency medicine residents of all levels.
Shortness of breath (SOB) is one of the top ten most common chief complaints seen in the Emergency Department, accounting for close to 10% of presenting complaints.1 An acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a frequent culprit, accounting for roughly 15.4 million visits and 730,000 hospitalizations per year.2 The diagnosis of treatment of mild to moderate AECOPD can be relatively uncomplicated; however, multiple factors can increase the complexity of management and pose additional challenges that the emergency physician (EP) must be prepared for. Severe AECOPD can necessitate the need for both Non-invasive positive pressure ventilator (NIPPV) such as bi-level positive airway pressure (BiPAP) as well as emergent intubation. Furthermore, managing the ventilator settings in patients with an AECOPD is far from routine, requiring an intricate understanding of pulmonary physiology.3
By the end of this simulation, learners will be able to (1) assess for causes of severe shortness of breath, (2) manage severe COPD exacerbation by administering appropriate medications, (3) identify worsening clinical status and initiate NIPPV, (4) assess the causes of hypoxia after establishing endotracheal intubation and, (5) identify indication for needle decompression and perform chest tube thoracostomy.
This simulation was conducted with a high-fidelity mannequin with a separate low fidelity chest tube mannequin that allowed for hands-on practice placing a chest tube. A total of 16 PGY-1 residents participated in the simulated patient encounter.
Following the simulation and debrief session, all residents were sent a Likert scale survey via surveymonkey.com to assess the educational quality of the simulation. The survey contained the following questions; 1) Overall, this simulation was realistic and could represent a patient presentation in the Emergency Department, 2) Overall, the case contained complexity that challenged me as a learner, 3) This case helped to expand my medical knowledge, 4) I feel more confident in diagnosing and treating AECOPD, 5) I feel more confident in recognizing the indications for NIPPV and intubation, 6) This simulation offered an opportunity to improve my procedural skills, 7) I feel more confident in setting up the ventilator, 8) I feel more confident in addressing ventilator alarms.
Following the simulation and debrief session, all the participants (n=16), were provided a survey to assess the educational quality of the simulation. There were a total of 12 respondents and a hundred percent of them agreed or strongly agreed that the case contained complexity that challenged them. All of the respondents agreed that the simulation case was realistic and that the case helped expand their medical knowledge. Furthermore, all the learners agreed or strongly agreed that the case helped them in improving their procedural skills.
This case combines a mixture of high fidelity and medium fidelity components to encompass both clinical knowledge and procedural skills. This case is effective in expanding beyond the basic approach to managing an AECOPD patient and forces learners to address clinical deterioration, escalate airway interventions, manage ventilator settings, and address ventilator alarms, including placement of a chest tube. Residents commented that this case was very realistic and particularly challenging because it highlighted gaps in their clinical knowledge and procedural skills. Residents were most challenged by identifying when to escalate care as well as how to manage ventilator settings in AECOPD patients.
Acute exacerbation COPD, intubation, positive pressure ventilation, ventilator alarms, chest tube thoracostomy.
This case begins with the patient presenting with shortness of breath and a history of COPD. The learners will have to perform a primary assessment, identify signs of respiratory distress, and start initial interventions (objective #1). They will have to obtain further history and identify the likely diagnosis of AECOPD and then initiate disease specific treatment (objective #2). The patient will progress to respiratory failure and require escalation of interventions (objective #3 and #4). The ventilator high peak pressure alarm will trigger as the patient deteriorates, requiring the learner to evaluate for causes of post-intubation hypoxia and high peak pressures (objective #5). Learners will need to ultimately perform needle decompression and chest tube thoracostomy (objective #6).
We strongly recommend reviewing the following articles and videos about managing ventilator
If the instructor is unfamiliar with placing a chest tube thoracostomy, we recommend reviewing the following
This simulation was designed for emergency medicine residents to improve their resuscitation skills by managing a decompensating acute exacerbation of COPD that requires intubation and subsequently develops a tension pneumothorax and requires needle decompression and chest tube thoracostomy. The case was performed in a high-fidelity simulation setting using an additional low fidelity modified chest tube thoracostomy mannequin to simulate chest tube placement.
Some tips for successful implementation of this simulation
This simulation was designed and implemented during the 2022–2023 academic year. It was conducted with first-year emergency medicine residents in a total of four separate in-person sessions. The debrief session was conducted in two large groups immediately after the simulation. All learners were from the same residency program.
Following the simulation and debrief session, participants (n=16), were provided a survey to assess the educational quality of the simulation, as well as open ended feedback. There were a total of 12 respondents (75% of participating residents). Figure 1 shows 100% of them agreed or strongly agreed that the case contained complexity that challenged them.
Figure 2 shows that all of them agreed that the simulation case was realistic. All of them agreed or strongly agreed that the case expanded their medical knowledge (Figure 3). In addition, the last figure showed that the learners agreed or strongly agreed that the case helped them in improving their procedural skills (Figure 4).
The most common suggestions for improvement surrounded utilization of NIPPV and managing ventilator alarms. One resident suggested pairing this case with another simulation that demonstrates the difference in ventilator settings based on disease process. Given the depth and complexity of ventilator management, it may be beneficial to give a broad overview of ventilator settings and physiology prior to conducting this simulation. This may give learners the opportunity for spaced repetition and practical application of learned material. In addition, this case involves utilization of BiPAP as a ventilator adjunct; however, some learners progressed straight to intubation without a trial of BiPAP first. Learners could be encouraged to trial BiPAP by the nurse or by senior learners.