Published 11/05/2023





RIJ CVC & left radial arterial line  


Sedatives, muscle relaxant, noradrenaline, 1L crystalloid at 60 ml/hr 


ETT, 22cm at teeth  


PC-SIMV, Pinsp 25, PEEP 12, FiO2 0.8, Vt 290 ml, RR 22  


Emergency trolley 

Airway trolley 

Patient’s notes and ITU chart 

Full PPE 

Clinical Setting:

I: You are the ICU registrar called by the nurse of the patient in bed 3 

S: Nurse reports patient is hypoxic 

B: 50F with COVID-19, presented after 10-day history of pleuritic chest pain, fevers, dry cough, and progressive difficulty in breathing. CTPA- no PE, ground glass consistent with COVID. Confirmed COVID positive. Day 1-2 on high flow oxygen, day 3-4 in CPAP, admitted to ICU overnight, intubated yesterday (Size 8.0, Grade II view, 2s cm at the teeth) 

A: Hypoxic despite being on FiO2 0.8 

R: Called for help 

Potential Clinical Course:

  • Initially A ETT, 22 cm at the teeth, B SpO2 89% on FiO2 0.8 PC-SIMV Pinsp 25, PEEP 12, Vt 290 ml, ETCO2 5 kPa, RR 22, bilateral air entry, C HR 65 bpm SR, BP 110/60, D Sedated+ paralysed 

  • If FiO2 is put up to 1.0- SpO2 still does not improve.  

  • Following initial assessment, patient remains hypoxic and the aim is for the candidate to decide to prone and to proceed with the proning  

  • Manage emergency proning safely

Info Sheet For Faculty

  • Initial settings: 

    • SpO2 89% on FiO2 0.8 
    • Pinsp 25, PEEP 12, Vt 290 
    • EtCO2 5 kPa 
    • RR 22/min 
    • Bilateral air entry 
    • HR 65 bpm SR 
    • BP 110/60 


  • Progress to: 

    • SpO2 88% on FiO2 1.0 
    • Pinsp 25, PEEP 12, Vt 290 
    • EtCO2  5 kPa 
    • Bilateral air entry 
    • HR 65 bpm SR 
    • BP 110/60 


  • Progress to:        

    • SpO2 99% on FiO2 1.0 (once prone)       
    • Pinsp 25, PEEP 12, Vt 290 
    • EtCO2  5 kPa 
    • Bilateral air entry 
    • HR 65 bpm SR 
    • BP 110/60 

Faculty Roles:

Bedside Nurse 1: 

  • You are a critical care nurse 

  • You are looking after a 50F with COVID-19, intubated yesterday 

  • You have noticed that despite being on 80% oxygen, her saturation is still hovering between 87% and 89% 

  • You are concerned that something is wrong or that something needs to be done about this.  

  • You take direction well, and can perform tasks asked if you in a timely fashion 

  • If the candidate asks nothing unexpected has happened. The patient just slowly gradually became more hypoxic.  


Bedside Nurse 2: 

  • You are a new starter – you have never seen an ARDS patient before 

  • You are quite startled when asked questions/given directions, requiring instructions to be repeated to you 

  • If the candidate names equipment using technical terms then you inform them that you don’t know what that is eg bougie 

  • You are keen to help, but are unwilling to do anything beyond your skill set 



  • You are very junior and just started working in ITU 

  • You have never seen an ARDS patient and have never seen a prone patient 

  • You are keen but a bit worried that you do not understand what is going on 


HiLLO: 6