• Resp Care · Jun 2010

    Case Reports

    Ventilator-disconnect and death: a case study and a safety device.

    • William S Lowery.
    • Pulmonary/Subacute Service, Alameda Hospital, 2070 Clinton Avenue, Alameda, CA 94501, USA. slowery@pol.net
    • Resp Care. 2010 Jun 1;55(6):774-6.

    AbstractDeaths and injuries related to accidental ventilator disconnection occur in complex ways. A death related to accidental ventilator disconnection is presented from a subacute ventilator facility, and corrective action is discussed. Single-limb ventilators are now equipped with a flow-bypass coupling that prevents patient-side occlusion during disconnect and therefore prevents low-pressure alarm malfunction. Physicians and respiratory therapists can consider this device to prevent partial or total occlusion of the ventilator tracheostomy adapter, thus allowing a low-pressure alarm in the event of a disconnect.

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