Mismanaged Breathing Tube And Ventilator Settings Lead To Hypoxic Brain Injury, Death

Summer Hawcroft was less than 2 months old when she passed away as a result of severe brain damage. Summer suffered hypoxic (lack of oxygen) brain injury after her breathing tube became dislodged and nobody noticed. By the time the staff realized that Summer was not being ventilated by the breathing machine (ventilator), it was too late. Summer had been severely deprived of oxygen, and brain imaging scans taken after this incident revealed “quite extensive and widespread” brain damage.

Summer had been born prematurely after 27 weeks gestation. She was delivered by C-section and weighed just a little over 2 pounds. After birth, Summer needed resuscitation and was given some inflation breaths before being placed on the ventilator. The physician taking care of Summer, Dr. Ash Kale, had to use a tube that was smaller than what would typically be used on an infant of Summer’s size and age; he had failed 3 times when he tried to insert the correct size tube. An independent expert who investigated the case said he found it “puzzling” that Dr. Kale had difficulty using the larger tube. Dr. Kale told the Hawcrofts’ lawyers that he had no specialized training in putting in breathing tubes (intubation).

Dr. Kale also stated that the standard respiratory rate had been set on Summer’s ventilator. Despite this, Summer was being over-ventilated, which causes carbon dioxide (CO2) levels in the blood to fall below normal. This can cause brain damage. Dr. Kale conceded that incorrect settings on the ventilator can cause complications in a baby, such as over-ventilation, which can cause permanent brain injury. Dr. Kale checked Summer’s blood gas levels (which help determine how well a baby is oxygenating and ventilating, and includes CO2 measurements) every 3-4 hours, and he stated that more frequent checks could have adverse effects, such as lowering her red blood cell level.

In commenting about Summer’s overall care, Dr. Kale stated that her blood gas levels dropped after birth, but he felt she was improving and had no concern over her neurological condition. He stated that Summer had difficulties due to the immaturity of her lungs and kidneys, but was making progress in the right direction. Dr. Kale did not believe she merited transfer to a specialized facility, and he felt that replacing her breathing tube would have subjected her to more harm than good.

At less than 2 weeks of age, Summer’s breathing tube became dislodged and she was starved of oxygen. A few weeks after this traumatic event, Summer passed away. It was revealed that Summer had a long-standing hypoxic brain injury that could have been caused by a number of complications. The physician that did the post-mortem exam on Summer stated that the following issues could have caused her brain damage:  she didn’t have enough red blood cells to transport oxygen to her brain (anemia); she had low blood pressure; something was affecting the blood vessels going to her brain (low CO2 levels can do this); or it could be a combination of several factors rather than a single event, such as the tube being dislodged.

Ventilation Injuries and Hypoxic Brain Injury

This very sad incident highlights the importance of properly managing a baby’s airway and ventilator. Preventing ventilation injuries and hypoxia is crucial. This means that a physician skilled in intubation and mechanical ventilation should properly place and secure the baby’s breathing tube. A skilled medical team must properly analyze blood gases and apply appropriate ventilator settings so that the baby is safely ventilated. Of crucial importance is that the alarms on the baby’s ventilator be set appropriately so that if the baby becomes disconnected from the breathing tube or ventilator–as was the case with baby Summer–the staff is instantly notified. Furthermore, if a hospital does not have an appropriate ventilator for a baby’s condition, it might be necessary to transport the baby to a different facility.

Many newborns, especially premature infants, require admission to a neonatal intensive care unit (NICU) where they can be carefully monitored and managed. Unfortunately, even in these specialized units, mismanagement of the baby’s condition can occur. Listed below are some of the issues that can occur in babies admitted to the NICU.

1. Ventilator injuries. Premature babies often have lungs and other organs that are not fully developed. The underdeveloped lungs frequently require that the baby have a breathing tube placed in her airway and be put on a ventilator right after birth. Mechanical ventilation has its own complications, such as over-ventilation injuries and pneumonia. When a baby is on a ventilator, it is imperative that physicians closely monitor her to ensure that she is not getting too much oxygen, which can cause damage to the eyes, and sometimes the brain and lungs. In addition, the baby must not be over-ventilated because this can cause hypocarbia and decreased oxygen and blood flow to the baby’s brain. This, in turn, can cause permanent brain damage, such as periventricular leukomalacia (PVL).

Mechanical ventilation also can cause too much pressure to build up in the baby’s lungs, which can cause damage to the lung tissue, called volutrauma. In addition, a condition called a pneumothorax may occur, which is when the baby gets a hole or leak (or multiple holes) in the lung. As air builds up outside and around the baby’s lungs, the lungs have difficulty expanding, which can cause oxygen deprivation and acidosis (low pH caused by high CO2). Both can cause brain damage. A pneumothorax also may put pressure on the veins that bring blood to the heart, which can cause a lack of blood flow to the brain, with resultant brain injury.

Indeed, pneumothoraces and over-ventilation injuries are serious problems, which is why it is imperative that the medical team be skilled in analyzing blood gases and applying appropriate settings to the ventilator. If a hospital lacks skilled physicians or an appropriate ventilator, the baby may need to be transferred to a different facility. If a baby’s lungs are delicate and difficult to ventilate, many hospitals have special ventilators that keep pressures very low so that pneumothoraces, volutrauma and over-ventilation injuries are much less likely to occur.

2. Breathing tube (endotracheal (ET) tube) complications. Inserting an ET tube into a baby’s upper airway requires a lot of skill, and if the baby is very small, insertion may be even more difficult. If the baby is born with breathing problems, the physician must have the skill to do a quick and safe insertion of the tube, and the tube must be properly secured so it does not become dislodged. It also is crucial to verify tube placement, which can easily be done by carefully listening to the baby’s lungs and also by placing a disposable device on the end of the tube to measure the CO2 being expired. An x-ray can additionally verify placement, although physicians typically try to minimize a baby’s exposure to radiation. Improper insertion of an ET tube can result in the tube going into one side and ventilating only one lung, or going into the esophagus, thereby blowing air into the stomach and not the lungs. Untimely or failed intubation can result in oxygen deprivation to the brain. These events are very dangerous and can lead to brain damage and death.

3. Surfactant administration complications. A premature baby often has difficulty breathing, and one of the common causes of this is respiratory distress syndrome (RDS). In RDS, the baby’s immature lungs don’t produce enough of a substance called surfactant. Surfactant allows the inner surface of the lungs to expand properly. When a baby is born prematurely, the physician usually administers 3 doses of surfactant within 72 hours. The first dose typically is given immediately after birth, or shortly after breathing problems are revealed. Surfactant therapy has been shown to substantially reduce mortality and respiratory morbidity in premature infants, but it does have some risks. Sometimes lung function greatly improves, but the ventilator is not adjusted for this. In turn, ventilation injuries can occur, such as over-ventilation and abnormally low CO2 levels (hypocarbia), which can cause brain damage. It therefore is crucial for physicians to closely monitor the baby after surfactant administration.

Medical Malpractice, Ventilation Injuries and Hypoxic Brain Injuries

Problems that can arise from intubation and mechanical ventilation are very serious. Failure to properly place or secure a breathing tube is negligence. Failure to properly monitor a baby who is being mechanically ventilated and failure to correct an abnormal carbon dioxide level also constitute negligence. When these failures cause injury in a baby, it is medical malpractice.

If your child was resuscitated or on ventilation of any sort at birth and now suffers from injuries, call Reiter & Walsh ABC Law Centers today. Our nationally recognized birth injury attorneys will review your child’s case, answer your questions, and inform you of your legal options. The initial consultation is free and we never charge any fees until we win your case. Call us at (888) 812-6009.

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