Neonatal Breathing Mismanagement

Some infants need help breathing after birth, requiring either resuscitation, intubation, or several other forms of less invasive breathing assistance. Medical professionals must carefully monitor CO2 and oxygen levels, blood acidity, ventilation pressures, and other factors in order to make sure that the baby receives the proper gases in correct proportions. Improper ventilation can result in retinopathy of prematurity (which leads to childhood blindness), lung injury, oxygen deprivation-related injury, periventricular leukomalacia (PVL), collapsed lungs, and other health issues (1).

Newborn Breathing Problems

Many babies need help with breathing after birth. Sometimes babies must be resuscitated right after they are born, which means a little mask is put over their nose and mouth, and air with extra oxygen added to it is pumped into their lungs. Other babies may have long-term breathing problems, such as apnea, respiratory distress, or problems with lung compliance due to prematurity (2).

It is extremely important to properly monitor infants receiving breathing assistance. It is crucial that medical professionals measure the amount of oxygen and carbon dioxide in the baby’s blood to ensure proper amounts of each are present. In many cases, too much carbon dioxide will cause blood acidity and the baby’s blood will have a low pH. If there is too little carbon dioxide in the baby’s blood, the pH will typically be higher than normal. Both abnormally high and abnormally low blood pH levels can be harmful to a newborn. In addition, an excess of oxygen, or significant fluctuations in oxygen levels can be very dangerous to the baby. Abnormal levels of oxygen  and carbon dioxide can cause permanent brain damage, a form of eye damage known as retinopathy of prematurity (ROP), and other serious consequences (1, 2).

What is retinopathy of prematurity (ROP)?

Retinopathy of prematurity (ROP) is one of the leading causes of childhood blindness in the United States. When a baby is born prematurely, blood vessels in the eyes may not be fully developed, if these vessels grow and branch in an abnormal way, the baby may have ROP. While the main risk factor for ROP is indeed premature birth, giving a premature baby too much oxygen, or allowing oxygen levels to fluctuate significantly, can increase the risk of ROP and related consequences (4).

Because retinopathy of prematurity can cause permanent damage and blindness, medical professionals are supposed to administer only enough oxygen to keep the baby’s oxygen in the blood at the normal level. High fluctuations in oxygen levels should be avoided unless it is an emergency. Medical professionals must pay very close attention to a premature baby’s oxygen levels because too much oxygen can cause ROP (as well lung problems), but too little oxygen may cause permanent brain damage such as hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), and cerebral palsy (5).

All babies born prematurely should be tested at regular intervals for ROP, especially those who were given supplemental oxygen (4). Early intervention can prevent the disease from becoming severe or affecting the baby’s eyesight. In addition to prematurity and excess oxygen, other risk factors for ROP include low birth weight, infection, heart defects, and more (4).

Management of neonatal respiration

Depending on the clinical situation before, at, and after birth, different forms of respiratory support may be required. Below we will discuss some of the most common types of neonatal respiratory management used today.

Non-invasive respiratory support

Many babies only need a little help with oxygenation after birth, so they receive oxygen through prongs in their nose called a nasal cannula. Both low- and high-flow oxygen may be delivered by way of a nasal cannula (2). If a nasal cannula is not effective, or is inappropriate for the clinical situation, continuous positive airway pressure (CPAP) is often the next step used for respiratory support.

Newborn baby with nasal CPAP for a birth injury in the neonatal intensive care unit (NICU)

CPAP keeps the lungs open and helps with breathing and oxygenation, which in turn can help prevent periods of apnea (2). If a baby needs more help than is provided by way of nasal cannula or CPAP, nasal intermittent positive pressure ventilation (NIPPV) can be used.  NIPPV is often given to neonates as an alternative to invasive respiratory assistance (discussed below). NIPPV forces air into the baby’s lungs at a set interval, and is often used to treat apnea and respiratory distress syndrome, and can be used as a supportive measure after extubation (2).

Invasive respiratory support

If none of the non-invasive methods are indicated, or if they are ineffective, intubation may be required to provide proper neonatal breathing assistance (1). Since intubation is invasive, it poses additional risks to the baby, and physicians typically try other methods of assistance before intubating a baby. Of course, in an emergent situation like respiratory distress, time should not be wasted on the use of other methods.

Intubation establishes a clear airway and allows for precise volumes or pressures of air to be delivered to the baby. Many components of oxygenation and ventilation can be controlled when a baby is intubated, such as the baby’s breathing rate and inspired oxygen level. Intubation also allows certain drugs to be easily delivered, such as surfactant, which is given to help a premature baby’s lungs mature and become more compliant (1).

Intubation with positive pressure (IPPV) is indicated when one of the following conditions is present (1):

  1. Respiratory acidosis: A condition in which the baby’s blood is acidic. This means the blood’s pH is abnormally low (< 7.2) and the carbon dioxide in the blood is abnormally high (PaCO2 > 60-65 mmHg).
  2. Hypoxia: The baby has a low level of oxygen in the blood (PaO2 < 50 mmHg), despite administration of supplemental oxygen, OR the baby requires a lot of oxygen while on CPAP.
  3. Severe apnea: The baby experiences unusually long pauses in breathing.

IPPV is commonly used to manage the following conditions (1):

IPPV increases the chances that a baby will have ventilator-associated pneumonia and bronchopulmonary dysplasia (BPD), both of which are discussed further below. If the medical team follows standards of care, including keeping the peak pressure in the baby’s lungs low, the risk of BPD and pneumonia decreases.

Forms of neonatal breathing mismanagement

It is crucial that babies are closely observed after birth, especially with regards to It is crucial that babies are closely observed after birth, especially with regards to their respiratory state. If a baby experiences any form of breathing difficulty, it is crucial that medical staff intervene in a proper and timely manner. If they fail to do so, it constitutes negligence. Ways in which neonatal breathing is often mismanaged are reviewed below:

Overventilation injuries: Bronchopulmonary dysplasia (BPD) and pneumothorax

All babies should have their oxygen saturation and breathing closely monitored, and if a baby is experiencing low oxygen levels, respiratory distress, or apneic events, blood gases need to be regularly drawn in order to assess the baby’s oxygen, carbon dioxide, and pH levels. This is especially important if a baby is on a ventilator. Overventilation injuries can occur if ventilation is not properly managed. One major type of overventilation injury is bronchopulmonary dysplasia (BPD). BPD is a chronic lung disease that results from issues in lung development in premature infants (6). BPD can be caused when the lungs take in too much oxygen, which is common if supplemental oxygen administration is mismanaged. Many infants with BPD will improve gradually overtime with proper care, but others go on to suffer from pulmonary hypertension, prolonged reliance on ventilation, and other complications (6).

Another injury that can come as a result of overventilation is a pneumothorax. Pneumothoraces may occur if the volumes of air administered during ventilation are too large and create too much pressure in the baby’s lungs. When pressures in the baby’s lungs are too high, the alveoli (tiny air sacs in the lungs where gas exchange takes place) become over-distended and can rupture. This results in holes in the lungs which allow air to leak through into the spaces around the lungs, forming a pneumothorax. This build-up of air prevents the lung from fully expanding. The longer this is left untreated, the more air leaks into the space around the lungs, which further restricts the ability of the lung to expand. This causes pressure in the lungs to increase even more and can hinder gas exchange, which can cause hypoxia and acidosis (7).


In other cases, the ventilator may be working so well that the baby gets rid of too much carbon dioxide (hypocarbia). Abnormally low carbon dioxide levels are often overlooked in the hospital, but these low levels can cause permanent brain damage such as periventricular leukomalacia (PVL) and cerebral palsy (8). It is very important for the medical team to pay close attention to a baby’s carbon dioxide levels. Certain factors, such as surfactant administration, can cause a baby’s lungs to become more compliant, which usually increases the amount of carbon dioxide removed while on the ventilator. A wide variety of other factors can affect a baby’s carbon dioxide levels, and it is important for changes to be made to the ventilator very quickly if the baby’s carbon dioxide level becomes low. Hypocarbia is very easy to correct with simple changes in the ventilator settings, and there is absolutely no excuse for prolonged hypocarbia.

Apnea, hypoxia, and acidosis

Sometimes medical professionals mismanage conditions such as respiratory distress, apnea, hypoxia, and acidosis (high carbon dioxide levels causing a low blood pH). These conditions, if treated improperly, can lead to permanent brain damage such as hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), and cerebral palsy. In some cases when these conditions are present, the medical team seeks to avoid intubation due to the risks it poses, and the baby is instead supported using less invasive methods of breathing and oxygenation management. With proper management, though, the risks of IPPV can be significantly reduced, and this method should be used when indicated in order to avoid permanent brain damage and other issues (1).

Legal help for birth injuries due to breathing mismanagement

Cerebral palsy, periventricular leukomalacia, hypoxic-ischemic encephalopathy (HIE), and ROP are difficult areas of law to pursue due to the complex nature of the disorders and the medical records that may indicate malpractice. The award-winning lawyers at ABC Law Centers: Birth Injury Lawyers have decades of experience with birth injury cases involving breathing mismanagement and other complications and medical errors. Our firm is based in Michigan, but we handle cases throughout the United States. Our birth injury team also handles cases involving military medical malpractice and federally-funded clinics. You pay no fee for any legal services unless we win your case, or achieve a favorable settlement.

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Helpful resources

  1. Eichenwald, E. C., Martin, R., & Kim, M. S. (2018, June). Mechanical ventilation in neonates. Retrieved from
  2. Martin, R., & Deakins, K. M. (2018, September). Oxygen delivery and oxygen monitoring in the newborn. Retrieved from
  3. Childhood Blindness. (n.d.). Retrieved from
  4. Coats, D. K. (2018, November). Retinopathy of prematurity: Pathogenesis, epidemiology, classification, and screening. Retrieved from
  5. Martin, R. (2019, January). Neonatal target oxygen levels for preterm infants. Retrieved from
  6. Eichenwald, E. C., & Stark, A. R. (2018, December). Bronchopulmonary dysplasia: Definition, pathogenesis, and clinical features. Retrieved from
  7. Janahi, I. A. (2017, October). Spontaneous pneumothorax in children. Retrieved from
  8. Rainaldi, M. A., & Perlman, J. M. (2016, October 21). Neurologic Effects of Respiratory Support. Retrieved from