Neonatal Breathing Mismanagement | Birth Injury Practice Area

Neonatal ventilation is very complex. Some infants need help breathing after birth, requiring either resuscitation, intubation or several other forms of less-invasive breathing assistance. This requires that medical personnel monitor CO2 and oxygen levels, blood acidity levels, ventilation pressures and other factors very precisely in order to make sure that the baby is receiving 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, PVL, collapsed lungs and other health issues.

Newborn Breathing Problems

Many babies need help with breathing after birth. Breathing mismanagement (giving the baby too much or too little oxygen) can cause permanent injuries such as cerebral palsy (CP), hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL) and retinopathy of prematurity (ROP).

Sometimes babies have to 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.  Some babies have long-term breathing problems, such as apnea, apnea of prematurity, respiratory distress, or problems with lung compliance due to prematurity.  It is extremely important to properly monitor a baby who is getting help with breathing.  Oxygen and carbon dioxide are the gases that are measured in a baby’s blood to make sure she is not getting too much or too little oxygen, or that her blood doesn’t have too much or too little carbon dioxide.  In most cases, too much carbon dioxide (CO2) will cause the blood to be acidic and the baby will have a low pH.  If there is too little CO2 in the baby’s blood, the pH will typically be higher than normal.  Abnormal levels of oxygen (O2) and CO2 can cause permanent brain damage, such as cerebral palsy and periventricular leukomalacia (PVL).  Giving a baby too much O2 or having huge fluctuations in the baby’s O2 levels can cause eye damage called retinopathy of prematurity (ROP), which can even lead to blindness if severe or not diagnosed early.

Retinopathy of Prematurity (ROP)

Retinopathy of Prematurity (ROP) is the second leading cause of childhood blindness in the U.S.  When a baby is born prematurely, blood vessels in the eyes may not be fully developed.  If the vessels grow and branch in an abnormal way, the baby will have ROP.  Giving a premature baby too much oxygen can cause abnormal development of the vessels in the eyes.  This is because excess O2 causes normal blood vessels to degrade and cease to develop.  When the baby is taken off of supplemental O2 or it is turned down (excess oxygen is removed), blood vessels quickly begin forming again and they grow abnormally and into the wrong part of the eye, causing ROP.

Because retinopathy of prematurity can cause permanent damage and blindness, the physician and medical team 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.  Very close attention must be paid to a premature baby’s O2 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.

All babies born prematurely should be tested at regular intervals for ROP, especially those who were given supplemental O2.  Early intervention can prevent the disease from becoming severe or even affecting the baby’s eyesight.  In addition to prematurity and excess oxygen, other risk factors for ROP include low birth weight, infection, and heart defects.

Management of Neonatal Respiration

Some babies need just a little help with oxygenation, so they receive O2 through prongs in their nose called a nasal cannula.  High flow oxygen through a nasal cannula is currently being studied.

Newborn baby with nasal CPAP for a birth injury in the neonatal intensive care unit (NICU).Other babies need more help, so a machine is used to force a small amount of continuous pressure into the baby’s airway, which keeps the lungs open and helps with breathing and oxygenation.  This continuous positive airway pressure (CPAP) can help prevent periods of apnea when breathing stops for 20 seconds or more.  CPAP can be given through nasal prongs or a mask.  BiPAP is a variation of CPAP, giving the baby a little more help with breathing in addition to a continuous airway pressure.

If a baby needs more help than CPAP or BiPAP can offer, but the physician does not want to put a tube (Et tube) in the baby’s upper airway (intubation) to help with breathing, nasal intermittent positive pressure ventilation (NIPPV) can be used.  NIPPV is what physicians typically use on the baby before using an invasive form of ventilation that requires intubation.  NIPPV is CPAP with positive pressure breaths given to the baby at set intervals.  A positive pressure breath is air forced into the baby’s lungs.  Even though CPAP is a treatment for apnea, a baby can still have apneic periods while on CPAP or BiPAP.  NIPPV, however, allows the medical team to set a number of breaths that a baby will get per minute to make sure a baseline level of ventilation is met.

With nasal prongs or a mask, the medical team must worry about air leaking out; the more air that leaks, the less help the baby will receive.  The goal of NIPPV is to give the baby ventilatory help that is similar to what the baby can receive if intubated.  Sometimes, however, air leaks prevent this from happening.  Air leaks that occur with non-invasive forms of breathing assistance do not occur with intubation.

NIPPV is often used for apnea of prematurity (apneic periods that occur due to the baby’s immature systems), after a baby is extubated (breathing tube taken out), and when a premature baby has respiratory distress.

The next step is intubation.  Since this 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 use of other methods.  Intubation establishes an airway in the baby 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.

Invasive ventilation (intubation) with positive pressure (IPPV) is indicated when ONE of the following conditions is present:

  1. The baby’s blood is acidic.  This means the pH is abnormally low (< 7.2) and the CO2 in the blood is abnormally high (PaCO2 > 60-65).
  2. The baby has a low level of oxygen in the blood (PaO2 < 50), despite administration of supplemental O2, OR the baby requires a lot of oxygen while on CPAP.
  3. The baby has severe apnea.

IPPV is commonly used for the following:

IPPV increases the chances that a baby will have ventilator-associated pneumonia and bronchopulmonary dysplasia (BPD).  BPD is inflammation and scarring of the lungs, and it is associated with long-term ventilator use.  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 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. Some ways in with neonatal breathing problems are often managed improperly are detailed below.

Overventilation, 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 O2, CO2, and pH levels.  This is especially important if a baby is on a ventilator.  Overventilation injuries can occur if ventilation is not properly managed.  First of all, if pressures in the baby’s lungs are too high, the baby could develop bronchopulmonary dysplasia (BPD), although this typically doesn’t occur unless the baby is on the vent for more than 28 days.

Secondly, a pneumothorax or 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 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 can cause pressure in the lungs to increase even more and can hinder gas exchange, which can cause hypoxia and acidosis.

The pneumothorax may also compress the veins that bring blood to the heart.  As a result, less blood fills the chambers of the heart, the output of the heart decreases, and the baby’s blood pressure drops. This can lead to serious problems and can cause a lack of blood flow to the brain, thereby further increasing the chances of brain damage.


In other cases, the ventilator may be working so well that the baby gets rid of too much CO2 (hypocarbia).  Abnormally low CO2 levels are often overlooked in the hospital, but even 5 or 6 hours of a low CO2 level can cause permanent brain damage such as periventricular leukomalacia (PVL) and cerebral palsy.  It is very important for the medical team to pay close attention to a baby’s CO2 levels.  Certain factors, such as surfactant administration, can cause a baby’s lungs to become more compliant, which usually increases the amount of CO2 removed while on the ventilator.  A wide variety of factors can affect a baby’s CO2 levels, and it is important for changes to be made to the ventilator very quickly if the baby’s CO2 level becomes low.  Hypocarbia is very easy to correct with simple changes in the vent settings, and there is absolutely no excuse for prolonged hypocarbia.

Apnea, Hypoxia, and Acidosis

One area of breathing mismanagement commonly seen is the failure to properly treat respiratory distress, apnea, hypoxia, and acidosis (high CO2 levels causing a low pH).  Apneic events, chronic hypoxia, and acidosis can cause permanent brain damage, such as hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), and cerebral palsy.  Respiratory distress can cause chronic hypoxia and acidosis, and it is also associated with apnea.  Sometimes the medical team seeks to avoid intubation due to the risks it poses, and the baby is supported using less invasive methods of breathing and oxygenation management.  With proper management, though, the risks of IPPV can be significantly reduced.  The consequence of not treating apnea, hypoxia, and acidosis is potential permanent brain damage.

Apnea can last for around a week or for much longer.  Despite the fact many babies outgrow apnea, precautions must be taken to avoid periods of oxygen deprivation and a very slow heart rate (bradycardia), which can cause permanent brain damage such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy.

Respiratory distress and apnea both frequently occur in premature babies.  Respiratory distress syndrome (RDS) occurs when a baby’s lungs aren’t fully developed and are non-compliant (lack elasticity).  RDS can cause a baby to struggle to breathe, and often, the baby has a hard time getting enough oxygen and releasing enough carbon dioxide.  This often leads to hypoxia and acidosis, both of which can cause permanent brain injury.  If non-invasive modes of ventilation aren’t working to help prevent hypoxia and acidosis, the baby must be intubated or placed on IPPV.
Meconium Aspiration Syndrome (MAS) and Birth Injury

If a baby has abnormally high lung pressures, he or she should be placed on a ventilator that gives small and very frequent breaths, called high-frequency ventilation or oscillation.  With current in-line suction catheters and other devices that help keep procedures aseptic or sterile, and with the development of high-frequency ventilators, pneumonia and BPD are much less of a risk.  The bottom line is that there is no excuse for failing to intubate a baby undergoing severe apnea, respiratory distress, or acidosis that cannot be managed with non-invasive methods.

As mentioned earlier, apnea can frequently be easily managed with CPAP or BiPAP, as well as with caffeine.  But apnea in premature infants is often accompanied by respiratory distress, which often means that intubation is necessary.

Oxygen Toxicity and Failure to Properly Monitor Neonatal Breathing

Too much oxygen can not only cause retinopathy of prematurity (ROP), but it can also cause lung damage, including bronchopulmonary dysplasia (BPD).  Very close monitoring of a baby’s O2, CO2, and pH must occur, especially if the baby is premature.  Failure to keep a baby’s O2, CO2, and pH levels normal can cause conditions such as retinopathy of prematurity (ROP), hypoxic-ischemic encephalopathy (HIE), cerebral palsy and periventricular leukomalacia (PVL).

Help for Birth Injuries Due to Breathing Mismanagement

Michigan Birth Injury Attorneys with a National Presence

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 support them. The award-winning lawyers at Reiter & Walsh have decades of experience with birth injury cases involving breathing mismanagement and other complications and medical errors. Reiter & Walsh ABC Law Centers is based in Michigan, but we handle cases throughout the United States. We’ve handled hypoxic-ischemic encephalopathy cases in Michigan, Ohio, Washington D.C., Pennsylvania, Tennessee, Arkansas, Mississippi, Texas, Wisconsin, and more. Our birth injury team also handles cases involving military medical malpractice and federally funded clinics.

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Video:  Newborn Breathing Mismanagement Lawyer Discusses Hypoxic Ischemic Encephalopathy (HIE) and Cerebral Palsy

Watch a video of Michigan cerebral palsy lawyer Jesse Reiter discussing hypoxic-ischemic encephalopathy (HIE) and cerebral palsy.