PT  - JOURNAL ARTICLE
AU  - William S Lowery
TI  - Ventilator-Disconnect and Death: A Case Study and a Safety Device
DP  - 2010 Jun 01
TA  - Respiratory Care
PG  - 774--776
VI  - 55
IP  - 6
4099  - http://rc.rcjournal.com/content/55/6/774.short
4100  - http://rc.rcjournal.com/content/55/6/774.full
AB  - Deaths 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.