LETTERS TO THE EDITOR
Reply
Dear Dr. Guilherme,
First, I would like to thank you the attention given to our paper and for your comments. The diagram, as you pointed out, presents erroneously an inversion of the ins- and expiratory signaling of the device. In the report, it was not mentioned that this accident occurred after interrupting mechanical ventilation, but while maintaining the patient connected to the circuit to resume spontaneous ventilation. Under those conditions, what happened can be easily demonstrated by obstructing the inspiratory gas tube, as illustrated in the report. When it happens, the flow of fresh gas will be directed to the patient, the manometer of the ventilator does not show increased pressure in the system, and the reservoir bag is not filled; consequently, elimination through the pop-off valve does not occur. Changing the tube by a tracheal-type tube, which was done by the manufacturer, prevented the reoccurrence of this problem. It is important to mention that the original configuration of the device was not changed by my colleagues, and all of them were familiar with the device at the time of this accident.
Dr. Affonso H. Zugliani, TSA
Publication Dates
-
Publication in this collection
04 Sept 2008 -
Date of issue
Oct 2008
