The Journal of the Arkansas Medical Society Issue 12 Vol 114 | Page 10

CASE STUDY
Fatal Accident Caused by Displacement of an Unsecured
Home-Heated Humidifier Unit in a Child with a Chronic Tracheostomy
Requiring Long-Term Mechanical Ventilation
Dennis E. Schellhase, MD
Pediatric Pulmonology
Levine Children’s Hospital,
Carolinas HealthCare
Denise Willis, RRT-NPS
Pulmonology and
Sleep Medicine Section
Arkansas Children’s Hospital
Brandi N. Whitaker, PhD
Pediatric Psychology Section
Department of Pediatrics
UAMS, Arkansas Children’s Hospital
Keywords:
Mechanical Ventilation, Respiratory Technology
Abstract:
ue to improved medical care,
there are increasing numbers of
children with chronic tracheosto-
mies who require long-term mechanical
ventilation. Reported preventable tracheosto-
D
my-related causes of death are rare. We report
an additional potentially preventable cause of
death: accidental displacement of an unsecured
home-heated humidifier unit located above the
level of the child and resulting in catastrophic
spillage of water into the ventilator circuit and
tracheostomy tube.
Introduction:
There are increasing numbers of children with
chronic tracheostomies requiring long-term me-
chanical ventilation. 1,2 Mortality in this population
is primarily due to the child’s underlying condition;
however, an estimated 7-50% of deaths are due to
preventable tracheostomy-related causes 2-5 includ-
ing: accidental tracheostomy decannulation, 5 trache-
ostomy obstruction, 3,5 tracheal bleeding, 3 accidental
disconnection of ventilator-tubing, 4 and replacement
of the tracheostomy tube into a false track. 3 Children
on chronic mechanical ventilation via a tracheostomy
require heated humidification to prevent injury to the
airway epithelium, loss of ciliary function, and thick-
ening of airway mucus. This is usually provided by a
heated humidifier unit utilizing a gas source directed
through a heated water chamber. 6 We describe an
additional cause of potentially preventable tracheos-
tomy-related death, namely accidental displacement
of an unsecured home-heated humidifier unit locat-
ed above the level of the child with resultant cata-
Unsecured heated
humidifier
above child
Figure 1: Home ventilator and heated humidifier unit
showing incorrect setup with a tracheostomized infant
mannequin in an infant bouncer below the level of an
unsecured heated humidifier unit.
strophic spillage of water into the inspiratory limb of
the ventilator circuit and tracheostomy tube.
Event Description:
The patient was an 18-month-old former 24-
week, 739g premature infant with severe chronic
lung disease of prematurity and chronic respiratory
failure who was initially discharged home from a
tertiary care children’s hospital at eight months of
age. Echocardiogram prior to initial discharge was
normal without evidence of pulmonary hypertension.
Between 8 and 18 months of age, the patient had
several hospital admissions, including an admis-
sion at 12 months of age after tracheostomy tube
dislodgement requiring cardiopulmonary resuscita-
tion (CPR) effectively provided by the family. Capil-
lary blood gases during the last hospitalization at
17 months were normal (pH 7.38-7.44 and PcCO2
36-39 mmHg).
274 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Sonya Thompson, RN
CARE Developmental Pediatric
Section, Department of Pediatrics
UAMS, Arkansas Children’s Hospital
The patient had a Pediatric Bivona 3.5 flextend
tracheostomy with deflated cuff and was chronically
ventilated with a LTV 1150 ventilator. The patient’s
parents and adult cousin all received tracheostomy,
ventilator and resuscitation training and were skills
validated. The patient had been at home at baseline
health for one week prior to the fatal event. Just prior
to the event the patient was in the patient’s room
with two family members. The patient’s ventilator
and heated humidifier unit were on a nearby table at
a level below the child when being held or in the crib.
The humidifier unit had been filled with water about
30 minutes prior to the event and was unsecured on
the table. The patient was placed in an infant bounc-
er on the floor, while the humidifier unit remained
on the table 2-3 feet higher than the patient. When
placing the patient in the infant bouncer, the humidi-
fier unit was inadvertently tipped over, causing water
to be spilled into the inspiratory limb of the ventilator
circuit, the patient’s tracheostomy tube, and the pa-
tient’s airway. Almost immediately, a family member
disconnected the vent