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Updated: Jun 12, 2026

Mechanical Ventilation Boot Camp Curriculum
Published on: March 12, 2018
Ventilator-disconnect and death: a case study and a safety device
1Pulmonary/Subacute Service, Alameda Hospital, 2070 Clinton Avenue, Alameda, CA 94501, USA. slowery@pol.net
Abstract:
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.
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