Critical care expert witness advises on fatal aspiration pneumonia following traumatic brain injury

A critical care expert witness advises on a case happened in New Hampshire involving a patient who died as a result of aspiration pneumonia following a traumatic brain injury. This case involves a fifty-five-year-old female patient who died as a result of aspiration pneumonia whilst under the care of several hospitals and health care facilities. The patient’s past medical history was significant for type II diabetes mellitus controlled with insulin for 15-years, peripheral neuropathy, gastroparesis, hyperlipidemia and a retinal bleed corrected with laser surgery. The patient suffered a near fatal fall from the balcony of a three-story building that resulted in a traumatic brain injury, which was later diagnosed to be anoxia encephalopathy. The brain injury put the patient at heightened risk factor for the development of aspiration pneumonia. Other risk factors and inconsistencies that may have contributed to her aspiration pneumonia included history of gastroparesis, poorly documented enteral feedings, placement of feeding tube not confirmed by x-ray, impaired level of consciousness, poor oral health due to prolonged hospitalization, presence of tracheostomy tube with no cuff measurement documented, presence of gastrostomy tube, history of stroke, history of seizures, and undocumented position of the patient’s head. The patient’s tracheostomy was changed to a fenestrated tracheostomy. She did not tolerate this change evidenced by respiratory difficulties while attempting to speak, which was not recognized by the nursing staff. Twenty hours later the patient went into cardiopulmonary arrest requiring transfer to the ICU. In the ICU, she showed signs of not being able to tolerate enteral feedings including increasing gastric residual volume (GRV) trends, nausea, vomiting, and abdominal distention. The patient eventually succumbed to aspiration pneumonia and acute respiratory distress syndrome.

Question(s) For Expert Witness

1. Did the traumatic brain injury, anoxic encephalopathy, contribute to the death of this patient?

2. Did the management of this feeding tube contribute to the development of aspiration pneumonia in this patient?

Expert Witness Response E-001259

It is very likely that the patient's traumatic encephalopathy contributed to the patient's demise. Patients with altered mental status are unable to protect their airways adequately from aspiration events. It is however completely unclear to me why the patient would have a fenestrated tracheostomy. Based on the synopsis provided I would have assumed that the patient would be non-verbal and unable to protect his airway from aspiration. Unless the patient was improving significantly from his brain injury she would not be decannulated and therefore there is no need for a fenestrated tube. With respect to the feeding tube, it may have been the source of the aspiration. Patients regularly aspirate despite a tracheostomy tube being in place however this patient would be at increased risk secondary to his fenestrated tube.