Pulmonology Expert Discusses Inadequate Monitoring of ICU Patient’s Ventilator

This case involves a patient with a history of alcohol abuse that presented to the hospital with complaints of abdominal pain. She was admitted to the ICS for management of alcohol withdrawal, put on non-invasive ventilation, and given a sedative. She was eventually found unresponsive and taken off the ventilator. An X-ray revealed the patient’s lung had collapsed due to a severe fluid buildup. The patient went into cardiac arrest resulting in irreparable brain damage. It was alleged that brain damage resulted from aspiration. A pulmonology expert was sought to opine on the protocol for monitoring patients requiring respiratory assistance in the ICU.

Question(s) For Expert Witness

1. How often do you manage patients with alcohol withdrawal that are put on respiratory assistance in the ICU?

2. Would managing a patient with alcohol withdrawal in the ICU require precautions that are otherwise not required for other patients? If so, what are they?

3. What qualifies a patient to be put off respiratory assistance while in the ICU?

Expert Witness Response E-135423

I frequently manage patients with alcohol withdrawal in the ICU, many of whom have required some form of respiratory assistance (both noninvasive and invasive mechanical ventilation). Attending to patients suffering from alcohol withdrawal requires particular precautions due to the strategies needed to appropriately manage these symptoms. These precautions include close monitoring of the patient's ability to maintain airway latency, and protection in the context of both alcohol withdrawal itself and side effects of alcohol withdrawal medications (including benzodiazepines and other agents). Ideally, patients are managed in a way that avoids the need for invasive mechanical ventilation, though depending on the severity of withdrawal, this strategy may not be feasible. Typically, the ability to maintain adequate ventilation and oxygenation (i.e. gas exchange) with an appropriate mental status and the ability to protect their airway qualifies a person to be removed from respiratory assistance in the ICU. However, specific considerations apply for noninvasive ventilation that differ from invasive mechanical ventilation, and certain circumstances make noninvasive ventilation inappropriate, even if they continue to require respiratory assistance.