Neonatologist Improperly Intubates Premature Newborn

This case involves a fetus who was delivered at twenty-four weeks with hypoplastic lung disease. The mother experienced a premature rupture of membranes in the nineteenth week of pregnancy and was transported to the hospital. In spite of bed rest, antibiotics, and steroids, labor began abruptly and an emergent C-section was performed for a breech presentation. A code pink team attended the birth and, upon delivery, the baby had 7/10 on initial apgar scores, but subsequently desaturated. The baby required intubation that was performed with some difficulty, with the tube being incorrectly positioned at the carina. It was immediately repositioned but bilateral pneumothoraces developed and needle aspirations had to be performed. The baby was deemed to be medically unstable and further intervention efforts were futile. A discussion was conducted with his parents who opted to remove life support shortly after his birth.

Question(s) For Expert Witness

What other techniques could have been employed to help save this young patient?

Expert Witness Response E-001491

In fetuses with pulmonary hypoplasia, before delivery and depending on the underlying lesion, a few interventions can be performed to increase the fetal lung volume and improve lung development. Preterm rupture of membranes without signs of fetal distress or intrauterine infection is treated conservatively with or without tocolytics, antibiotics, and steroids in various combinations. Attempts have been made to seal the defect in the membranes by transcervically using "fibrin glue." This technique, however, requires a preliminary cerclage, increases the risk of infection, and has limited efficacy. After delivery, the infant needs respiratory support, which can range from supplying supplemental oxygen to mechanical ventilation, including high-frequency ventilation and extracorporeal membrane oxygenation (ECMO). Ventilatory strategies have veered toward the use of permissive hypercapnia, especially in cases of congenital diaphragmatic hernia (CDH), with an increased survival rate in several reports. Partial liquid ventilation has also been used, without definite advantages.