TY - JOUR
AU1 - Thomas, R. C.
AU2 - Kuppurao, L.
AB -  We wish to report a critical incident during use of a Draeger Oxylog ventilator. Transfer was arranged for a burns victim whose lungs were mechanically ventilated. In preparation for the transfer he was changed to a Draeger Oxylog ventilator (Draeger Medical Ltd, Hertfordshire, UK) and the end‐tidal carbon dioxide continually analysed. The initial end‐tidal carbon dioxide measurement was 5.1 kPa, but within minutes this value increased to 11.0 kPa in association with a raised inspired concentration of carbon dioxide (1.5 kPa). Arterial blood gas analysis confirmed an elevated P a co 2 of 13 kPa. The patient was reconnected to the ICU ventilator and ventilated to normocapnia. There appeared to be adequate chest expansion and appropriate movements of the pressure gauge on the ventilator were observed, but no gas flow could be detected from the PEEP valve situated on the expiratory port and the characteristic expiratory noise was absent. The Oxylog ventilator was examined closely and the non‐return valve unit was discovered to have been incorrectly assembled such that the dark red ‘mushroom’ part of the valve had been inserted the wrong way around (see Figure 3 ). The result was that the patient was being ventilated predominantly 
TI - Incorrect assembly of non‐return valve of an Oxylog ventilator
JF - Anaesthesia
DO - 10.1111/j.1365-2044.2004.04105.x
DA - 2005-02-01
UR - https://www.deepdyve.com/lp/wiley/incorrect-assembly-of-non-return-valve-of-an-oxylog-ventilator-257PC400cp
SP - 209
VL - 60
IS - 2
DP - DeepDyve
ER -