Background: Amiotrophic Lateral Sclerosis (ALS) is a progressive, fatal, neurodegenerative disease with most affected patients dying of respiratory compromise and/or pneumonia 2 to 3 years since diagnosis. As ALS progresses, ventilatory assistance is required. In the end stages of disease, patients suffer from respiratory failure and may become ventilator-dependent. Deaths due to malfunction of mechanical ventilators are reported but forensic autopsy records are few. We report the case of a 69 years old ALS female ventilator-dependent, trachostomised patient found dead by her husband, with the ventilator in “stand-by” mode. Method: A forensic autopsy was performed. Samples of internal organs were taken for histological and toxicological examination. The ventilator internal memory was also analysed and tested in order to find possible malfunction. Results: Rough examination did not reveal any sign of trauma but showed brain and lung congestion. Pulmonary histological examination revealed thickening of peribronchial interstitial space, alveolar over-distension, break of inter-alveolar walls and diffuse alveolar haemorrhages. Focal microhemorrhages were also detected in other organs. Analysis of the ventilator internal memory showed that during the night of death, several voltage drops happened. Specific tests revealed malfunction of the internal battery which was unable to provide the necessary voltage, as a consequence the ventilator switched off, stopping ventilation. Battery malfunction reduced the volume of the ventilator’s alarm which was not heard by caregiver. Conclusion: Histological pattern, with acute pulmonary emphysema and focal polivisceral haemorrhages, is strongly suggestive for a death due to acute asphyxia. The authors discuss also the need of strict supervision and follow up of these ventilatory dependent patients and their devices
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