Ventilatory pump failure is respiratory insufficiency caused by weakness of the inspiratory and expiratory muscles, leading to hypoventilation, hypercapnia, and ineffective cough rather than primary lung disease. This article analyzes five medicolegal cases in which conventional acute-care management of ventilatory pump failure resulted in death, anoxic injury, prolonged tracheostomy mechanical ventilation, or avoidable institutionalization. The cases were reviewed to identify recurrent clinical and legal failures, including removal of continuous noninvasive ventilatory support, administration of supplemental oxygen without correction of hypoventilation, inadequate low-pressure noninvasive ventilation, failure to use mechanical insufflation-exsufflation for airway clearance, and refusal to consider extubation to continuous noninvasive ventilatory support despite available published protocols. Across the cases, tracheostomy or death was often framed as inevitable, although feasible noninvasive alternatives existed. From a medicolegal perspective, these omissions raise concerns about breach of duty, failure to obtain informed consent, and loss of chance. The analysis suggests that customary practice is not necessarily reasonable practice when evidence-based alternatives are available and clinically applicable. For cognitively intact patients with ventilatory pump failure, acute-care teams should consider and document noninvasive ventilatory support and mechanical insufflation-exsufflation before proceeding to invasive or palliative pathways.
