Severe pulmonary barotrauma.

Pulmonary barotrauma is a well-known but rarely seen complication of mechanical intermittent positive pressure ventilation. It is thought to be related to raised pressures within alveoli which lead to their eventual rupture and the subsequent development of respiratory embarrassment. Mishaps related to faulty one-way valves in the self-inflating, bag-ventilation devices commonly used in cardiopulmonary resuscitation (CPR) can, although rarely, lead to severe barotrauma. In this report, we describe a case of pulmonary barotrauma that appeared to be related to the "locking" of the "Ambu" bag's one-way valve in the inspiratory position during routine CPR.