Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power,
real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another episode of “YOUR QUESTIONS ANSWERED” and in last week’s episode I answered another question from our readers and the question was
How Can I Stop the ICU Team from Pushing My Mom Out to LTAC?
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Tom as part of my 1:1 consulting and advocacy service! Tom’s mom is sedated and ventilated in ICU. Tom is asking what are the signs that his mom can be weaned off the ventilator.
What Are the Signs That My Mom Can Be Weaned Off the Ventilator in ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Tom here.”
Part 1
Part 2
Part 3
Dad: Hi Patrik.
Patrik: Hi there.
Dad: There are new updates with my wife but we don’t even know what to start looking for or what to ask.
Patrik: Yeah. Before I go into that, I’ll just quickly come back to the email that you sent earlier, Tom, especially with the ventilator, the picture
of the ventilator that you sent through. She is on a lot of support, right, and because she’s on so much support, I would almost say that … Let me ask you this. Have they highlighted how to wean her off the ventilator? Have they made any suggestions at all?
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Tom: In what way? What would they tell us or ask us? What do you mean?
Patrik: Yeah. What do I mean? So when someone is on a ventilator, they should always be striving for getting her off the
ventilator. Have they made any suggestions how to achieve that?
Tom: Just generally, getting her off of sedation, reducing her anxiety. Those have been the over lasting views of starting weaning and then gosh. I mean, no, they really haven’t
told us, or I guess encouraging her coughing which they’ve expressed has gotten stronger which is helping her cough up his secretions. Generally, that’s how I think of in terms of talking to us about what strategies they’re using. If they have explained more, we don’t understand. Dad, do you want to add to that?
Dad: No, I don’t. I don’t understand much, so no, I don’t think that they’ve explained.
Patrik: Yeah. The reason-
Dad: How would they explain? In your experience, what should we be looking or listening to?
Patrik: Yeah. Can you look at the picture of the ventilator because if I can talk you through that picture and then you have-
Tom: Yes. We have it open.
Patrik: Right, okay. Let’s just start on the bottom where you can see oxygen concentration 40, PEEP 8, RR 22, PC above PEEP 22. Can you see that?
Tom: Yes.
Patrik: So, let’s just start. Forget about the oxygen concentration. Forget about the PEEP for a moment. Just let’s focus on the RR. RR stands for respiratory rate. She’s on 22 at the moment, which means she’s guaranteed 22 breaths per minute by the ventilator. That’s guaranteed. Okay? You can see. When you
look on top of that, you can see Respiratory Rate 29? Can you see that?
Tom: Yeah, in green?
Patrik: Yeah, in green so that means she’s getting 22 breaths per minute from the ventilator and she’s triggering another seven breaths by herself. That’s 22 plus seven is 29. You’re with me?
Tom: Yes, okay.
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Patrik: Right. Okay, so 22 breaths from the ventilator per minute, that’s pretty much very little. It basically means she has very little own initiative. Okay? When you look at the other number there, PC above PEEP 22, PC stands for pressure control. Above PEEP is 22. That’s fairly high. She’s basically
getting … She’s in a pressure control ventilation mode, and I don’t want to get too technical here, but 22 of pressure is a lot. Right, so that’s indicating to me that she’s far away from being weaned off the ventilator at the moment. Okay? Now, that shouldn’t stop them or shouldn’t stop you from giving up hope. I mean, a lot of patients, that’s what they are in ICU, and it’s just a matter of trying to move them from that situation to a better situation. That’s in a nutshell where she’s up to.
When you look at the top, the top right corner where you can see 659, can you see that? VTI 659?
Tom: Yes.
Patrik: All right, that’s the volume she’s breathing in, in milliliters. Now she’s 90 kilos. According to that picture there, her weight is around 90 kilos, which I wouldn’t know how many pounds that is. I’m a metric person, but I know what-
Tom: I don’t know where it says that 90 kilos. Where did you read that?
Patrik: Yes, so where you see the 659, go up. You can see the time and the date.
Tom: Oh, that number.
Patrik: Yeah.
Tom: Okay, I see it now. I don’t know how many pounds that is either but how many pounds is common?
Patrik: Probably 130, 140, something like that. No?
Tom: No, no, so much heavier, 230 maybe more.
Dad: She’s less now. She should be like maybe 198.
Patrik: Right, okay. Anyway.
Tom: We’ll figure out the kilos.
Patrik: Yeah, but let’s just say for simplicity she’s 90 kilos. When someone is on a ventilator, roughly they should get 7 to 10 mls per kilo. With the volume of 659, that sounds about adequate. Okay, so what she’s getting seems to be adequate for her size. Now the question now is, if it’s adequate for her
size, what are her arterial blood gases doing? When I look at her arterial blood gases that you sent through, they look okay. They look okay. Her arterial blood gases are within range. That was at least what you sent us last week, so now the crux of weaning someone off the ventilator is they now need to start
reducing the support, and they could start with reducing the pressure control, so where you can see pressure control above PEEP. If they can reduce that down to 18, if they can reduce her breathing rate maybe down to 15 and she’s doing more work herself and the volumes are the same, that’s when you know you’re making progress.
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Tom: I see.
Patrik: However, that progress from my experience needs to be supported by physical therapy, by breathing exercises, by mobilization. It won’t happen just by reducing the numbers on the ventilator. That’s just one side of the equation. The other side of the equation is stimulating your wife, doing physical therapy, doing some mobilization. Am I making sense here?
Tom: Yeah, thank you. Actually, my dad and I were reading email of Sam.
Patrik: Oh, yeah, Sam.
Tom: The latest one explaining how the ventilator settings work. That was really helpful, but now that you’ve walked us through the monitor, that helps a lot because I did understand. When I asked her, I was like, “Oh.” Our thing is actually showing digression. I didn’t realize that because I was so focused on the
oxygen or the PEEP because during week 1 to 2, that was so critical, but now we’re in a different phase of this. Anyway, your explanation helped a lot, so thank you for breaking it down so specifically for us.
Patrik: It’s a pleasure. Yeah, so when you look also, on our calls we have been talking about the sedation, and we’ve been talking about the fentanyl. Let’s just quickly stay on the fentanyl for a moment. The main side effect of fentanyl is respiratory depression. What that means is it’s inhibiting a natural
respiratory drive, so if you turn down the breathing rate from 22 to 15, and she’s still getting fentanyl, she may not breathe up herself. If she does breathe up herself, she may not breathe up strong enough so she can achieve the volumes she needs. They need to get rid of that fentanyl. Right?
Tom: Okay. How do we push that?
Patrik: Some of her ventilator settings might be simply make her being critically ill and being deconditioned. That might be part of why they’re doing what they’re doing, but the other side of it is, well, let’s get rid of that fentanyl and see whether they can use something else, see whether she doesn’t
need it at all because that in and of itself will help her to increase her natural breathing drive.
Tom: Yeah. Well, now that she’s in this stage, so how would they manage her pain?
Patrik: Where is her pain?
Dad: I don’t know where the pain is but usually they say they give her that for pain.
Patrik: Can you ask?
Tom: Yesterday when we were there, Patrik, she did ask for more medication. Do you remember, Dad, because she asked in front of us. I mean, she’s not speaking, but we showed her a chart, a point pad where she could point out different things. She said that she was in pain, and she pointed at it. We said, “Are you
in pain?” She said yes. I mean, we also need to learn more, too. It’s just our instinct was, “Do you want more pain medication?” I mean, we’re just trying to take her out of suffering, but what else can we prompt her? What should we ask? “Can you tolerate it?” We don’t want her to think that we’re making her suffer because communication is so limited between her and us, without being able for her to speak or write right now, so I agree the fentanyl, yeah, is inhibiting that. I didn’t understand
that previously, to be honest. I don’t know if you did, Dad.
Dad: Mm-hmm (affirmative).
Tom: No? We’re just wondering how else is that managed because she generally said that it was hurting her neck when she was coughing, so we associated that with the tracheostomy wound because that’s what the nurse said. It’s not fully healed, so that’s expected, and she has developed a very strong cough over
the last couple of days, which is a big improvement, but it also makes sense, that much vibration and movement is causing more discomfort around the tracheostomy area.
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Patrik: Yeah, but it would be important for you to find out where is her pain. The tracheostomy generally speaking from my experience doesn’t cause a lot of pain,
generally speaking. There’s always the exception to the rule, of course. A lot of patients that are in a situation like your wife or dad, they’ve been lying in bed. They’re deconditioned. Just simply by them lying there might be painful for them because they’re so deconditioned, but you’ve got to ask her. The other thing is she’s still on the Precedex isn’t she?
Tom: Actually, did you say she was off it, Dad?
Dad: Yeah, I think.
Tom: They don’t have it in here. I think it’s off today, but yesterday when I asked, they said she was on the lowest dose possible until it’s turned off, so my dad sent me a photo today when he went to visit her. Let’s see. Heparin is on. No, Precedex, it was off.
Patrik: Was off. Oh, great.
Tom: It was off today at 6:30 AM. Yeah, so it was off, but fentanyl was on 0.5.
Patrik: Yes, I saw that.
Tom: Yeah, so Precedex was off today. Well, at that time. I don’t know right now. Patrik, can I ask you. I know you had asked. In your experience, where does the patient say that they have pain then if you’re saying that there shouldn’t be pain on the-
Patrik: Tracheostomy. Yeah, and that’s a good question. What often happens after, it’s been about five weeks now, hasn’t it?
Dad: Well, it’s going to be six weeks.
Patrik: Six weeks.
Tom: No, today is 42 days.
Dad: Oh, yeah. 42 days today.
Patrik: 42 days. Yeah, so imagine. Out of those 42 days, she would have been in an induced coma for most of the
time, so she would have had very little movement of her joints or her extremities, so now just by the nurses for example turning her, washing her, moving her arms, moving her legs, that in and of itself might be painful because she is so deconditioned. It could just be joint pain.
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Tom: You mean like soreness or achiness?
Patrik: Yeah, absolutely.
Tom: Or sharp pain?
Patrik: More the achiness I would think.
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Dad: I read her chart.
Patrik: But maybe you can ask her that question. Is it sharp pain, or is it achiness? Maybe you can ask her that question. Maybe you can get a yes or a no out of her to begin with.
The 1:1 consulting session will continue in next week’s episode
