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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
What Else Can We Do to Help My Sister Get Off the Ventilator in the ICU?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer questions from one of my clients Marsha, as part of my 1:1 consulting and advocacy service! Marsha’s sister is ventilated in the ICU. Marsha is asking why is it vital for her sister to be mobilized.
Why is it Vital for My Ventilated Sister to be Mobilized in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Marsha here.”
Part 1
Part 2
Part 3
Patrik: If you ask your sister is she in pain, you will get a yes?
Marsha: Yes. She will say the ventilator today was killing her. So then, yesterday, they cleaned it out, but that’s it. If she doesn’t have medication, when you ask her, “Dear, you’re in pain?” she just says, “My back.”. And then, she means the sore there. She means the sore on her back. Yeah, she’s a tough lady, trust me. I saw the picture. Patrik, I’m sure you saw this thing.
Patrik: Oh yeah.
Marsha: I can’t believe what it looks like. You can see her spine. It’s like someone shot her with a gun-
Patrik: Oh, my goodness.
Marsha: And put a hole in her back.
Patrik: That’s bad.
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Marsha: No, it’s bad. I want you to trust me, I know how she got it. And you know how she got it, and my husband knows it. It’s terrible that she’s had that. And it’s so bad, because I want to tell the nurses that were responsible for this that it’s really hampering her getting better. It really is.
Patrik: Right.
Marsha: The day she gets it bleeding, she can’t do anything that day. She’s shot for a day. She’s in pain. It’s just terrible, just terrible.
Patrik: Right, right.
Marsha: Yeah, yeah. I feel like in the beginning, I was like, “Well, can you give her pain medication where she couldn’t feel it and she can be moving?” but it seems like the problem with doctors and nurses, they don’t take this the wrong way. It’s like, “Liza, are you in pain?” and then they give her, it’s always just more, “Okay, give her more pain medication, more pain medication.” And to me, I tried to tell them in the beginning, “This
is not your normal patient.”
Marsha: And the doctor told me then. She’s like, “You don’t know how hard it is to treat a woman like your sister.” She goes, “The woman that wants the pain medication all the time and you handle it, she’s the easy woman. Your sister is a pain because I got to always be in the middle. I’m always worried, “Is that too much? Is that too little?'” So, I understand it’s just the way she is. But yeah, I’m sorry.
Patrik: Yeah. I’ve lost my train of thought now.
Marsha: We were talking about which medication, Fentanyl, or morphine.
Patrik: Yeah. Look, a patch-
Marsha: And you told me the fentanyl patch, you’d rather-
Patrik: Yeah, I’d rather a patch. I’d rather a patch than the morphine sort of injections. Yes, that would be my-
Marsha: You know what? Well, okay, let me stop you there. So just to let you know, they were giving her a fentanyl patch. And then, in addition when she requested, morphine injections. Now, she’s just getting morphine into her stomach. That’s it.
Patrik: Yeah, yeah. As an injection, not through her PEG (percutaneous endoscopic gastrostomy)?
Marsha: Through her PEG. No, through her PEG.
Patrik: Okay, I see, I see.
Marsha: Where they feed her, same thing, like a pill. They told me, “This is like she took a pill”. But they give her liquid through that way.
Patrik: Yeah, yeah. No, no, I-
Marsha: They give her a liquid, yeah.
Patrik: Yeah, no. I hear you, I hear you. Okay, but how often does she need suctioning? How often, every hour, three times a day?
Marsha: It depends on the day. Sometimes, it’s more than others. I would say, it’s definitely more than three times a day. Is it every hour? No. So when you say suction, let me clarify. You have the suction through her tracheostomy, and then you have the suction catheter.
Patrik: That’s-
Marsha: She does the suction by herself a lot in her mouth. She’ll do that herself.
Patrik: Right, right. That’s what I’m referring to, suctioning-
Marsha: And then, she has the suction, yeah.
Patrik: I’m referring to suction through the tracheostomy. That’s what I’m referring to-
Marsha: He does it herself.
Patrik: Okay, but I’m referring to-
Marsha: Through the tracheostomy?
Patrik: Yes. I’m referring to-
Marsha: You know, like-
Patrik: … to suction through the tracheostomy.
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Marsha: The trach, as you say, you know what? That’s tough to say. I would say it’s definitely not only three times a day, but I would say it’s probably not every hour. The other day was probably closer to two every two hours. Today, it might be a little less. So, I think that part is getting better, but in the beginning when she first got home again, she was getting suctioned a lot.
Patrik: Right, okay. And she’s got a good, strong cough?
Marsha: I would say she’s got a pretty strong cough.
Patrik: Okay. What size is the tracheostomy tube? Do you know what size?
Marsha: No, I can find that out. I know they made it smaller, so I don’t know what that was about.
Patrik: They made it smaller, okay. No, that’s good, that’s good. No, no, no, that’s good. When did they make it smaller?
Marsha: That was before she went on that run where she did 11 days without the vent. A little bit before that, they made it smaller.
Patrik: And she’s still on that small one?
Marsha: As far as I know, they haven’t changed it.
Patrik: Right, okay. So that’s a good thing if they keep downsizing. When she’s on the ventilator, she’s on pressure support of 12, did you say?
Marsha: Yeah. So far, she’s been bouncing back and forth between 12 and 14, the last couple of days.
Patrik: Do you know her positive end-expiratory pressure (PEEP)?
Marsha: You’re talking about continuous positive airway pressure (CPAP) or full support?
Patrik: Yes, CPAP and full support. I’m talking about both, really.
Marsha: Okay. When they put her on CPAP, she’s down to 14 or 12. When they put her back to full support, she’s at 60.
Patrik: Okay. When she’s on CPAP, do you know her PEEP?
Marsha: PEEP is 5.
Patrik: Okay. Do you know her volumes?
Marsha: I got a couple pictures, yeah. I took, so just give me a second.
Patrik: If you can text or email them to me, that would be great.
Marsha: Okay. And they’re from yesterday.
Patrik: Right.
Marsha: Okay. So, I’ll give you the early one in the morning. Do you want me to read them to you or text them?
Patrik: Text them is better. Text them is better or email. Text or email.
Marsha: It was yesterday morning, just took the one. This is the other monitor at the same time.
Patrik: Yeah, I haven’t received them yet.
Marsha: No?
Patrik: Are you on WhatsApp?
Marsha: No.
Patrik: No, that’s okay. Sometimes, it may not text. The picture may not come through. Can you email it if I text you my email address?
Marsha: Oh yeah, I think I have it. Do you have a different email than what you emailed me on?
Patrik: No, no, no. Yeah, I do have a different. But if you just send it to that one, that’s probably the quickest way.
Marsha: Send it to that one that you sent me my receipt on?
Patrik: Yes, correct.
Marsha: Okay. Do you want me to read them? I don’t know if you’ll get them real quick.
Patrik: Look, I think now I’ll tell you why I would like you to send it to me. I would also like to look at the ventilator itself.
Marsha: Okay. No, I will send them to you, but I can give you-
Patrik: Yeah. While you are sending them, just read it out to me. For sure, for sure.
Marsha: Okay. So, I don’t know if I sent it, but there are a lot of numbers on there. I don’t know what they are.
Patrik: Yeah, no, that’s good. I like numbers.
Marsha: Okay. Okay, let’s see, yeah. What is your email?
Patrik: Support@intensivecarehotline.com.
Marsha: Support@intensivecarehotline.com, okay. Okay, there’s one.
Patrik: Yep.
Marsha: I’ll send them in separate emails. Okay, that was yesterday morning.
Patrik: Right.
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Marsha: Hope you get that and then, I just sent it.
Patrik: Right.
Marsha: And this is yesterday afternoon. Today, she wasn’t on the ventilator for long, so I didn’t get a picture of that.
Patrik: That’s okay.
Marsha: Did you get that by any chance?
Patrik: Nope, not yet. It might take a second.
Marsha: Yeah.
Patrik: I’ll just have a quick look. Sometimes, it might even go into the spam folder. But no, it’s not in the spam folder, no. No, it hasn’t arrived yet. I’ve texted you my email address. Just have a quick look that it’s-
Marsha: Yeah, I’m going to resend it using that.
Patrik: Right, right.
Marsha: Just to make sure I got it right.
Patrik: Yes, yes, yes.
Marsha: I could’ve written it wrong. My phone takes forever.
Patrik: Yeah.
Marsha: Let me send them all in one email.
Patrik: Okay, got it now. Got it now.
Marsha: Oh okay, good. That’s one.
Patrik: So, this is CPAP. What’s your sister’s weight approximately?
Marsha: Her weight now or her weight what used to be?
Patrik: No, her weight now.
Marsha: She’s like 130.
Patrik: 130 pounds is that. Is it?
Marsha: Yes, yes, yes.
Patrik: Just give me one second. I just need to get that in kilos.
Marsha: Sure, sure. It’s like 59 kilos.
Patrik: 59 kilos, yeah, yeah. Yeah, got that, okay. So, the reason that’s important, apparently, it’s 59 kilos. So, the reason that’s important, just have a look at this first picture that you sent to me. So, when you look at the top left, you can see 26 breaths per minute. Then you can see the 523, the tidal volume.
Marsha: Yes.
Patrik: That’s quite important. So, the reason that’s important, so 59 kilo, it is suggested that it should be 7 to 10 mls per kilo. So, let’s keep that simple. Let’s just keep it with 10 mls per kilo. That’s 10 times 59, that’s 590 mls. So, she’s breathing 523, that’s pretty good. That’s pretty good.
Marsha: Okay, good.
Patrik: Right? So now picture this. So now picture this, Marsha. Her pressure support is 14 in that picture.
Marsha: Right.
Patrik: So, if you were to bring that down to 12 or to 10, she should still breathe that 523. That’s where the rubber hits the road, so to speak.
Marsha: Okay.
Patrik: Right? So, the further you decrease the pressure support, the tidal volume should stay the same.
Marsha: Okay.
Patrik: If that tidal volume on pressure support of 14 was 300 with 59 kilos, I would be worried. I would be concerned. But with the numbers that I’m seeing, I’m not concerned.
Marsha: Okay.
Patrik: Right? So, I think she’s in a pretty good position there.
Marsha: Okay.
Patrik: So-
Marsha: So, here’s my issue.
Patrik: Yeah?
Marsha: On the one I’m going to send you now, as well. She’s got pressure support of 12, but that number’s 354.
Patrik: It could be just a one-off-
John: Right. It could be, yeah.
Patrik: Just as much. But, just as much as the 523 could just be a one-off.
Marsha: But I don’t think the 523 is. Because when I go down and look at her 14 again on another picture, it’s 572.
Patrik: Oh okay, okay. That’s good, that’s good. I like that. And it could be when you took the picture with 300 or whatever, she might’ve just had a cough, or who knows.
Marsha: Right, right, right.
Patrik: So, the trend is important. So-
Marsha: I can show you another one with a pressure support of 12, so I’m looking at it right now.
Patrik: Yeah. Yeah, yeah. Sure, sure.
Marsha: Okay.
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Patrik: So then, just to keep this in perspective then, Marsha. When she’s on the tracheostomy collar, we can’t measure the tidal volume. You can’t measure tidal volume on the tracheostomy collar, okay?
Marsha: Right.
Patrik: But that’s where the blood gas is coming in. Because at the end of the day, all you can judge if someone is on the tracheostomy collar. You can judge, are they getting exhausted quickly? Are they breathing too fast? Are they getting drowsy? All of that. Are they starting to cough? And if that’s the case, then one could argue that she needs to go back on the ventilator. Or you do an arterial blood gas, and then you know. Okay, the arterial blood gas, if the numbers are poor, then you know she needs to go back on the ventilator.
Marsha: Right.
Patrik: So that’s where the arterial blood gas is coming in. So, for example, because it’s nighttime for you, are they putting her on the ventilator overnight?
Marsha: Full support overnight, usually whenever she’s done weaning. So, whenever she gets tired or they feel like, “Yeah,”. If her pressure goes up, they’ll put her back. If she complains, they put her back and it depends on the respiratory therapist. The good ones will try to get her through it. The crummy ones will just put her back and be done with her. So that’s where I have a problem with some of them, instead of trying to get her
through it. So yeah, now she’s on full support usually. Probably now, they probably go back to full support around 12 hours after weaning, sometimes 16.
Patrik: Right. Okay. Have you sent another picture?
Marsha: Yeah, I sent the one with 12.
Patrik: Right. It hasn’t gone-
Marsha: It has no subject.
Patrik: Yeah, no. It hasn’t come through yet. That’s okay. It’ll come in a second. Okay. So, when you’re saying full support, are you talking about where she gets a set rate from the ventilator?
Marsha: Right, right, no CPAP.
Patrik: Yeah, yeah, okay.
Marsha: They call it full support.
Patrik: Yeah, yeah. No, that’s fine. It’s fine if it happens overnight, as long as she keeps moving forward. It might help her to have a good night’s sleep.
Because if she sleeps at night, she’s rested for the day.
Marsha: Right, right.
Patrik: Ask them about the size of the tracheostomy tube.
Marsha: Okay.
Patrik: Right? Because if they keep downsizing, that’s a really good sign.
Marsha: Okay.
Patrik: That’s a really good sign.
Marsha: So, size of the tracheostomy tube. We want to make sure she’s sitting up as much as possible, and strengthening as much as possible. Fentanyl over morphine IV, but into her stomach. Still, the fentanyl patch over morphine into her stomach or you’d rather the morphine?
Patrik: No. You can’t give a fentanyl patch through the tube. You stick that on the shoulder or wherever the best place is.
Marsha: I know that, but I’m saying, so you told me you’d rather have fentanyl. But if she’s getting a morphine injection or a fentanyl patch, probably fentanyl patch?
Patrik: Yeah, I think so, because it’s slower. It’s a slower release, generally speaking.
Marsha: Okay, but as opposed to now I’m asking you, if they ask me, ” Marsha, you want to continue with the morphine through her stomach, where she gets it like she’s taking a pill, or the fentanyl patch?” Which one would you pick?
Because that would be, oh yeah, the easiest, the morphine through her stomach.
Patrik: Yeah, yeah.
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Marsha: Fentanyl patch.
Patrik: Yeah. Do you think that, when she’s getting the morphine, that it sort of knocks her out?
Marsha: It doesn’t knock her out. But if they give her too much, it could, but it doesn’t. And sometimes, I feel like it takes the edge off a little bit from the-
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Patrik: Sure, sure. How much is the fentanyl patch over 24 hours? Do you know?
Marsha: They have different ones on that. She doesn’t have any now, but I know the doctor talked about maybe putting it back and I think she would start with a 12.5.
The 1:1 consulting session will continue in next week’s episode
