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
Did My 23-year-old Son Die of COVID-19 ARDS Due to
Lack of ECMO Support? Live Stream!
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 Ashanti, as part of my 1:1 consulting and advocacy.
Ashanti’s dad is in ICU with a stroke & is on a ventilator. She is asking what are his chances of weaning off the ventilator.
My Dad is in ICU with a Stroke & is Ventilated. What are His Chances of Weaning off the Ventilator?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Ashanti
here.”
Part 1
Part 2
Hi Ashanti,
It’ll be difficult although not impossible for your dad to come off the ventilator with a GCS (Glasgow Coma Scale) of 5 or 6.
Please get a picture of the ventilator and arterial blood gas results so we can see and review them. These are important parameters
to know if he is tolerating the weaning process and hopefully to get him off the ventilator.
Pressure sore stage 4, I would argue is hospital negligence and that should never happen!
Please keep us updated.
Kind regards,
Patrik
Hello Patrik,
I am glad I have taken the monthly membership with the Intensive Care Hotline. I know this will help me and my dad a lot!
Below are the ventilator settings for my dad. Today was able to be with him in the Neuro ICU. Please share your thoughts.
Mode: (PRVC) Pressure Regulated Volume Control
Positive End Expiratory Pressure – 6
Fraction of Inspired Oxygen- 35 %
Respiration Rate – 16
Tidal Volume – 400
Another thing that was noticed which might be a concern was that for the last 2 days during his spontaneous breathing trials (SBT), there was no respiration effort from
his side. 3 days on Friday he did well for about 6 hours.
How do we progress from here? Parameters are stable. He is still in ICU. Do they de-escalate to the regular ward before planning for discharge?
Let me know.
Thanks & Best Regards,
Ashanti
Hi Ashanti,
The minimum breathing rate should be 10-12 per minute.
Spontaneous Breathing Trial (SBT) is dependent on how long he can tolerate it, arterial blood gas results, breathing rate per minute, tidal volumes, minute volumes, frequency of suctioning, and if there are signs of exhaustion.
The longer he can tolerate spontaneous breathing trials the higher chances he can come off the ventilator.
Kind regards,
Patrik
Hi Patirk,
Thanks Patrik.
Does the weaning process outcome be different for
stroke patients like my dad?
He could tolerate it for 6 hours last Friday. Now for the past 3 days not been much effort from his side during spontaneous breathing trials. Have you seen cases like this before in your past experience?
Can this
ventilator weaning process continue in a non-ICU hospital setting? How would be his progress from here? His vital parameters seem to be stable. He just came out of COVID restrictions a few days back. Just trying to know his best path forward for recovery.
Please provide your input.
Regards,
Ashanti
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Hi Ashanti,
Please see the answers in bold below
Does the weaning process outcome be different for stroke patients like my dad?
> What is
his Glasgow come scale? Let’s establish the basics first.
He could tolerate it for 6 hours last Friday. Now for the past 3 days not been much effort from his side during spontaneous breathing trials. Have you seen cases like this before in your past experience?
> are they mobilizing him? Is he getting out of bed, are they sitting him up, is he getting physical therapy (PT)? Are they sedating him? If they are doing all of the above, then he might simply be exhausted. If they are doing none of it my question goes back to what is his Glasgow coma scale? Is he sedated?
Can this ventilator weaning process continue in a non-ICU hospital setting? How would be his progress from here. His vital parameters seem to be stable. He just came out of covid restrictions a few days back. Just trying to know his best path forward for recovery.
> yes, it could continue with a service
like Intensive Care at Home. It is a specialized niche Intensive Home Care Nursing service provider,
providing quality of life and/or quality of-end-of life for long- term mechanically ventilated adults & children with tracheostomy or any other medically complex needs. Leaving ICU and going to LTAC is another option that we don’t advise as you are already aware.
Kind regards,
Patrik
Hi Patrik,
The nurse who attends him said he would give a Glasgow Coma Scale (GCS) of 8 as a
fair estimate. He is making movements on his body and reacts to pain, etc. But doesn’t follow verbal commands.
He is out of sedation for the last week to 10 days. Since his brain hemorrhage has been severe, he is not awake that much. They are turning him in every two hours and also for clean-up. His head is not steady yet, so they are not making him sit as per one of the nurses they are doing oral clean-up and suctioning h him as needed. No other physical therapy (PT) given so far.
Not sure about such an intensive care service at home in our place. Wish could find it here. Long-term acute care (LTAC) is not preferable. Confused and concerned about that part of care once he is ready to be discharged. The doctor had mentioned that their goal is to wean him off the ventilator but not sure as to how he would progress. He had been given some brain/neuro stimulant pills
as part of his medications. They are observing one day at a time.
Regards,
Ashanti
Hi
Ashanti,
Per your last email, we’ve got a couple of questions here that we need to ask.
What is the current ventilator setting for your dad today? Any current results for the arterial blood gas? What is his latest chest x-ray? Any recent Computerized
Tomography (CT) scan report? How frequent are they doing the spontaneous breathing trials for your dad? Is he having copious secretions? How frequent are they doing the suctioning now? Glasgow Coma Scale is 8 which is but fair. How frequent are they doing the GCS scoring for your dad? Mobilizing him is good coz it would regain his function back considering his tolerance.
Weaning off the ventilator for stroke patients depends on how extensive the brain damage is. In particular, compromise of brain regions regulating the level of
consciousness, breathing and swallowing should be taken into consideration. It is important to always give emphasis especially on airway safety, secretion handling and overall hemodynamic stability of your dad.
Keep us posted.
Regards,
Patrik
Hello Patrik,
Thanks for your replies. His ventilator settings have
not changed. It’s attached in the first email in this email thread. They are trying spontaneous breathing trials (SBT) every day in the morning. They also added some brain stimulants for him to stay more awake during the daytime. As mentioned, before he is near 8 on Glasgow coma scale (GCS) but still not able to follow directions. I feel that doctors are expecting a lot from him. They should give consideration to his severe brain hemorrhagic stroke and its long process
for recovery.
Today while trying spontaneous breathing trials (SBT), he took a lot of short breaths about 30 or so in a minute. So, they did not continue. The last successful SBT was about 6 hours last Friday. Not sure what’s happening with him during SBT. Can someone drop in their toleration level of SBT during the course and pickup? Please share your thoughts
as to such patients who are difficult to wean off the ventilator.
They are not doing much in terms of neural stimulation, mobilizing him, etc. except for turning him around, suctioning him, cleaning etc.
His vital
parameters have been stable but weaning off the ventilator seems to be a challenge for the last 4 days. Concerned that they might rush to conclusions in terms of his recovery. Let me know.
Try to get his arterial blood gas results. Chest X-ray seems to not have any abnormality.
Thanks & Best Regards
Ashanti
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Hi
Ashanti,
Thank you for your reply.
There are certain strategies to know if your dad can be able to come off the ventilator. A spontaneous breathing trial is a test wherein your dad will go from full support to minimal or no ventilatory support
as a test of his capacity to breathe on his own. Usually, the preferred method is with recognition of his readiness for spontaneous breathing [if he’s awake, with acceptable blood gas results, and manageable secretions] followed by timely spontaneous breathing trials lasting from 30 minutes to 120 minutes (depending on the hospital’s protocols), either conducted on a T-piece, continuous positive airway pressure (CPAP) or low levels of pressure support.
Weaning for your dad can also be done through progressive withdrawal wherein the ventilator support is gradually withdrawn. Like decreasing your dad’s ventilator’s pressure support as long as your dad will not show any signs of intolerance.
Difficult weaning from the
ventilator can be defined as failure to tolerate spontaneous breathing trials and failure to have tolerance with a decrease in ventilator
support.
Figuring out failure to tolerate SBTs or the systematic decrease in the level of ventilator support should be based on how they assess your dad clinically and therefore may require extended diagnostic effort to fully identify the underlying cause for his difficult weaning from the ventilator.
As per your dad’s case, where he has a decreased ventilatory drive because of his condition, consideration of weaning failure coupled with diagnostic testing should take place. It would also be helpful then as well if they can identify any reversible causes of weaning failure for your dad.
Your dad must be carefully observed during either an
SBT or during a reduction in the level of respiratory support so that the cause for weaning intolerance will be carefully documented. Such information may aid in efforts to identify the added causes that attribute to weaning intolerance.
The reason why we keep asking for your dad’s blood gas results and current ventilator settings is because, those parameters are
crucial to look at during SBTs: ABG (Arterial Blood Gas) results will tell if there is any development of hypoxemia (decrease oxygen in the blood), or an increase in carbon dioxide. Other thing to look out is if your dad has an increased breathing rate (greater than 35 breaths for at least 5 minutes), increased heart rate (above 140 bpm or increase by 20% from baseline heart rate), any development of an increase/decrease in blood pressure & signs of agitation.
With your dad having a decreased ventilatory drive, it usually impedes the weaning process.
Given that your dad took a lot of short breaths about 30 or so in a minute, affecting his hemodynamics and so they did not continue with SBTs meaning he’s unable to tolerate
weaning this time.
Normally, in that case, as your dad developed signs of intolerance to weaning, they should have returned him immediately to ventilator support so as not to result in respiratory muscle fatigue so that the next attempt for SBTs or weaning for your dad (after appropriate efforts to identify and treat the cause ideally) can be safely initiated again after
24 hours. In contrast, should your dad have not been rapidly returned to full ventilatory support, there is a risk that your dad will develop fatigue and in this case, your dad should be rested on full ventilatory support for at least 24 hours before further attempts at weaning. Failure to do so increases the likelihood that future attempts will fail.
I hope this
helps. If you could get the current results for blood works and blood gas that would be great.
Keep us posted.
Kind regards,
Patrik
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Hi Patrik,
Thank you for your response and
for all the information.
I will get further information regarding my dad.
Thanks,
Ashanti
Hello Patrik,
It’s been a while since my last email. My father is still in ICU on ventilator support. He had been little more than a month in this condition.
Pluses:
- Hemodynamical stability.
- Conscious level slight improvements noticed.
- Moved out of initial COVID restrictions.
- Was able to be on CPAP support (SBT) for about 8 hours on a couple of days. Average is 2 to 3 hours.
Minuses:
- Unable to wean off ventilator support for long hours consistently. Some days seem too exhausted and could not tolerate it.
- Pressure sore on tail bone now attended as level four.
- Not much physical therapy/ brain stimulation given thus far. Simply saying not responding to commands.
How can we improve his outcome? Is this way patients wean off after a major stroke? How best we can improve?
As per
pulmonary technicians and nurses, they are suspecting due to covid aftereffects. I suspect it’s related to brain hemorrhage/stroke. Please share your thoughts.
Pulmonary technicians and doctors are mentioning that their goal is to wean him off the ventilator. Thus far had been slow progress with some improvement in terms of days having more than 8 hours off the ventilator.
How can we approach it so that he can achieve that goal?
Awaiting your reply.
Thanks & Best Regards,
Ashanti
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Hi Ashanti,
How are you, Ashanti? I hope this email finds you well.
Thank you for emailing us again.
It’s nice to know that your dad has been hemodynamically stable.
In regard to weaning your dad off the vent, having
neurological issues such as stroke is one of the most common issues that might prolong weaning off a ventilator. The process of weaning off the ventilator for your dad might not be a straightforward process and numerous setbacks might occur and therefore delay and prolong the weaning process. Your dad may have the ability to be tried getting off the ventilator but not enough endurance.
It is extremely challenging for sure and sometimes frustrating when we are faced with a loved one that is unable to be weaned off the ventilator. However, the weaning process for your dad is a team effort. It is a multidisciplinary team approach, while the respiratory therapists initiate the protocol for weaning your dad, nurses, doctors, nutritionists, and physical therapists should be involved in the process giving emphasis on good clinical assessment.
Moreover, I have seen that you mentioned about a pressure sore stage 4. That needs to be fully addressed and needs to be assessed by the wound care management team so they can advise how to manage and prevent any potential infection this may bring.
The following
precautions can help minimize the risk of developing pressure ulcers in at-risk patients and to minimize complications in patients already exhibiting symptoms:
- Patient should be repositioned with consideration to the individual’s level of activity, mobility, and ability to independently reposition. Q2 hour turning is the standard in many facilities, but some patients may require more or less frequent
repositioning, depending on the previous list.
- Keep the skin clean and dry.
- Avoid massaging bony prominences.
- Provide adequate intake of protein and calories.
- Maintain current levels of activity, mobility and range of motion.
- Use positioning devices to prevent prolonged pressure bony prominences.
- Keep the head of the bed as low as possible to reduce risk of shearing.
- Keep sheets dry and wrinkle free.
I hope this helps.
Take care.
Kind regards,
Patrik
The 1:1
consulting session will continue in next week’s episode.
Kind Regards
