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

My Dad is with Tracheostomy and is Getting Worse in the Pulmonary Ward. Why Don’t They Want to Bring Him Back to ICU? Help!

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 Joy, as part of my 1:1 consulting and advocacy. Joy’s dad is with tracheostomy and is always sleepy. She is asking if the sedatives make his condition worse.

My Dad is with Tracheostomy & is Always Sleepy. Do Sedatives Make His Condition Worse? Help!

“You can also check out previous 1:1 consulting and advocacy sessions with me and Joy here.” 

Part 1

Part 2

Part 3

Part 4

Joy:  Yeah, I think up until, you know, it’s hard to say, but definitely we feel like the nutrition was, we feel like he was looking better. He was more alert. I mean, because he was completely delirious right before they had put him on the ventilator the first time. So, he seemed, he was able to have a conversation. They were mobilizing him. And I think if we felt like if we could mobilize him, we felt like he was getting better and that we were right. We wanted to make sure that that tumor stopped growing also.

Patrik:  Would you say that between last time and now, besides the, I mean, it sounds to me like he’s made progress. I mean, it’s not unusual that in a situation like this that it’s two steps forward, one step back. It’s not unusual. So, no recovery. I’ve seen very few recoveries in ICU that are just up, up, up all the time. It’s usually two steps forward, one step back. So, my concern is, from what you’re sharing with me, how will they get the CO2 down in the long run? He might need a sleep study. Do you know whether he had a sleep study?

Joy:  I don’t think so.

Patrik: The one way to determine what he needs going forward is probably a sleep study. Has he ever suffered from sleep apnea?

Joy:  No.

Patrik:  Okay. And the tumor, just remind me, the tumor is in the brain?

Joy: It’s not. It’s sitting right here.

Patrik:   Yes, it’s external.

Joy:  It’s external, right.

Patrik:   Yes, I remember.

Joy:   Yeah, it’s bleeding and he’s got blood clots, so they don’t want to do coagulants. And of course, they don’t want to do thinners on the blood clot. So, I thought, my understanding was that we were kind of waiting to see how it ran its course. But now these CO2 (carbon dioxide) levels have crept up.

Patrik:   Right.

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Joy:   Sleep study would be what you recommend for to get the CO2 level to see what’s going on?

Patrik:  So very much so. What happens is, for example, we are dealing with a client at the moment that’s sort of on the verge from no BiPAP (bilevel positive airway pressure) onto BiPAP. One way to determine what BiPAP levels he needs going forward is to do a sleep study with blood gases. That’s the way to determine what’s the sleep pattern like and what are the best BiPAP settings going forward to not let CO2 rise?

Joy:   I do not know.

Patrik:  Right. So that might be a way forward. I’m just trying to; I’m really trying to work out. So, you’re basically saying it has been around five days between being off the ventilator and CO2 rising. Around five days?

Joy:  Gosh, it seems like it’s been even longer. Yeah, it’s probably been a week.

Patrik: Okay. Been a week.

Joy:   I think.

Patrik: And prior to that, when he was on the ventilator, how much time would he have spent on the ventilator within a 24-hour period?

Joy:  So they had gotten him down to, actually, they got him to 20 hours off of the ventilator on the trach collar. And then the next thing we knew, they said he was okay. He had been off of it and he refused it and that he was okay and they were just going to move him. My dad had refused the ventilator. He felt like he was okay on the trach. So he was that aware of what was going on.

Patrik: Yeah. Yeah. Okay. And at that stage when he said, look, I don’t want the ventilator, you felt like he was oriented, made sense?

Joy:   He very much was. I guess to the extent that he can be, I think that there is a little bit of responsiveness.

Patrik: Yeah, sure. Fair enough. Fair enough. Okay. So the other thing is this. If he was to go to LTAC, I might be wrong here, but I haven’t heard LTAC (long- term acute care) doing a sleep study. I haven’t heard that. Sleep study is usually done at a tertiary hospital.

Joy:  Okay.

Patrik:  Right? So again, got to ask the question because once he’s gone, he’s gone. And ask them what’s the plan for them to manage the CO2 going forward.

Joy:  Okay.

Patrik: What’s the plan? It could just be that he’s simply tired. Here is something else. Joy, is he on any opiates? Morphine, fentanyl, oxycodone, Oxycontin. Is he on any pain relief that’s potentially an opiate?

Joy:  He is.

Patrik:  He is? Okay. Stop.

Joy:   I think so. Stop that?

Patrik: Stop that. So, the main side effect of an opiate is respiratory depression. Okay? If you and I slow down our breathing, our CO2 will rise as well. Okay. Why is he getting that? Is he in pain?

Joy:  I don’t, I may be wrong. I don’t know. I’m sorry.

Patrik: That’s okay. That’s good. Just ask. Just ask. He may not be.

Joy: Yeah.

Patrik: He may not be. But if he is, if he’s on any opiates, morphine, fentanyl, Ordine, Oxycontin, Oxycodone, any of that stuff, I would argue either reduce or stop. And if he is on it, why is he on it? What would happen if they take it off? Is he sitting in pain? Very important. Also, is he on any other sedative medication? Fairly unlikely. But for example, is he getting something to help him sleep overnight? You know?

Joy:  Let me find out. I don’t know.

Patrik: Yeah. So for example, if he’s getting some diazepam or Valium to help him sleep overnight or also another medication, Temazepam or Ativan to help him sleep overnight, that may also contribute to a high CO2. It may. Anything that’s sort of sedating him, whether that’s with an opiate or the benzodiazepines that I just mentioned, like the Temazepam, diazepam, or Ativan, that may all be contributing factors to this.

Joy:  Oh wow.

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Patrik: Okay? Another thing that may contribute is simply, for whatever reason, the numbers of breaths he’s taking per minute has gone down. We don’t know why. One of the reasons could be the painkillers if he’s on any, but there could be other reasons as well that we don’t know why at the moment. That’s something they need to find out. But they are the most obvious reasons that I’ve seen over the years. Painkillers, sedatives. And the other reason that, that’s why I asked you. I didn’t remember that the tumor was external. God forbid if the tumor was internally, it could also put pressure on the respiratory center in the brain. But that doesn’t seem to be the case.

Joy: Right. Okay.

Patrik: And again, mobilization in and of itself might help because hopefully he will get a bit more mobile. He will start to breathe more actively without hyperventilating, without breathing too fast. So I’d say anything between 12 and 20 breaths per minute would be normal. Maybe 12 to 25. And obviously nice deep breaths. Another thing they could do, if there is a good physical therapist or a good respiratory therapist, they know how to help him breathe. They will teach him ideally some breathing exercises. Just trying to think what else.

Joy:  Yeah. Because they did tell me that the physical therapist that came yesterday that sat him up on the edge of the bed, they said they can only come twice a week.

Patrik: Oh my goodness.

Joy: And that’s only for a half hour.

Patrik: They should be coming twice a day. Other question, Joy. Is he having a good sleep pattern? What I mean by that is does he have a good day and night rhythm? Do you know? Is he sleeping at night?

Joy: I thought he was. It seems like that’s all he does is sleep.

Patrik: Okay. Even during the day?

Joy: During the day. That’s what he’s doing.

Patrik: I see. No wonder his CO2 is up. But if you’re telling me he’s sleeping during the day, that could also mean he’s not sleeping at night. Right? A lot of patients coming out of ICU have a disturbed day and night rhythm.

Joy:  Oh, okay.

Patrik: Right? Because of medications, because of lights on and off, people talking there. A lot of patients coming out of the comas have a disturbed day and night rhythm. Which is why I also asked you, is he getting something to help him sleep overnight? Because one way sometimes to get people back into a normal day and night rhythm is to help them sleep overnight with some medications. Not that I’m a big favor or a big friend of it, but that is one way to reestablish a natural day and night rhythm. So you can see there’s several factors that could play a role here. Another thing to get people back into a natural day and night rhythm. Have you heard of melatonin?

Joy: No.

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Patrik: Melatonin is a natural product. And they could start with some. If the day and night rhythm is an issue, I’m just speculating here, but often it is. If the day and night algorithm is an issue, rather than looking at sedatives almost like chemical restraints, you should be looking at natural products. And melatonin is the first natural product that comes to mind.

Joy:   Okay.

Patrik: I tell you what I’m predicting in the short term, only in the short term. He will need the BiPAP to get the CO2 down. Once they’ve got the CO2 down, they need to establish what are we going to do next to keep the CO2 down? Is that something that can only be achieved with a vent, with a BiPAP, or is that something that can be achieved without the BiPAP? I would argue, you’ve heard of sleep apnea? You’ve heard of that?

Joy:  Yeah.

Patrik: A lot of people at home are on a little BiPAP or CPAP machine because they’ve got sleep apnea. If they didn’t have the sleep apnea machine, they would be waking up in the morning with a high CO2.

Joy:  Oh.

Patrik:  That’s the main reason. And they all go through a sleep study. They all go through a sleep study. So that’s what I believe you need to look for as a next step. A sleep study, I believe. And also, as I said, I don’t think there’ll be sleep studies in LTAC. I haven’t heard of it. I’m sure there’s a respiratory department in this hospital where you’re at, and they should be able to organize a sleep study for him.

Joy:  Okay. And then find out about the medications?

Patrik:  Definitely find out about the medication. 100%.  Look, I can’t rule it out, but I would, look, I can’t be 100% certain, but if he’s on any amount of opiates, morphine, fentanyl, oxycodone, Oxycontin, or Ordine, that may be the main contributor to his having a high CO2, or any other sedatives. And it might be as simple as stopping all of these. And hopefully he can breathe without all of the sleep studies. It could be as simple as that, but it may not.

Joy:  Okay. Wow.

Patrik:  Do you think he’s in pain?

Joy: Oh, they said no.

Patrik:  What do you think?

Joy:  I don’t think he is, but I can’t tell. He says that he’s not.

Patrik:  Okay. Well then, the question is, why is he not in pain? Is it because he’s on maximum strength of painkillers? And can that be stopped? And that is the first question.

Joy:  Oh, I see.

Patrik:  They need to stop that. So, I’ll give you an example to really illustrate that to you. I’ve seen over and over again, you take a breathing tube out of a patient, and they just had surgery, for example. And they’re in excruciating pain. So you extubate them, you take the breathing tube out and you give them pain killers. Right? And then all of a sudden, they stop breathing because the painkillers kick in. And the first sign you’ll see is their CO2 is going through the roof.

Joy:   Oh. Okay.

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Patrik:   And it might be similar in your dad’s situation, it might not. I really don’t know. But it’s definitely something for you to ask. Another painkiller that just comes to mind that could be in the mix there is Endone. Endone is oxycodone but it’s a different name.

Joy:   Endone.

Patrik:   Yeah.

Joy:   Okay.

Patrik: I would hope that they would have considered that in the last few days with CO2 going up. I would hope that someone would’ve looked at it and would’ve said, okay, why is CO2 going up? Are we on opiates here?

Joy:    Yeah. Okay. So I’m going to ask Rey actually, right now. So, can I text you whatever our answers are?

Patrik:  Yes. Absolutely. Yeah. You reach out to me what you want to do next.

Joy:   Yeah. Okay. All right. Thank you, Patrik. Okay.

Patrik: The pleasure. All the best.

Joy:   All right.

Patrik:  All the best.

Joy:  Yeah. Okie dokie. I know you have to go. All right. Thank you so much.

Patrik:  Thank you. Bye bye.

Joy:   Okay. Bye bye.

Patrik:   Bye.

Kind regards,

Patrik

The 1:1 consulting session will continue in next week’s episode. 

I only have one consulting spot left for the rest of the week, if you want it, hit reply to this email and say "I'm in" and I'll send you all the details.