Should I Give Consent to Tracheostomy for My Mom in ICU If Extubation Fails?
Published: Sat, 05/06/23
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
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, Lloyd, as part of my 1:1 consulting and advocacy service! Lloyd’s mom is in the ICU and she is close to extubation and he is asking if he should give consent to tracheostomy if extubation fails.
Lloyd : Tomorrow. Well, they won’t. They’re going to try to do-
Belle: The trache tube.
Lloyd : Because we were pushing for the extubation and so they’re going to do it tomorrow, but they said they can’t do it
straight. If she fails, they can’t do it straight to trache. They’re going to have to intubate her again and then do the
trache.
Patrik : Yes. No, I agree.
Belle: Does it sound premature that they’re going to try tomorrow? Should they wait another day, do
you think? I mean, the doctor seemed yesterday to be not optimistic. And then today he said, “She’s better today. Let’s try it tomorrow, if she’s even better tomorrow.” So, I’m surprised that the doctor came around in 24 hours from, “No way we’re going to try this,” to “Let’s give it a try to extubate her.”
Patrik
: Right. Do you know what ventilator settings she’s on?
Lloyd : I can go look at the back.
Patrik : Can you send me a
picture?
Lloyd: Oh, I can send you a picture. Yeah, absolutely. I’ll do that now. Let me see.
Belle: I think the doctor said
she was breathing on her own basically. Wasn’t that pretty much what he said, right?
Lloyd: Yeah. Let’s see.
Belle: I didn’t realize you
could have a trach without having a ventilator. I thought tracheostomy needs ventilator.
Patrik: Yeah. No, you can.
Belle: That’s good.
Patrik: No. You see, given that she’s been two weeks now, two weeks is sort of the cutoff when you should do a trach, but then by the same token, if she’s close to extubation, but if she’s not awake, it could be very risky extubating her. Again, just remind me, why did extubation fail last time?
Lloyd: Because she was belly breathing.
Patrik: Yes. Okay. Yeah. Recall it now. Yes, I remember now.
Lloyd: Yeah. She was belly breathing. I don’t know if that was because she had mucus in the chest.
The only reason I say that is because the following day, the same thing… I mean, she was belly breathing and then they cleared her chest with the tube and then it turned out okay. It cleared up.
Lloyd: I mean, she stopped belly breathing. Though that was
the only two times, I’ve never seen her belly breathe before. Wait, I think I just sent you… Hold on. I guess ignore what I just sent you. It didn’t copy right. Hang on and then let me see. Let me try it again. It didn’t copy right. I’m going to try to send a picture again.
Patrik: Yes, hang on. But I can see pressure
support, PEEP (positive end expiratory pressure), backup rate 15, oxygen concentration 40%, PEEP 5. Yeah. Do you know your mom’s weight?
Lloyd: 180. Now, I think it’s 180, right? Well, is that what she said yesterday, Paul?
Paul: I think it was 176.
Patrik: One-seven?
Lloyd:
Good.
Paul: 176.
Patrik: 176.
Paul: 176 pounds.
Patrik: Yeah, I get it. Okay. That’s about 80 kilos. Just give me a second. The volumes are too low for her weight. So, when you texted me VT (tidal volume) around 379 or 380, that’s too low for her weight. Oxygen
concentration is 40%, which is little bit too high for extubation, but then it comes down to what her blood gases look like. Do you have blood
gases?
Lloyd: Let me see. How do I see the blood gases?
Patrik: Do you have
access-
Lloyd: I had the ones from a couple of days ago.
Patrik: Right. Oh, okay.
Lloyd: I can give that to you if that’s-
Patrik: Look, you can, but it comes down to what the blood gases are like in the settings that she’s on at the moment.
Lloyd: Oh, okay. Yeah. So, I don’t know what the blood gases are now.
Patrik: Yeah, that’s okay. That’s okay.
Lloyd: I could ask.
Patrik: Definitely. But I would say oxygen concentration 40% is a little bit too high. The tidal volume 380, what that means is it’s the volume she’s breathing per breath. With a weight of 176 pounds,
that should be more around 500 to 700 mils.
Lloyd: So, should they not try to-
Belle: Is that the work she’s doing or is that the work the machine is
doing?
Patrik: I believe it is the work that she’s doing. But what I can’t see from your text, Lloyd, is what ventilation mode she’s in. I think it’s a pressure-
Lloyd: How do I see that on here?
Patrik: If you can send me a picture, that would be best.
Lloyd: Okay. I took the picture and I’m trying to send it, so I’m going to do my best right now to see if I just have-
Patrik: Yeah, it’s here now. Yeah. No, she’s under pressure support. You can see on the top PS CPAP (pressure support/ continuous positive airway pressure). So that means all the effort is coming from her. All the effort is coming from her, which is good, but it’s just a little bit too low with the volumes, I argue. Just a little bit too low.
Patrik: That’s a good
question. It would mean that pressure support potentially would need to be increased. That would probably get the volumes up, another option, but then that would potentially set her back a little bit in terms of getting off the ventilator. The other question that I have, is she still sedated?
Lloyd: No, she’s not
sedated at all. What was it, yesterday or the day before they gave her oxy in the morning? But she hasn’t been sedated since.
Patrik: Right. That’s good.
Lloyd: And so, we asked because when we spoke to the respiratory therapist, the other one of them said she should overnight have the machine breathe for her so that it’ll rest for her. But then when I talked to the doctor this morning, he said no, since she’s doing all the breathing, he wants her to continue to do the breathing.
Patrik: Right. Yeah. No, that’s good. To a degree, I like it. Are they sitting her out of bed? Are they mobilizing her?
Lloyd: No, I actually sat her up today on my own. I took the initiative and put it… She was awake. I noticed that when I sit her up, she’s more awake
than when she’s inclined. She’s like at a… I don’t know. Is it 30% inclined?
Patrik: Yeah. Yeah. 30%. Yeah. Yeah.
Lloyd: We don’t
want to slant her back, but not slant back. But today, earlier today, I just sat her up straight. She could sit, like sitting up as if someone could eat or something. She was alert and awake for a good amount, given that she wasn’t awake the last day or two at all. So, we’re just hoping that tomorrow it’ll work out. If they do it tomorrow, the respiratory therapist that was here said that he would keep an eye on her and he would try to do his best to help her, just to make sure that everything’s
done the way it should be done.
Patrik: Yeah. Yep. Look, I would say that she has a very good chance of coming off the ventilator, but I also think she may need a tracheostomy, at least in the short term until they’ve established whether she can swallow or not. Do you think that the tube is bothering her?
Lloyd: No, not right now. I mean, she’s used… I can’t tell, but I don’t think it is. I don’t know for sure, but she doesn’t-
Belle: The feeding tube or the breathing? Which tube? Which tube are we talking about?
Patrik: The breathing tube. The breathing tube in the mouth.
Lloyd: Oh, the vent?
Patrik: Yes.
Lloyd: I think she’s gotten used to it because otherwise her rates would be going high. Usually, I was asking them how I would know that she was in pain, and they said that the machine… Her breathing
and her heart blood pressure, everything would go wacko if she was in pain.
Patrik: Right. Right. Okay. So, look-
Belle: Do you think
it’s worth the risk to do the removal tomorrow, or should we wait? You’re thinking she needs the trach no matter what.
Patrik: Well, let’s put it that way. I argue that the volumes are too low. I think with those volumes, I do believe she’ll be set up for extubation failure. She would need to have spectacularly good
blood gas with the settings, and I doubt that she’s got spectacularly good blood gas with those numbers. I could be wrong. I mean, you always have to look at the numbers first. But if you’re telling me she’s 176 pounds, those volumes are too low. Oxygen is still at 40% room air. The air that you and I are breathing is 21%. So, she’s getting 40%. For extubation, it usually suggests 35% or less, right?
The other thing is that pressure support is fine. If her volumes were 500 or more, I’d say, “Yep, let’s extubate her,” but assuming the swallow would be there. So, I would think a tracheostomy… The last missing piece for me is really the arterial blood gas. It’s the last missing piece for me. Let’s assume she can’t swallow for now. Let’s not to say it’s permanent. Let’s assume she can’t swallow for now. Let’s assume her arterial blood gases are average,
then I’d say she probably would need a tracheostomy at least temporarily to determine what the next steps are.
Belle: So, the key is they need to take the blood tomorrow. They never mentioned that they’re going to do that, but that’s really a requirement before they even attempt it. They need to check those things. Is that what you say?
Patrik: I would argue. Yeah.
Lloyd: Okay. I can ask them if they have them tonight and then I could send them to you.
Patrik: Oh, absolutely.
Lloyd: Is that okay?
Patrik: 100%.
Lloyd: Okay. I’ll see if they have them and I’ll try to send them to you. I just don’t know how to approach this tomorrow.
Patrik: Well, you can-
Belle: Look, do we have a hard stop in two minutes? Do we have a hard stop in two minutes?
Patrik: Yes, we do. We do. But we do need to stop in two minutes, but I
can be back in about half an hour. I just need to jump on another call for half an hour. I can be back at 9:00 PM your time for another half an hour and then later in the day as well, but I know then it’s getting late for you.
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