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 ICU with swallowing difficulties and failed extubation
attempts. He is asking how his mom can avoid aspiration pneumonia in ICU.
Lloyd: All right. So, it didn’t work out the way we were hoping it would work out. So, I think what she has is
something called dysphagia.
Patrik: Sure.
Lloyd: And so, the last time she had a similar symptom where she was, I think we explained
last time that they put a trumpet tube so that it could clear out and then they didn’t want to do it this time. They were just like, there’s going to be a risk for, oh, aspiration or food going down the wrong throat or whatever. And so, we were telling her that we just wanted to go ahead with the tracheostomy.
Belle: I think Patrik needs a little more details about how it happened. Because she was doing much better over the last few days. The doctor went from not
wanting to try it to this morning saying, we’re going to give it a shot, because she was getting stronger. You want to go over the vitals?
Lloyd: Yeah. She was able to kind of flicker, move her fingers and her toes, and she’s been very alert. She’s been staying up a lot of the day. She’s following
commands. She’s tracking and she was doing pretty well.
Belle: And very minimal suctioning.
Lloyd: Yeah, very little mucus, that sort of
stuff.
Belle: The problem was that she was having difficulty while…
Patrik: And how did-
Lloyd: Well, when they saw that, because what they did was they saw that she had this, almost like when you have a snoring thing, they were saying that she was having trouble breathing. I mean, we saw her and it’s, yeah. So, what he did was he pulled the jaw
out and I see it went away, once you pulled the jaw out, it opened the airway.
Belle: This is what you got to explain the timeline, because they removed the tube successfully and there was no issue other than she
couldn’t…She was coughing, she had a strong cough. She was bringing up mucus, but the mucus was sitting there. I guess she couldn’t spit it out or whatever the next step is. And in order for her to breathe fully, the doctor was pulling on her jaw. Can you describe that incident? I don’t remember how-
Lloyd: Yeah, she was pulling it out so that, yeah, she was pulling her jaw out so that I guess the tongue and the back of the throat, whatever it is, kind of separation. I’m sure you know what that is. And they said that she couldn’t, they didn’t want her to continue like that. And so they said they had to put the tube back in.
Patrik: I see. Okay. And how long did that take from extubation to reintubation? What timeframes are we talking about?
Lloyd: Well, they had to give her pain medications. I guess they kicked us out. So, we don’t really know exactly.
Belle: The decision was made in 10 minutes. The decision or the actual procedure? Because the
decision was made very quickly.
Patrik: Right.
Belle: Within minutes.
Lloyd: Yeah. I mean, yeah, within 10 minutes.
Belle: He was very serious. The doctor was not fooling around. He wasn’t saying, do you want me to do it? This is not safe. We need to do it.
Patrik: Okay.
Belle: It was not, he wasn’t asking our opinion.
Patrik: Okay. I see. Okay. And from the time of extubation until reintubation, how much time passed?
Lloyd: Well, they did it right away. I guess they were numbing her. So, it must have been within, I would say within another 10 minutes or 15
minutes. We were out of the room. So, we couldn’t see the sequence of events. But the whole thing might have taken over 40 minutes, I guess, before we were able to come back into the room.
Lloyd: Just like a regular oxygen mask. But they didn’t want to try BiPAP on her.
Patrik: Right. Do you know if they’ve done an arterial blood gas after extubation?
Lloyd: I do
not.
Patrik: Right.
Lloyd: I do not. Yeah.
Patrik: Okay.
Lloyd: But they did say that if she gets to tracheostomy that they’re confident that she’s not going to need the vent-
Patrik: Yeah I-
Lloyd: He was pretty adamant about, well, he seemed adamant about that.
Patrik: I agree with that. I understand what they’ve done, they pulled the jaw out. It’s called the jaw thrust. I get that. Did they use what’s called a Guedel airway? Did they put something in the mouth to keep the airway open? Did they put something in?
Lloyd: No.
Patrik: No. Okay.
Belle: Not that we saw, but, and I asked them if they could put the
trumpet tube back like they did last time. He said, oh, like I said, he didn’t want to do it. He just thought that was going to be, at least until the tracheostomy, and he didn’t want to do it. She was just not having it.
Belle: He said it would keep delaying the inevitable.
Patrik: Sure.
Belle: He said it would work. It’s just that it would delay the inevitable. And the doctor is hung up on the fact that she cannot swallow.
Patrik: Sure.
Belle: She can’t swallow and doesn’t want to give her a chance to swallow.
Patrik: I see. Okay. Look-
Lloyd: And to add insult to injury, tomorrow’s going to be another attending day. Today was his last day.
Patrik: Yeah, sure. Yeah. Monday is often the change-over day. Okay. I see. Okay. So look, I guess given that she had two failed extubation attempts, I do believe the argument has been made for a tracheostomy if they are so certain that she can’t swallow, right? I mean, the only question that I have here is if she can’t swallow, was there coughing? Was she coughing after extubation? Could you
see?
Lloyd: Yeah. I mean, she was coughing.
Belle: The doctor said she coughed very well. The doctor was happy with her coughing. The
reason she wasn’t happy with the cough is that it actually brought up mucus from way down and she couldn’t get rid of it. But he was glad. He said the coughing was great.
Patrik: Okay. Because if she can’t swallow and she has a good strong cough, that could prevent everything that they’re trying to prevent, which is
aspiration. If she can’t swallow, the biggest risk is aspiration so that her saliva is going into the lungs and causes an aspiration
pneumonia. But anyway, look-
Lloyd: How do you treat the aspiration pneumonia?
Patrik: Oh, you don’t want to-
Lloyd: If she does get it, is that treatable?
Patrik: You don’t want to treat it to begin with. I mean, you want to avoid it to begin with. This is the thing. If they’re saying she can’t swallow, I agree that she needs a trach at least until her swallowing can be assessed better. And her swallowing can be assessed better if she has a trach in, as opposed to assessing the swallowing whilst she’s having a breathing tube in the mouth. The simple reason for that is that a trach is much more
comfortable compared to a breathing tube in the mouth. And one way to test the swallowing is you can deflate the balloon at the back of the throat and then, with the speech therapy, you can assess whether she can swallow or not. And that is so much easier with a trach. But the risk due to-
Patrik: To answer your initial question, how do you treat an aspiration pneumonia? Well, you don’t want to treat it to begin with, because if someone, let’s just say they would’ve kept your mom off the ventilator, and she would’ve ended up with an aspiration pneumonia at that stage. She would need reintubation anyway. But you don’t really want to get to that place in the first place, if that makes sense.
Lloyd: Yeah. Well, I’m just asking.
Patrik: Yeah, sure.
Lloyd: If she swallowed
some saliva today and the doctor was intimating, that she may have swallowed some stuff, but they couldn’t get everything. They couldn’t like suck everything up. So, they don’t know. But I was just like-
Patrik: I-
Lloyd: I just want to make sure. Go ahead.
Patrik: I argue they do know. And I’ll tell you why. So, after reintubation, they would’ve done another chest x-ray.
Lloyd: Okay.
Patrik: So they would see in the chest x-ray whether she aspirated or not.
Lloyd: They did another chest x-ray. Let me pull it up
Patrik: Right.
Belle: And if she aspirated, does that guarantee pneumonia, or?
Patrik: No, it’s not guaranteed. But I guess for someone as critical as your mom, I’d say chances are very high.
Belle: Endotracheal tube terminate approximately 4.9 centimeters above the carina. Enteric tube courses below the diaphragm with
tip collimated from view. The cardiomediastinal silhouette is stable. No significant interval change, in mild bibasilar opacities, atelectasis versus pneumonia. Probable small left pleural effusion. No discernible pneumothorax. I will email this chest X-ray result.
Patrik : That would be great if you can send an email. Especially, I would be curious about what they’re saying about the pneumonia. Can you email it to …
Patrik: Yeah, that’s all right. Can you just read out again what they’re saying there about the pneumonia?
Belle: Oh, well, it says, “The cardio mediastinal silhouette is stable. No significant interval change, in mild bibasilar opacities, atelectasis versus pneumonia. Probable
small left pleural effusion. No discernible pneumothorax.”
Patrik: Okay. Yep.
Belle: I can send it. I can email it to you.
Patrik: I don’t know whether you can see what I just sent there? If you can email it to that email address, support@intensivecarehotline.com.
Belle: Okay.
Patrik: If you can email it to support@intensivecarehotline.com.
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.
