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Today’s article is about, “Can My Boyfriend Have A
Tracheostomy On 40% FiO2 (Fraction Of Inspired Oxygen) And PEEP (Positive End-Expiratory Pressure) 5? Live Consulting For Families In ICU!”
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Can My Boyfriend Have a Tracheostomy on 40% FiO2 (Fraction of Inspired Oxygen) and PEEP (Positive End-Expiratory
Pressure) 5? Live Consulting for Families in ICU!
Patrik Hutzel: Hi, Nic. Welcome to the show. How can I help you?
Nic: Hi, how are you?
Patrik Hutzel: I’m very well, thank you. How are you?
Nic: Good. So, I’m out of state, and I was calling in getting updates morning and night, and then me and his family had a little argument. They banned me, basically, from the hospital, from everything.
Patrik Hutzel: Yeah.
Nic: So, all I know right now is lung infection. He’s been in there for 2 weeks. He is on the breathing tube still. It is not pneumonia. They tried to get him off of the tube, and they just
did it like cold turkey. They didn’t wean him off or anything. He freaked out and his blood pressure went sky-high, and they had to put him back on the ventilator with 100% oxygen.
Patrik Hutzel: Okay. Thank you. This is good that you’re explaining that because therein lies the answer why, (A), they can’t extubate him yet, and (B), why they probably haven’t discussed a tracheostomy yet either. If
he’s on 100% of oxygen, it wouldn’t be safe to (A), extubate him, and it wouldn’t be safe to, (B), do a tracheostomy. Do you know what I mean when I talk about a tracheostomy?
Nic: Yes, yes. He actually right now is only on 40% oxygen.
Patrik Hutzel: Okay.
Nic: They’ve got him down to 40%, but it’s the lung infection that is making it difficult. But he is breathing along with the tube, they said.
Patrik Hutzel:
Okay, so he’s breathing, but he’s not waking up.
Nic: Right. Yesterday, he actually opened his eyes but he’s not responsive.
Patrik Hutzel: So, opened his eyes, but he’s not responsive. Okay. They stopped sedation.
Nic: No, he’s still sedated.
Patrik Hutzel: Okay. It’s been two weeks now, has it?
Nic: Yes.
Patrik Hutzel: There’s nothing else besides the pneumonia that you’re aware of?
Nic: Correct.
Patrik Hutzel: Okay. So if he’s now on 40% of oxygen, that’s one
ingredient to do a tracheostomy. But there are other ingredients too. So, for example, he would be on a PEEP (Positive End-Expiratory Pressure), and I don’t want to get too medical here, but if he was on 100% of oxygen, there’s a
very high chance that he’s got a high PEEP.
Nic: Yes.
Patrik Hutzel: If oxygen is
not less than 40%, and if PEEP is not less than 10, it wouldn’t be safe to do a tracheostomy. So, that’s where the delay might be to do a tracheostomy. Because I don’t know how much research you’ve done, but after about 2 weeks of mechanical ventilation and the inability to wean, it is recommended to do a tracheostomy, if that makes sense. Are you following?
Nic: Yes, I’ve been doing a ton of research, of course. Yes, I figured that was the next step. Because 2 weeks is, I’m thinking, yeah, at that point. But as far as I know, they have not mentioned that.
Patrik Hutzel: Right, okay. How long ago was it that he was on 100% of oxygen? How long ago?
Nic: I’m sorry?
Patrik Hutzel: You mentioned earlier he was on 100% of oxygen.
Nic: Yeah, that was 5 days ago.
Patrik Hutzel: 5 days ago. Okay, so now he’s down to 40%.
Nic: Yes.
Patrik Hutzel: Okay. Again, a lot of it depends now, what is his PEEP like? If PEEP is less than 10 and oxygen is less than 40%, they should be getting very close of doing a tracheostomy, given that I’m hearing he’s not waking up.
Nic: Okay. Now, you are not really for tracheostomy, correct?
Patrik Hutzel: Well, I tell you what it depends on. A tracheostomy can be a wonderful thing.
A tracheostomy has their time and their place. A tracheostomy is also in the context of which country. I presume you are in the United States?
Nic: Correct.
Patrik Hutzel: Right. So I tell you why it really depends on circumstances and the country. So, in countries like Australia or in the U.K., a tracheostomy is often being placed with the goal to wean a patient off the ventilator as quickly as possible. That, I believe, is the original purpose of a tracheostomy, and that’s a good purpose.
In the United States, however, if your fiancé, I think it was, is going to have a tracheostomy, they will try and send him to an LTAC (Long Term Acute
Care) as quickly as possible. I’m very opposed to that. I’m very opposed of a tracheostomy being used to send patients to LTAC. That is unique for the United States. Do you know what I’m talking about? Do you know what I mean by LTAC?
Nic: I’m not, no. I don’t know what LTAC is exactly. I have no idea.
Patrik Hutzel: Sure, sure. So, in the United States in particular, a lot of patients
in ICU end up with a tracheostomy if they can’t be weaned off the ventilator, they end up with a PEG (Percutaneous Endoscopic Gastrostomy) tube, and then ICUs want to send them out to an LTAC. LTAC stands for Long-Term Acute Care facility. From my experience, it’s not even the better version of a nursing home. Therefore, patients go to LTAC simply to save the health insurance money, and to save the ICU or to free up a bed in ICU, which they so desperately need, but
it’s not designed for clinical care. Then patients go to LTAC and then nothing’s happening.
Families get sold on LTAC, where ICUs are saying, “Oh, your family member goes to LTAC, they are specialized in weaning patients off the ventilator.” I say, “Well, that’s a whole lot of nonsense.” Just look up LTAC reviews online. Just look them up. They’re shocking. Absolutely shocking.
We are getting phone calls every week from families in LTAC saying, “Please help me to get my loved one back to ICU.” They’re finding out too late that it’s all designed to save money, but not for clinical care. So that’s the bottom line, unfortunately.
That’s why it’s so important that families are informed about
the next step. So I am not opposed to, if the ICU where your family member is at, if they’re using the tracheostomy to wean him off in the ICU, fantastic. Job done. Fantastic. If they are using the tracheostomy to send him to LTAC, ooh, red flags. Red flags everywhere.
Nic: Okay. How do I find out what the purpose of the tracheostomy will
be?
Patrik Hutzel: Good question. Just by simply asking them, what’s your plan? There’s also what we’ve seen over the years, Nic, is we’ve seen a lot of bait and switch. So, what I mean by that is, again, ICUs are talking to families and saying, “Oh, your family member should have a tracheostomy to wean your family member off the ventilator.” That’s great. That should be the purpose of a tracheostomy.
But what they’re not saying is, once they do have a tracheostomy and a PEG, I’ll
talk about the PEG separately in a minute, that the ultimate goal is to send them to LTAC. That is wrong, in my mind, that is absolutely wrong.
But there is a way to potentially work around that, that we’ve found out through trial and error. So, let’s just say your family gets approached about doing a tracheostomy for your loved one. Often they also ask for a PEG tube. And our advice is
tracheostomy, yes, if the patient gets weaned off the ventilator as soon as the tracheostomy has been done, because it is easier to wean off the ventilator with a tracheostomy than with a breathing tube after a certain period of time, i.e., sort of the two-week cut off, the two-week mark. But do not give consent to a PEG tube.
Nic: So, with the tracheostomy, is that for oxygen or is that just for food source?
Patrik Hutzel: Ventilator. Tracheostomy is just
ventilation.
Nic: Oh, it’s for ventilation. Okay.
Patrik Hutzel: So currently,
your loved one is ventilated through a breathing tube in the mouth that’s going into the lungs. That’s very uncomfortable.
Nic: Oh, okay.
Patrik Hutzel: A tracheostomy sits in the neck. It sits in the neck, in the lungs, and it’s much easier to tolerate. Much easier to tolerate. That’s why sedation and opiates can come off straight away most of the
time.
Nic: Okay.
Patrik Hutzel: One of the reasons your family member is sedated
and on opiates at the moment is because of the discomfort that the breathing tube is causing.
Nic: I get it. Okay.
Patrik
Hutzel: Right?
Nic: Okay.
Patrik Hutzel:
That’s why I’m sort of saying, I know for anyone watching you sometimes may wonder if you watch my videos, are you for tracheostomy? Are you against the tracheostomy? And I go like, a tracheostomy is a wonderful thing for the right patient at the right time. Tracheostomy can be a terrible thing for the wrong patient at the wrong time.
Nic: I see. Okay.
Patrik Hutzel: It’s not a one size fits all. Because I have an international audience here, it is also dependent on the
country.
Nic: Okay. Okay.
Patrik Hutzel: I argue absolute no to PEG tube in this
situation. In this situation. Not, like I mentioned, if someone, God forbid, has a high spinal injury, has motor neurone disease, has cerebral palsy, has SMA (Spinal Muscular Atrophy), a PEG tube is inevitable. But in your loved one’s situation, I don’t think he needs a PEG tube at this stage, from what you’re sharing with me.
Nic: Okay. So with the tracheostomy, then he has to have a PEG tube? A PEG?
Patrik Hutzel: No, no.
Nic: No. Okay.
Patrik Hutzel: Definitely not. Definitely not here. So this goes even deeper. This goes even deeper now. So let me talk about the PEG
tube. So currently, your loved one would most likely have a nasogastric tube, which is a feeding tube in the nose going into the stomach. They would get nutrition through that.
Nic: Yeah.
Patrik Hutzel: Okay. That’s perfectly fine. It’s a temporary device, and that’s perfectly fine. Now, again, in the United States, this is very unique to the United States, when patients
or families are being asked to consent to a tracheostomy in ICU, they’re also often being asked to give consent to a PEG tube. I don’t know whether you were here a minute ago when I read out the email from James, who talked about his mom having a PEG tube and nobody informed him what it really is. I don’t know whether you’ve heard me read out the email and comment on that because that sort of illustrates the issue about the PEG tube.
So, the issue with the PEG tube is, (A), it requires surgery. It’s sort of a minor surgical procedure, but at the end of the day, it’s still surgery. It gives health professionals a perception of, “Oh, this person will never eat and drink again because they’ve got a PEG tube.” That is the perception, unfortunately. No one will bother trying to wean someone off the ventilator, wean someone off the PEG tube, to get them to breathe again, and eat and drink again.
Whereas, if you keep the nasogastric tube in, the nasogastric tube gives the perception of it’s a temporary device, we need to wean this patient off the ventilator, need to take the nasogastric tube out, and start eating and drinking again.
So, a lot of what’s happening in ICUs in the U.S. in particular is based around the pathway the insurances have laid out. The pathway the insurances have laid
out is, well, a couple of weeks in ICU, if they can’t be weaned off the ventilator, let’s do a tracheostomy and let’s do a PEG, and let’s send them to LTAC where it’s much cheaper to look after them. But they’re missing critical steps. The critical steps
that they’re missing is, have we tried hard enough to avoid the tracheostomy and the PEG and wean them off the ventilator?
So that brings me,
again, in comparison to other countries, other English-speaking countries, Australia, the U.K., but many European countries, LTACs don’t exist. So, the ICUs are under pressure to wean someone off a ventilator. They are under real pressure. They make it happen most of the time. Whereas in the U.S., I believe there’s complacency in ICUs now because they’ve got the LTACs on the other end.
So it’s a
very complex, it’s a minefield. It’s a real minefield. Having worked in multiple countries, Nic, I argue in most English-speaking countries, Australia, the U.K., New Zealand, Canada even, the number of patients with a PEG tube in ICU is minimal. The number of patients with a PEG tube in the U.S. in ICU is huge.
Nic: Wow.
Patrik Hutzel: For no good reason.
Nic: Wow.
Patrik Hutzel: The reason is to keep the ICUs satisfied and keep the LTACs satisfied and keep the insurances satisfied. Well, what about patient
outcome?
Nic: Right. They’re not looking at that. They’re looking at money side.
Patrik Hutzel:
They’re looking at money side. It’s shocking. It is
absolutely shocking.
Nic: Wow.
Patrik Hutzel: Just this week alone, we helped two of our clients, with our advocacy, to go from LTAC back to
ICU.
Nic: Oh, wow. Wow. Good for you. Good for you.
Patrik
Hutzel: But that should never happen in the first place.
Nic: Never happen.
Patrik
Hutzel: It should have never happened in the first place.
Nic: Exactly. Exactly. Oh, that’s horrible.
Patrik Hutzel:
So, the system is flawed beyond anything that anyone can comprehend, I believe. But at least you’ve now got an overview of what questions to ask. What I can see with the information you’ve given me, Nic, probably yes to a tracheostomy. Probably yes to that. No, to a PEG tube.
Here is another thing that’s important. We have found that if families stay away from giving consent to a PEG
tube, let’s just say a tracheostomy is needed, and the ICU is pushing you to do a PEG as well, well, just stay clear of the PEG. That in and of itself is often enough for patients to stay in ICU and not go to LTAC. Here’s the reason why. Most LTACs cannot take patients with a nasogastric tube. They can’t look after it. Which should tell you everything about the skill level that you’re getting there. It’s nonexistent.
Nic: Oh my gosh. Oh my gosh. Okay. I feel like now, since it’s been 2 weeks, he’s overdue. They’re probably already thinking about-
Patrik Hutzel: Yeah, he’s
overdue. He’s probably overdue.
Nic: Right. Right.
Patrik Hutzel:
But the reason he’s probably overdue is simply his ventilation needs have been so high that no surgeon would touch him to do a tracheostomy. The risk of a patient dying on the operating table, doing a tracheostomy on 100% of oxygen, is too high.
Nic: Okay, I see.
Patrik Hutzel: It makes sense to me.
Nic: Okay. Makes sense.
Patrik Hutzel: It makes sense to me. They’re erring on the side of caution.
Nic: Okay. Okay.
Patrik Hutzel: Most likely.
Nic: How long can a patient stay in the ICU for
months?
Patrik Hutzel: Years. I’ve seen up to 18 months.
Nic: Oh my gosh. Okay.
Okay. Okay. So no PEG. Just no PEG.
Patrik Hutzel: Well, look, the sooner your family member can get off that ventilator, whether with or without a tracheostomy, the better. Time is of essence. You don’t want somebody to stay in ICU for 18 months. You don’t.
Nic: Right. No, of course not. Of course not.
Patrik Hutzel: But we’re talking about extremes here.
Nic: Right, okay. Now, I guess they’re just waiting for the infection to clear up, I guess. But keeping him on the ventilator is scary.
Patrik Hutzel:
It’s a little scary.
Nic: I read so… Yes, yes. They’re concerned a little bit about his brain activity as well. Because when they took him off the ventilator, they were telling him, raise your finger,
or raise your foot. He was too busy freaking out to be able to even do anything like that.
Patrik Hutzel: Yeah. The reality is that most patients, when they eventually come out of the coma, they’re confused, they’re agitated, they’re hallucinating. Unfortunately, a recovery process, what your loved one is going, it’s not going to be straightforward. Very rarely is it straightforward. So the next challenge lies ahead once he’s off the ventilator.
Nic: Right. It’s like a whole another big obstacle after the ventilator.
Patrik Hutzel: That’s right. That’s right.
Nic: Okay.
Patrik Hutzel: That’s why timing is so critical.
Nic: Yes.
Patrik Hutzel: The longer it goes on, the higher the risk for complications, of course. But on the other hand, a lot
of patients have come through this fine as well. But it’s not… It’s a struggle, let’s call it for what it is. It’s a struggle.
Nic: Right. Well, I’m going to be there for him. So, we’ll get through it. We’ll get through it.
Yeah.
Patrik Hutzel: That’s the right attitude to have, that you will get through it. It’s one of the biggest challenge that I believe families can ever experience. It’s terrible. It’s not for the faint of heart.
Nic: It’s literally the scariest thing I’ve ever been through. Like I said, I’m not even in the same state. It just makes it horrible.
Patrik Hutzel:
Of course.
Nic: But I appreciate you so much. I binge-watched all your videos, and I can’t believe I caught you live right now. It was meant to be. I truly appreciate your time and thank you. Thank you so much.
Patrik Hutzel: It’s a great pleasure. All the best to you and your family, Nic.
Nic: Thank you
so much. You have a good night.
Patrik Hutzel: Same to you. Thank you.
Nic: Thanks. Bye.
Patrik: Bye.
