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 last week was
CASE STUDY: My Mom has been in ICU ventilated with a breathing tube in an induced coma for 5 days, is a tracheostomy too early?
You can check out last week’s episode by clicking on the link here.
In this
week’s episode of “YOUR QUESTIONS ANSWERED“, I want to answer another question from one of our clients which is an excerpt from a 1:1 phone counselling and consulting session with me and the question this week is
My Mom has ventilator associated Pneumonia and is on the ventilator in Intensive Care! I don’t want her to have a tracheostomy, will she cope being extubated and on BIPAP (PART1)?
This is another great case study where I have helped a very concerned daughter who had her Mom in ICU and guided her in the right direction because of my insights and
experience.
Mandy writes
Hi Patrik,
my 78 year old Mom is in Intensive Care, ventilated with a breathing tube and in an induced coma. She was admitted to Intensive Care after she had a fall in the nursing she’s residing at.
She got intubated and then
eventually developed a ventilator associated Pneumonia* after about a week on the ventilator and in the induced coma.
(*Ventilator-associated pneumonia (VAP) is a type of lung infection that occurs in people who are on mechanical ventilation
breathing machines in hospitals. As such, VAP typically affects critically ill persons that are in an intensive care unit (ICU). VAP is a major source of increased illness and death)
They are now trying to get my Mom out of the induced coma to get her extubated, but she keeps failing to breathe by herself and she keeps failing her CPAP trials. (CPAP is a spontaneous ventilation mode, often leading to the removal of the breathing tube = extubation)
The attending physician thinks this is caused
by weakness and thinks the pneumonia is a non-factor. But my mother's decreasing white count makes her think that the pneumonia is resolving; she said that x-rays wont'show the improvement for a while.
Have you seen an elderly patient with ventilator-associated pneumonia – that has also failed CPAP trials – thrive on BIPAP and resolve their respiratory distress after being extubated (=removal of the breathing tube)?
Related article/video
Also, if she keeps failing extubation (=removal of the breathing tube), can the need for a short term tracheostomy be predicted. How long does a tracheostomy site take to heal in the
elderly?
Also, if my Mom needs a tracheostomy, what type of infections trend with tracheostomy patients especially elderly, and how are they addressed? My mother is bedridden with contracted hands caused by dementia/prolonged delirium from UTIs (=Urinary tract infection).
In addition to having a chronic foley catheter, my mother has a feeding tube that has helped sustain her weight. She has
consistently asked for and swallowed water at the nursing home.
Tracheostomies appear laborious, how soon can someone speak after receiving one, IF they have been intubated for ten or more days?
Next, what type of end of life comfort can be initiated in ICU and how does it transfer with a patient to hospice?
If all of the above fails,
could re-intubation with sedation be a humane transition to hospice?
Many thanks
Mandy
Here is my answer
Hi
Mandy,
thank you for being a client and thank you for signing up for 1:1 phone and email counselling and consulting with me.
From everything that you are describing and from all the information that
you provided I can see the following.
If your mother is failing the CPAP trials, she may not be quite ready to be extubated (=removal of the breathing tube).
CPAP is a spontaneous breathing mode on the ventilator and is usually
the last step before a critically ill Patient can be taken off the ventilator and the breathing tube can be removed.
Before your mother can be extubated she also needs to start obeying simple commands like squeezing fingers, she needs to be able to have a good strong cough so that she can protect her airway once she’s off the ventilator.
On top of that, she needs to have adequate oxygenation and her oxygen saturation should ideally be >92% with
satisfactory ABG’s (=Arterial blood gases).
In the arterial blood gas, her PO2(=oxygen levels in the blood) should ideally be >60 mmHg and PCO2 (=Carbon dioxide levels in the blood) should be ~35-45 mmHg.
Your mother should also show to be able to take good tidal volumes(=mls per breath) on the ventilator and she should be able to take breaths around 7-10
mls/kilogram.
I also hope that they have done some chest Physiotherapy to strengthen your mother’s ability to get off the ventilator, which would be particularly important if she’s contracted with already limited mobility.
Also, if she continues to be failing the CPAP trials, they may just need to wait a few more days until your mother is more awake after the induced
coma.
Especially in elderly Patients, coming out of an induced coma can take a little longer, despite your mother being off sedatives for a few days.
This article/video here describes this process
We also have some Ebooks around this topic
Therefore, a few more days of being
patient might just help your mother to avoid the tracheostomy.
Also, the longer a critically ill Patient in Intensive Care stays ventilated, the higher the risk for a ventilator associated Pneumonia (VAP).
I do strongly believe that getting your mother off the ventilator and extubated (=removal of the breathing tube) is the right thing to do, besides the Pneumonia.
If for whatever reason she’s struggling to breathe, they can always put her on the BIPAP (=BIPAP is a form of non-invasive ventilation with a face mask) as you have suggested.
By not giving her the chance to breathe without the breathing tube first, a tracheostomy might be a little premature.
There is a risk that despite
the BIPAP mask your mother needs to be re-intubated (=insertion of the breathing tube) and then have a tracheostomy.
But not giving her a chance in the first place and maximize chances to get her off the breathing tube would not be in your mother’s best interest.
Also, once she’s off the ventilator and the breathing tube, they need to continue chest Physiotherapy and look at things like giving her nebulizers to loosen up secretions on her chest, especially in light of the ventilator associated Pneumonia!
Mobilization and getting your Mom out of bed would be critical too and would improve her ability to breathe!
If BIPAP, chest Physio, mobilisation and nebulizers don’t help and your mother has to go back on the ventilator with a breathing tube, then you know for a fact
that she will need a tracheostomy.
Hopefully this then will only be a short-term tracheostomy and just what I described above with Chest Physiotherapy, mobilization and nebulizers should continue.
The main advantages of a
tracheostomy are
- No sedation is needed as a tracheostomy is mainly pain free and not as uncomfortable as a breathing tube
- The ability to suction secretions via the tracheostomy tube
- The ability to ventilate your mother intermittently and when needed, therefore increasing chances to wean your mother off the ventilator in her own time
- Starting to talk with the aide of a speaking valve and with speech therapy
Please also check out these related articles/videos here
If the ICU is doing all the right things, your mom hopefully can come off the ventilator within a few days and then they would be working on removing the tracheostomy.
This again all depends on whether your Mom has a strong cough so that she can protect
her airway without the tracheostomy!
Once the tracheostomy has been removed, the tracheostomy site usually heals within a few days.
Also, if a tracheostomy is well looked after, if the skin is being kept clean, if the inner tubes are changed regularly and if either humidified air or oxygen are applied, there tends to be less infection risk compared to a breathing
tube.
If for whatever reason she does get another infection, they would be treated with antibiotics if there is bacterial growth.
There is definitely a risk of aspiration with a tracheostomy, therefore the tracheostomy will need to be blocked with an air balloon so that no gastric content can enter the lungs.
Once your mother is more
stable, they should be able to get the air balloon down and do some speech and swallowing exercises.
Tracheostomies can be laborious, but they are way more Patient friendly compared to breathing tubes stuck in the mouth.
Next, you are asking what type of end of life comfort can be initiated in ICU and how does it transfer with a patient to hospice?
Normally what happens is that ICU’s either initiate end of life care in ICU if they think it’ll be a relatively quick death.
If they think it might be a prolonged end of life situation, they might offer hospice care, but it also depends on the availability of a hospice bed.
Related article/video
If they do send Patients to a hospice,
they tend to send them without a breathing tube and without a ventilator.
From my perspective and from my experience, if your mother will end up with a tracheostomy you may want to check out INTENSIVE CARE AT HOME.
INTENSIVE CARE AT HOME from my perspective and from my experience is usually the best option and if needed, end of life care could be provided at home as well!
