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 Husband Showed Great Improvement In Trying To Wean Him Off The Ventilator. Why Can’t He Be Totally Removed From It?
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 Rebecca as part of my 1:1 consulting and
advocacy service! Rebecca’s husband is ventilated in the ICU, on weaning treatment from CPAP then now back on SIMV and is asking about the reason why he is not getting off the ventilator.
My Husband is with COPD in the ICU. Will He Be Able to Wean Off the Ventilator?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Rebecca here.”
PART 1
Rebecca: Patrik?
Patrik: Yes. Hi Rebecca. Thank you-
Rebecca: Hi.
Patrik: Payment, so thank you so much.
Rebecca: The doctor is here right now.
Patrik: Right, okay. Well, that’s good. So how do you want to proceed? Should we just start talking to him and ask him? We can do that right away now, if you like.
Rebecca: Okay. Actually, just real quick. Let me see.
Patrik: I’m ready, I can…
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Rebecca: Okay, let’s see if we can talk now. Doctor A, I have my cousin on the line. My cousin. We have to ask you a couple of questions. Is that okay?
Doctor A.: Oh, okay hold on.. please excuse me.
Rebecca: Okay, hold on. Patrik?
Patrik: Yeah.
Rebecca: Patrik?
Patrik: Yes.
Rebecca: Okay, here’s Doctor A.
Doctor A.: Yes, what can I do for you?
Patrik: Okay, I was talking, I’ve been talking to Rebecca over the last few weeks, you know, and we’ve got some concerns around, you know, it sounds like her husband isn’t moving forward in terms of getting off the ventilator. He’s been sort of going from CPAP to SIMV from what I understand.
I’m an intensive care nurse by background. And we were just wondering, you know, how far away he seems from getting on to the T-Piece.
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Doctor A.: Oh he’s a ways away from T-Piece.
Patrik: Right. And why is that?
Doctor A.: He had CO2 values that went up to 113.
Patrik: Right.
Doctor A.: And when he’s on C-
So that’s lethal, so now we’re talking about the feasibility of proceeding with CPAP knowing that he has the potential to go that high. I usually use the analogy of a two year old child next to a pool. Now you could go in and put some water on the stove and come out and the kid might be walking on the side of the pool, and you’re pretty good. But one day you’re gonna go in, put the flame under the pot, and you’re gonna come out and the kid’s gonna be drowning in
the pool. So, as long as you know that that’s the risk, then you decide if it’s real important to go in there and put the flame under the pot of water. So the analogy I’m giving you is because when he was on the CPAP, he gave no warning signal that his respiratory rate was at, or his CO2 was at a lethal level.
So when you don’t have that alarm system, we don’t have CO2 monitors here, but at the same time, sometimes he’ll breathe in the high 30s and that’s really the only indication that he’s not tolerating the machine. So, when that happened we put him back and that’s been the process we’ve been using because obviously if he’s breathing at 30 something times a minute, he’s not getting effective ventilation. And that was documented with the
CO2. That was the highest we’ve done for him.
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Patrik: Right, and-
Doctor A.: So, the thing… Going forward, we have to decide that, is it in his best interest to attempt weaning him if he has the potential to arrest in the process?
Patrik: Right, and when you’re saying his CO2 levels were high, you’ve obviously done, and I’m curious, blood tests I would imagine, to get those numbers.
Doctor A.: To get the what?
Patrik: You mentioned-
Doctor A.: I didn’t get that.
Patrik: How did you get the numbers for the high CO2? You’ve done an arterial blood gas?
Doctor A.: Yes, exactly.
Patrik: Right. And one concern is, it sounds to me like he’s not getting mobilised after all this time. I mean, from my experience, as an intensive care nurse, I mean part of weaning somebody off the ventilator is always mobilisation.
Doctor A.: Yeah, for some. That’s not my area, per se. There must be some other reason that the primary care doctor, who’s putting his activity levels in, I don’t know if you see him or talk with him. You know, the Mrs.A, if she winds up talking to him, as far as what his limitations are. I know he has a bad sacrum with a previous ulcer which is the only obvious reason why he wouldn’t be able to put pressure on that. And you’re treating it
for like an osteomyelitis of the sacrum. So, that could be one reason why he can’t get up or he’d make the time, but you’d have to discuss it with Art and Dar and ask him, say hey, why isn’t he out of bed 'cause you know, that’s not my call as far as that goes.
But even today, you just leave people in the supine position, I know that a lot will just… if I’ve had seen him early in his hospitalization, if he is out of the bed, and stuff, but then if he wasn’t, you know, as cognizant as he has been, so part of that is, you know, your own really gain benefit the physical therapy if you’re able to participate. But that would be a whole line of questioning to the physical therapy people, the primary care doctor, and that’s how
I would advise you there.
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Patrik: Yeah, sure, I know-
Doctor A.: But you had that meeting the day after, you said, what was that all about? That meeting with the primary care..
Patrik: You would have to ask Rebeca because… Yeah.
Rebecca: Go ahead.
Patrik: Rebecca, what was the meeting all about?
Rebecca: I didn’t go. It was the wrong day.
Patrik: Oh, I see. I see. But then, you know, I mean in order to wean somebody off the ventilator, I mean I don’t need to explain to you getting somebody mobilised, strengthening respiratory muscles. You know, I mean, that to me is almost a no-brainer. And if you’re not in control of that, I
understand. But you know, from my perspective and experience, a successful weaning process can, you know… it helps tremendously if patients are being mobilised.
Doctor A.: Yeah, well you’re in a different setting. In the acute care setting, it’s different than the chronic care setting ’cause there’s all different variables. There’s not like, you know, post-op, post-open heart, whatever it is that we do
to get people moving around. He had a lot of physical limitations. Everything from his central nervous system to his ulcer. He was hemiparetic in some respects. I know there’s usually one arm more than the other. He’s got a neurologist seeing him for that. But that again, she’d have to hope and find out what the plan is from physical therapy.
We can literally leave and wean any body position, it has nothing to do with that.
But the people who do get up and move around do theoretically do better, just the physics of just getting the patient up. That hasn’t been a really limiting factor for him. It’s more he’s got advanced COPD from his… you know, you don’t get a CO2 of 113. That’s almost as if he was being smothered. I
mean, you know, that’s like pre-morbid at that high.
Patrik: I know.
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Doctor A.: But at the same time, there’s no alarm on the ventilator. There’s no alarm down in the monitoring area. So everything was looking good, except he was breathing a little fast, but sometimes we let him breathe a little fast if the numbers look good and none of the alarms are going off.
But here, when we did a blood gauge just to see how he’s tolerating things, it was 113. So had we left it like that, you know a couple hours later, it might have been 130, and then his pH would have been 7.1, like I was telling the missus here, that, you know, he’d wind up with a PEA arrest or something like that. So we don’t wanna really put him in harm’s way.
Patrik: No, understood. And that high CO2 would have been on CPAP, so one of the things you would have done is you would have probably got him in a controlled ventilation mode, into SIMV or something like that. That would have probably been your course of-
Doctor A.: Yeah. He’s got a back-up support that we have for him. So we put him right back on that and he snapped back into shape.
Patrik: Right, okay.
Doctor A.: He was on CPAP.
Patrik: Okay. So from your perspective, that won’t be a quick fix. It will take some time if it’s possible.
Doctor A.: Yeah. It will. At this point in the game, you know, with those numbers and knowing he could get that way, this is on CPAP and pressure support. He’s on a fair amount of pressure support. So would that… If you would venture off and say, what if he was on a T-Piece, where he doesn’t have any monitor like the ventilator tells you what’s going on, you’d have to do it like knowing that you’re weaning him at the expense of his life. So
if you say, okay, one of these days, you take the two year old child… Oh, I only went in for a second and then the kid drowns. So you’ll make that decision. You’ll go forward… You know what I’m saying? Just like if you don’t wear seat belts and you’re driving in traffic, or you don’t mind yourself and walk across the street.
But if you do it knowing that this is what you’re gonna get, then something happens and, you know… I like to look for the safest thing, the well good for the patient. And it might be if he stays on the ventilator that might be the best scenario for him. But if not, the goal was to get him off the vent during
the day and on the CPAP at night.
Patrik: Right, right.
Doctor A.: But the CPAP, you know, it wound up showing us that that numbers were potentially lethal. So, now with that in mind, if something were to happen and you looked at the chart critically and you say, listen. This guy had CO2s that high. Would you still go ahead and put him on CPAP? So sometimes you do things, once you… If you don’t know, it’s one thing. But if you do know and you do it, then it begs the question, are you
making the best decision in this case, for him? You know what I’m saying?
Patrik: Absolutely.
Doctor A.: You can say, okay he’s off the vent, but precariously. You really never know if he’s sleeping. He could be in a CO2narcosis kind of thing.
Patrik: Yeah. I understand. And-
Doctor A.: That will be awful.
Patrik: Then the next question really is, you know, he’s been in your care, I believe, since February the first. Would you say there’s been any progress at all?
Doctor A.: Well, it’s been limited. I just call, he has a variable tolerance for the CPAP. You’ll have a good day and a bad day, a good day and a bad day. My general experience over 30 years is that if you’re having good and bad, good and bad, good and bad, then that’s not good. You’re either gonna do it, or you’re not gonna do it. And then you start thinking, okay so what’s the point? If the point is that he’s failing, you’re failing through
the point where he has lethal numbers, then you have to say listen, he would live longer and be better if he were on a ventilator. He did not operate well with CO2s in the 80s and 90s. You know, even on a good day. So, then you say, what are we doing here?
So sometimes, you know, you have to get to a certain point where you’ve exhausted every option that we have. Thankfully he hasn’t had any active infections and his heart’s been pretty good. And his fluid status has been good. And his nutritional status has been good. So all those things have been good. So, you know, we tweak all the things we can tweak, but this just happened a few days ago and I was very, very shocked that he had a CO2 like
that.
Patrik: So it’s really single organ failure. You know, you’re telling me the heart is okay. The kidneys are okay. We’re really dealing with single organ failure, which is the lungs at this point in time. So, would that be fair to say?
Doctor A.: Yeah, (choppy line) mostly. He does have other issues. When I say okay, meaning… he’s not like a totally healthy individual.
Patrik: No, no.
Doctor A.: The thing is, they’re not rearing their heads and causing this… not like he’s in refractory pulmonary edoema or has bilateral fusions or an infection, or things of that nature. So all that seems to be controlled.
Patrik: Yeah, yeah. I mean, as I said, I haven’t seen him lately. But from my perspective, you know, successful weaning, even for long-term patients, mobilisation from my experience is a big part of it. And you know, I understand it’s not within your scope to make that decision, but you know, if he is withering away in bed, that’s not going to help him.
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Doctor A.: Yeah. And I don’t know that he’s doing purposeful things. Like, if you tell him to raise your arm. Will you raise your arm for me? If you tell him raise your arm. Yeah. So he doesn’t follow simple commands from me sometimes. So what he’s doing for physical therapy when they come and work with him, I’m not here during that time. So they say is, he’s making progress from just a therapy standpoint. You know, gets into his neuro, the
neural aspect of his health and the neurologist said that, you’ve met Dr. Harry? Or Harwin?
Patrik: Yeah.
Doctor A.: So, I mean there was a time when he wasn’t really with the programme, but he seemed like he was coming around. You’d get some good days, a little more lucid than others. But the consistency wasn’t there.
Patrik: Yeah, but I mean if he’s myopathic, if he’s not lifting his arm, again it’s a case of improving on that aspect and again it comes back to physical therapy.
And again, I don’t know whether that’s happened or not. I mean, just because he’s not moving doesn’t mean people shouldn’t be trying.
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Doctor A.: Yeah, I know they’ve tried. They’ve tried. I mean, he hasn’t been here all that time. You’d have to document it to try and learn things. But that would be a whole other conversation you’d have to have with the other nurses to see his progress and from their perspective. I don’t evaluate him for that aspect of his care when I come here and see him. I look at the general picture. Not the minutia and then to think that the physical
therapy people would be able to tell you did he make any improvement in the last several weeks. And then if not, why? What are they finding when they come in here to assess him and work with him? Are they working with him? Why not? What’s going on at the time? Things are kind of the things…
You know, I come in here, I’m seeing him now. See he might have had the greatest day ever, and I’m coming in now. So I’m seeing him various times of the day. But over the course of that two months or so, I would have caught him randomly… I usually see him, I see him begin here in the day and at the end of the day, so what happens in the middle of the day, I may not be privy to. But the primary doctor would be keeping track of that and seeing what kind of progress
he’s making. In that respect, I haven’t seen any physical progress as far as purposeful movement, the ability to communicate with me. He will try and talk with me if I say something to him, but whether or not he’s confabulating or not, if the Passy-Muir valve was met with the talking valve, was met with limited… you know, I don’t see him own that too often. I don’t know if they’re doing it.
Once I put that order in, it would be for you to come in and say hey, honey, do you wanna talk with me, talk with him and see what he’s doing with that. When I come in to evaluate him, they not gonna put the Passy-Muir valve just for my visit, but…
What’s your first name, I’m sorry Rebecca. So when Rebecca’s here, she’s gonna be here for hours. So she might be able to put the talking valve in, see what’s happening. I don’t know if they’ve been doing that or usually they have orders, they do that. So that’s something they’d have to do on a daily basis. If it’s once, they’ve gotta convince him or it’s not gonna help us any. So he still has the feeding tube, so feeding hasn’t been… the guy hasn’t been able to
eat and try and attempt to eat. I think it’s more his neurologic status that doesn’t allow him to do that. The lack of using those muscles for a long period of time. As far as the feeding tube is concerned, it was always his haemoglobin they wanna do that, but his hemoglobin’s well enough that it’s been eight.. eight..
Rebecca: Yes, Patrik. His haemoglobin now is 9.0, so I think we’ve gotta do the take tube.
Doctor A.: So now that would help to keep him supple. So set him up with it, you know, long haul as far as getting feeding. And then letting his wound heal. It’s a long process.
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Patrik: Sure.
Doctor A.: Situations.
Patrik: Okay, so at this point in time, he’s breathing in SIMV, or in CPAP at this… right at this point in time?
Doctor A.: At night he’s on support.
Patrik: Right, right, right. And then during the day you put him into CPAP or what’s your sort of process around managing that?
The 1:1 consulting session will continue in next week’s episode.
