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 Mom is Critically Ill in ICU and is Ventilated. Is it Safe for my Mom to Remove Her Breathing Tube If She is Confused?
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 client Julie as part of my 1:1 consulting and advocacy
service! Julie’s mother is critically ill in the ICU with sepsis, extubated today and she is asking if her mom needs to be re-intubated because of high breathing rate and struggling to stay at 90 % saturation.
My Mom is Critically Ill in ICU, Extubated Today But Seems to Be Exhausted. Is There a High Chance My Mom Will Be Re-intubated?
PART 1
PART 2
PART 3
PART 4
PART 5
PART 6
PART 7
PART 8
PART 9
PART 10
PART 11
Patrik: How can I help?
Julie: Hi Patrik, this is Julie. I talked to you a little while ago about my mother.
Patrik: Yes, how are you?
Julie: I’m good. How are you?
Patrik: Very good, thank you. How’s your mom?
Julie: She… They went to go to extubate her today and she is on a BiPAP right now. She was doing that really rough it at first
it was like the BiPAP was on 96 oxygen and she was struggling to stay at 90 % saturation. And then a couple of time her heart rate is staying at 140. And an hour later she was able to go to, let’s see, 90% oxygen and she was staying at 94 % saturation. So then they dropped it to 85%, and she was saying at 96. And then they came in and moved her. They moved her to shift her on the bed because they shift her so often not to get bed sores, I guess. And then she just declined rapidly, and now the
pulmonologist is on his way back to intubate her.
Patrik: Okay. So they already extubated her?
Julie: Yeah.
Patrik: And when was that? How long ago was that?
Julie: That was, oh, I would say around four-ish.
Patrik: Oh, so today? Today?
Julie: Yes. Yes.
Patrik: Okay. So, and then after they extubated her, they put her on the BiPAP. So she didn’t, she did… Were they predicting that? Were they predicting that she needs the BiPAP?
Julie: Yeah.
Patrik: They were? Okay. So they basically…
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Julie: Yes. They said that, that they would try her on the cannula but they wouldn’t be surprised that she ended up needing the BiPAP, especially for sleep.
Patrik: Right. Okay. When, and when they put her on the BiPAP, she was put on 90% of oxygen pretty quickly?
Julie: Ninety-six, yes. And her oxygen was struggling to stay at 90 and her heart rate was at 140.
Patrik: Right. Is your mom awake?
Julie: She’ll open her eyes, but she’s exhausted.
Patrik: Yeah. Yeah. And is she sort of, you know, was she talking or was she following commands? Would she have squeezed your fingers and all of that?
Julie: She did yesterday. Yeah. They’ve been wanting to extubate her since Saturday night. But they said that there wasn’t enough staff there to do extubation and they wanted to make sure that all the doctors were there. So they’d wait until Monday. But yeah, she’s been
smiling and she’ll nod her head yes or no.
Patrik: Okay. And what did they say in terms of you know, what’s the next step? They would like to intubate her, and that’s imminent?
Julie: They said that they want that they called the pulmonologist back to intubate her again because she’s struggling too much. Even though they just gave her a nebulizer, she’s not… And it brought her oxygen back up to 90, they said that because her heart is staying at 140. Is that true?
Patrik: Say that again. Say that again please.
Julie: Is it true that if your heart stays at 140 but you’re still breathing in the 90s that you need to be have intubation?
Patrik: Well, I would argue that if she’s got a heart rate of 140 and she’s on 90% of oxygen on the BiPAP, and her oxygen saturation is just hovering around the 90% mark, there’s a very good chance that she will need re-intubation. However, however, what I would like to see is number one, a chest
X-ray and number two an arterial blood gas
Julie: Yeah, they did do a chest X-ray tonight, before they even took her off intubation, to check. They also checked her blood gases and they said that everything looked good. I don’t know a number exactly, but they said that the blood gases looked good and that the X-ray looked good, so they decided to go ahead and extubate.
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Patrik: Sure, sure. And that’s great. But now, now that she’s struggling… Now that she’s struggling, they would need to do another blood gas and another chest X-ray.
Julie: Okay.
Patrik: Because-
Julie: And now they said… Okay?
Patrik: Because one way to find out if ventilation is effective is to do arterial blood gas and to do a chest X-ray. Right. The quickest way though, is an arterial blood gas. That’s the quickest way.
Julie: Okay.
Patrik: Are you in the hospital at the moment?
Julie: No, but I will be in about another 20 minutes. I just wanted to speak to you on the phone because, so you think it’s okay to let us intubate her again.
Patrik: I don’t think, I don’t think there’s another option if that, if what you’re sharing is accurate and I assume it is accurate. So if she needs 95% of oxygen on the BiPAP, and she’s just saturating around 90% she’s a very… And her heart rate is 140, I also would want to know, I also would want to know how fast she’s breathing. What do I mean by that? You know a normal breathing rate per minute is sort of 10 to 20 breaths per minute. Her
breathing rate would probably be 30 and above.
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Julie: They did, they said she’s breathing really, really fast. So this is the question I have for you. Another question is, is just 25 minutes ago they were able to start dropping the oxygen. So, they dropped it to 85% and she was still saying saturated at 96.
Patrik: Okay.
Julie: And then they came in to move her. They came in to move her and right after they moved her, she dropped. Why?
Patrik: I’ll tell you why she might’ve dropped. So, if the lungs, you know, are fading or there’s a pneumonia or any issue with the lungs. Often the left side of the lung or the right side of the lung, one side of the lungs would be better. Okay? And, let’s just say the left
side is worse, and they would have turned her on her right side?
Julie: Yeah.
Patrik: There’s a chance that she might have decompensated because of that.
Julie: Oh my God. So, what might be happening?
Patrik: Well, clearly the right position in a situation like that is important. Right? And they should be able to manage that just by looking at the chest X-ray, you know, they should be able to see from the chest X-ray. You know, the left side of the lung is better than the right side. Let’s
keep her on the right side so we can expand the good side of the lungs. You know. It’s often that, but then you can’t be on one side all the time. You know, you got to be on both sides, otherwise you will get pressure sores. You know, you just have to minimise the time you, you know, it’s usually better if you can stay on your good side for a little longer compared to your bad side, you know?
Julie: So they moved her back to where she was, and they’ve given a nebulizer treatment. How long can you stay breathing fast, but still 96 saturation and 140 heart rate. How long?
Patrik: Look, it depends. Have you seen her on the BiPAP? Have you seen her?
Julie: No, but I saw her when she first went into the hospital on the BiPAP.
Patrik: Right. Because I’ll tell you, you know, in order to answer your question, it’s really a matter of how long can she tolerate it. You know, how long can she-
Julie: Or what? Like, what can happen?
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Patrik: Look, if she’s getting exhausted on the BiPAP right? Eventually she could, number one, her oxygen saturation would drop lower if she can’t, you know, if she’s getting exhausted. And also there is another risk, when you are on BiPAP and you’re getting exhausted, the other risk is, for
example, vomiting and aspiration. Right? Do you know what I mean by that?
Julie: Yeah. Yes I do. So you recommend that she does go back on intubation?
Patrik: Well, you see the worst, the worst-case scenario is that your mom gets exhausted. Okay. That your mom gets exhausted and she can’t continue to breathe and she, potentially, vomits and aspirates. That would be much worse than going on the ventilator now. You know. But-
Julie: So what does that mean for us, that she goes on the intubation. What does that mean for us?
Patrik: Yeah. Yeah. So, how long has she been on the ventilator up until today? How long? Three weeks?
Julie: Yeah. Like about 19 days or so.
Patrik: Nineteen days. Okay. There is a very good change that if she… there’s a very good chance that if she can’t maintain the BiPAP and she ends up being intubated again, that she will need a tracheostomy. Do you know what-
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Julie: They’re Saying that she’s not… they’re saying she’s not a candidate for a tracheotomy due to her short neck and her anatomy. So she’s… They’re saying that they don’t even have a specialist and that they would lean more towards living on a tracheotomy ventilator. She told me today and said that I should prepare for a meeting.
Patrik: Okay, okay. I see. And, and that could be-
Julie: And she said that-
Patrik: And, and that could be. .
Julie: And she said that they would feed her through her stomach. That she would spend the rest of her life… Before my mom even crashed she was like, “Your mom’s struggling and there’s a good chance she’s going to need to be on a tracheotomy that was done through a specialist ventilator for the rest of her life, getting fed through her stomach.” And she’s like, “Is that what you really want?”
Patrik: Look the reality is that, when people… When the, when the topic is being discussed about a tracheostomy and you would have seen it with other issues now too, they’re always painting the worst-case scenario, always. I mean, you’ve seen it now that they are always painting the worst-case scenario.
Julie: Yes.
Patrik: You would be aware of that by now. It’s always doom and gloom. It’s always black and white, and it’s always, you know, they’re always covering their downside. Always.
Julie: Okay.
Patrik: Whatever they tell you… Whatever they tell you, they’re always covering that worst-case scenario. So if they told you, “Oh, you know, we do a tracheostomy and your mom will be walking out of ICU in four weeks’ time,” and she’s not doing that. You could sue them.
Julie: Okay.
Patrik: Right? So you would have seen by now.
Julie: Yeah.
Patrik: You know what I mean? If their predictions had come true when you first contacted me, your mom would be dead now.
Julie: Yes.
Patrik: So you got to question their approach. You’ve got to question their clinical judgement. Because if their clinical judgement would be accurate, your mom would be dead by now. Let’s face it.
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Julie: Yes, very true.
Patrik: Right? So, you always have to read between the lines. Always. Okay?
Julie: Okay.
Patrik: So the short neck could well be preventing your mom from having a tracheostomy. That could be the case. I don’t know. I haven’t seen it. By the same token, you know, it would need the input from a specialist, like a ear, nose and throat specialist. Right? Would need the input from them in order to say if your mom can have a tracheostomy or not. Because they would be the people doing that. Okay?
Julie: Yes.
Patrik: So in a situation like that, where it’s questionable that your mom would qualify for a tracheostomy. Yes, we’ll put you on her shoes that you want to keep the BiPAP for as long as you can. Right? At the same time. Yeah. You know, you got to be aware of the risks.
Patrik: You know, you’ve got to be aware of the risks. If your mom comes to a point where she can’t tolerate the BiPAP for whatever reason, she would need to be re-intubated and you would need to reassess from there. You know, there could come a point where your mom seems to get too exhausted on
the BiPAP, and there is no other option but to re-intubate to buy time. And then for the next step.
Julie: So there’s no way that it buys time to re-extubate. Like, couldn’t maybe just made her lungs even stronger because she had it, she had to use them and breathe on her own and tolerate it. Like, could it also buy time to re-extubate later?
Patrik: It could.
Julie: Or because we have to re-intubate… It could?
Patrik: You see, the thing is when your mom gets re-intubated, right, she would need to go into an induced coma.
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Julie: Okay.
Patrik: Okay? So, and when you go into an induced coma, you’re generally speaking, you’re getting weaker, not stronger.
Julie: Right. So they won’t continue to do the breathe treatments.
Patrik: Say again?
Julie: You know how they’re weaning her? You know how they’re weaning her off of…
Patrik: Yeah.
Julie: They won’t continue to do that?
Patrik: Well, they have to. They have to. You know, I mean, the reason for… Needs to continue.
Julie: The breathing trials need to continue?
Patrik: Yeah. Yeah.
Julie: So they’ll basically, they’ll put her in a coma, reintubate…
Patrik: Correct.
Julie: And then they’re going to, and then they’re going to continue the breathing trials.
Patrik: Yes. Yes. Very much so. Very much so.
Julie: Okay. So then they’ll kind of keep pulling her off of sedation. And then doing the breathe trials every day?
Patrik: Depends. If she’s in a coma, if she needs to go back in induced coma, they can’t really do the breathing trials.
Julie: And why do you… Because right now, why do you go back into the … Because she still came off the intubation today, and was not in the coma.
Patrik: Say that again please?
Julie: While she was up… So, this morning she was on intubation, but she was completely off all sedation medication.
Patrik: Right, right. And that’s probably one of the reasons why, why it was so risky…
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Julie: To take her off?
Patrik: Yeah. Yeah. You see you have a limited time window. When you extubate somebody, you have a limited time window.
Julie: Okay. For what?
Patrik: To find the extubate. Right? If you’re choosing the wrong time, things like that can happen. By the same token, because it’s been 19 days, I argue they had to try. Right? Because otherwise 19 days is overstayed. She’s overstayed the 14 day mark, you know. And I’m glad they haven’t done a tracheostomy yet because you know, you always want to try first.
Julie: Yes. So, will they continue to try? Because after she gave me the speech… But you’re saying, Hey, you know the speech is because she’s giving me worst-case scenario again, right?
The 1:1 consulting session will continue in next week’s episode.
