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 Dad In ICU Is Not Waking Up. What Should I Do? Help!
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Lalaine as part of my 1:1 consulting and advocacy service! Lalaine’s mom is ventilated in ICU and is
not waking up. Lalaine is asking if tracheostomy will be safe for her mom’s condition.
My Mom is 14 days Ventilated in ICU and is Not Waking Up. Would Tracheostomy Be Safe for my Mom?
Hi Patrik,
My name is Lalaine. I would like to ask few questions on tracheostomy.
My mom is admitted in ICU and currently on mechanical ventilator. Her breathing is ok now. She is able to breathe on her own and ventilator oxygen reduced to 30%, PEEP 6. Doctors are suggesting tracheostomy, but for her condition of still in recovery of sepsis and lung infection she is not fit for surgery, GA is also dangerous for her.
Today she is 14 days ventilated and doctors are not able to wean her off the ventilator even though she is breathing on her own because she is in minimal conscious state. Her other parameters are all normal but general well-being is not good.
In this case what would be your advice? We are confused to go for tracheostomy or not. If prolonged on mechanical ventilator for another 2 weeks, will it be fine? Any other option than tracheostomy? Please advise.
Thank you.
Lalaine
RECOMMENDED:
Hi Lalaine,
Thank you Lalaine for being a client, I very much appreciate it.
You have a very relevant question here.
Can you share more information with me so I can help you to the best of my abilities?
1.) Can you get arterial blood gas results?
2.) A picture of the ventilator.
3.) A list of medications your mother is on.
4.) What has led to the sepsis and lung infection?
5.) Is your mother still in an induced coma?
6.) Has your mother been in prone position with the lung infection?
7.) Latest chest X-ray results?
The more information the better.
Once we have more relevant clinical information then we can advise you.
Kind regards,
Patrik
Hi Patrik,
Thank you for the prompt reply. Please see my responses.
1.) Can you get arterial blood gas results?
2.) A picture of the ventilator
Attached here.
3.) List of medications your mother is on
- Zyvox
- Human Albumin
- Diflucan
- Insulin
- TPN
- Remifentanyl (stopped last week)
4.) What has led to the sepsis and lung infection?
She had flu infection in her foot that led her to sepsis. 2 weeks back she underwent below the knee amputation. Before operation she was ok but weak. The lung infection began after the operation. The leg wound is healing and due to low albumin, her lung filled with water, caused difficulty in breathing and placed on a ventilator and now the lung is clearing up but she still has the pneumonia.
Doctor said the infection due to sepsis is fine now. But WBC high due to lung infection. Other parameters are normal. Her albumin is low causing her body to swell up. The swelling reduced at hands and face but leg and body still swollen. Human albumin is given but still not able to increase level.
Today’s lab result is: Albumin 21, WBC 47.
5.) Is your mother still in an induced coma?
Yes. She’s able to open her eyes but minimally. She can hear and respond but for a while only. It’s like on and off.
6.) Has your mother been in prone position with the lung infection?
No, she is in supine position.
7.) Latest chest X-ray results?
Attached
She is currently on feeding tube and urine is ok. She is on 3rd day on ventilator with sedation (Remifentanyl). She still responds, conscious but sleepy, able to move hands.
The sedation stopped last Tuesday and from Tuesday until now, there is slight improvement in her, from fully unconscious to open eyes slowly and sleep again. Yes, she responded, not able to lift her hand but when I hold, she grabs my hand. Open her eyes but very minimally.
In between this is, I saw few times that she is coughing but no sound. Doctor did CT scan on Sunday and say there are old scars only. Brain is normal. Previously she had stroke and paralyze left side. But she was able to talk and was conscious. Doctor is saying maybe the blood flow to brain is slow due to infection
so she’s not able to open her eyes. Her parameters are: Pulse 78, O2 100%, BP 145/60 (diastolic now 50-68 range), systolic above 110 always.
I personally don’t want my mother to undergo tracheostomy but I want the best for her. I need advice if there are any other option that we can go for or continue with mechanical ventilator or go for tracheostomy. Is tracheostomy a safe procedure? Please advise.
Attached is her blood test results and chest x-ray results.
Waiting for your prompt reply. Thank you.
Regards,
Lalaine
RECOMMENDED:
Hello Lalaine,
Thank you for giving us sufficient clinical information about your mom’s current condition. Please see the details below:
1. Arterial blood gas results
We need to have the results of the last series of your mom’s arterial blood gas results to help in determining the oxygenation status of your mom.
2. A picture of the ventilator
I have seen the picture of the ventilator and your mom is currently on SIMV (PRVC) + PS mode = Synchronized Intermittent Mandatory Ventilation (Pressure Regulated Volume Control) + Pressure Support. This is a conventional mechanical ventilation that provides mandatory breaths which are synchronized with your mom’s own spontaneous breath efforts at a preset rate. Your mom’s mechanical ventilator setting is as follows: FiO2 = 40 %, PEEP = 6, RR = 10, TV = 450, PS =
14.
Your mom has minimal ventilator setting and has the possibility of extubation (removal of the breathing tube) provided that her series of blood gases and chest X-rays are acceptable, another is, if she is awake and cooperative, sitting up in bed and with the presence of a spontaneous cough.
For added information about your mom’s ventilator setting:
TV = typically 6-8 cc/kg; – What is your mom’s weight?
RR = usually 10-30 breaths/min, adjusted according to the result of blood gases.
PEEP = 5-12 cm H20; adjust for FiO2, CXR (higher PEEP needed for sick lungs).
PS = usually 10 cm H20, common range 6-14; adjusted for desired work of breathing, lower PS makes your mom work harder.
FiO2 = 21-100%; adjusted with saturations (FiO2 above 60% is toxic). Your mom’s 40% is moderately minimal.
3. Lists of medications your mother is on:
- Zyvox – used to treat different types of bacterial infections, such as pneumonia, skin infections, and infections that are resistant to other antibiotics.
- Human Albumin – It is used to treat or prevent low blood volume. It is used to treat low blood pressure. It is used to replace albumin in people with low blood albumin levels.
- Diflucan (Fluconazole) is an antifungal medicine.
- Insulin – It is used to lower blood sugar in patients with high blood sugar (diabetes).
- TPN – Total Parenteral Nutrition
Total parenteral nutrition (TPN) is a method of feeding that bypasses the gastrointestinal tract. A special formula given through a vein that provides most of the nutrients the body needs. The method is used when someone can’t or shouldn’t receive feedings or fluids by mouth. This should be infused in a good central line.
- Remifentanyl (stopped last week)
If the sedation has been stopped from last week, your mom should be getting much more awake over time. What is her latest GCS (Glasgow Coma Scale)? It’s important to know about this to assess if your mom is improving or deteriorating.
4. What has led to the sepsis and lung infection?
Your mom’s WBC is very high which is indicative of an infection and she is already covered with a strong antibiotic. But if she is already taking very strong antibiotics but remains still having the infection, have they consulted any Infectious Disease Consultant about it? Have they taken any recent blood cultures? What are the results? Those are very important questions to have a good lead on how to combat the infection appropriately.
5. Is your mother still in an induced coma?
“Yes. She’s able to open her eyes but minimally. She can hear and respond but for a while only. It’s like on and off.”
It is important to know about the series of her GCS (Glasgow Coma Scale).
https://intensivecarehotline.com/questions/how-to-assess-glasgow-coma-scale-gcs-in-adults-and-children/
6. Has your mother been on prone position with the lung infection?
“No she is in supine position.”
Your mom is currently bedridden because of her condition and she should be turned from side to side every 2 hours to improve chest expansion on the upward side and increased perfusion of the lung on the dependent side. The prone position is used to improve oxygenation in ventilated patients who continue to be dependent on the ventilator despite other interventions.
7. Latest chest X-ray results?
Chest x ray result attached is ok but I need to see the updated results please, if you can provide and any latest result thereafter. Thank you.
Additionally, hemoglobin is on the low side, they should keep an eye with the kidney markers and they should be doing chest physiotherapy and passive or active mobilization for your mom if her condition permits.
I hope this all helps.
For any questions, please don’t hesitate to ask.
Thank you.
Kind regards,
Patrik
RECOMMENDED:
Hi Patrik,
Thank you for the detailed explanation.
I don’t have the result for the arterial blood gas. But when I ask the nurse they said mom is very minimally dependent on ventilator. Her oxygenation is good. They just wait for her to be fully focused so they can remove the ventilator otherwise need to do tracheostomy. I will try to ask tomorrow. But my mother’s GCS rate is 7.
Chest x ray that was the latest. Today, the doctor said her lungs is improving. The breathing and lung movement is normal so far. Only problem she is not waking up.
This hospital don’t have infectious disease specialist and we could not shift my mother to other hospital also due to her condition. We don’t want to do tracheostomy for her but I need advice based on what I have given you.
Do you think we can extubate and remove her from the ventilator? She is opening her eyes minimally and sometimes grasp my hand when I hold her but sometimes she cannot. But she is coughing sometimes.
Is tracheostomy permanent? If we go for it, will it affect her quality of life? Or can we extubate her and just give her oxygen?
They have taken the recent blood culture, there was MRSA detected. They have taken the test again, it showed negative MRSA. Previously, mom had ESBL infection due to the leg which lead to sepsis. But recently, the doctor said no infection of ESBL. Meropenem stopped and continued with Zyvox.
Regards,
Lalaine
Hello Lalaine,
Thank you for the response.
Taking off a ventilator is different for every patient with different situations. If your mom is going to continue from having good parameters like having good chest x-rays, acceptable results of blood gases, able to cough on her own and fully awake, she may be able to be extubated and be removed from the ventilator. It is better to let her be extubated than having the tracheostomy in the first place.
Have they done any Brain MRI apart from the brain CT scan? Depending on the result of this diagnostic finding, together with her overall condition will they suggest that your mom needs to be having tracheostomy because of the possibility that she will be dependent on the ventilator.
If she will be dependent on the ventilator, she needs to have the tracheostomy then, but the ICU team should exhaust all efforts in trying to wean her off the ventilator first before doing the tracheostomy for her.
You can read this article below for more information about tracheostomy and weaning off the ventilator:
https://intensivecarehotline.com/questions/how-long-somebody-should-a-patient-be-on-a-ventilator-before-having-a-tracheostomy/
https://intensivecarehotline.com/questions/what-are-the-risks-and-benefits-of-a-tracheostomy/
https://intensivecarehotline.com/questions/what-is-a-tracheostomy-used-for-in-intensive-care/
Hope this helps.
Kind regards,
Patrik
Hi Patrik,
Her parameters are all ok. The only reason they are asking to go for tracheostomy is because my mom is minimally unconscious and they afraid if she’s not able to breathe later after extubation, they need to re-ventilate her again. They are saying they want to do tracheostomy also to wean her off the ventilator because she’s more than 14 days on the ventilator already.
Regards,
Lalaine
Hello Lalaine,
Yes, that is correct. Generally speaking, if a patient is expected to be ventilated for more than 7 days, then the tracheostomy should be necessary. You can try reading the articles I gave you. That will give you good information about tracheostomy and ventilation.
Kind regards,
Patrik
Hi Patrik,
Yes, I read the articles. May I ask few more questions?
Is tracheostomy a safe procedure? I mean, are the complications rare or can it be tolerated in most cases. Generally how is it?
The sedation for tracheostomy, will it be given on a higher dose? Will it affect my mom’s brain?
Will tracheostomy cause any other problems in the future?
With my mom’s current situation, as she is not fully awake normally, is this case good to go for tracheostomy?
If let’s say we extubate her without tracheostomy, any chances that she will not be able to breathe during extubation? If yes, will the doctor intubate her back? Is it safe?
Regards,
Lalaine
Hello Lalaine,
Thank you for reading the articles. I hope you have learned something from it.
Anyway, here are my answers to your questions:
“Is tracheostomy a safe procedure? I mean, are the complications rare or can be tolerated in most cases. Generally how it is?”
Yes, definitely, tracheostomy is a safe procedure. Like any other surgeries, there will always be risks and complications involved. All surgeries have risks of bleeding and infection. There is also risk of damaging other areas of the neck. These risks are typically small and tracheostomy is overall a safe procedure. Complications are more common if patients are very sick, weak or malnourished.
“The sedation for tracheostomy, will it be given on a higher dose? Will it affect my mom’s brain?”
The doctors will then gauge how much sedation they’re going to give your mom depending on her current health and mental status.
“Will tracheostomy cause any other problems in future?”
We have the short-term and the long-term risks. Most of the short-term risks are related to the surgery like for the bleeding. For long-term risks, over time, the tracheostomy tube also can cause some damage to the windpipe, which can cause problems if the tube is removed. The tracheostomy tube can sometimes cause breakdown of the area around the hole in the neck (this area is called the stoma). This can lead to infection and rarely serious bleeding.
“With my mom’s current situation, as she is not fully awake normally, is this case good to go for tracheostomy?”
Yes, even if your mom is not fully awake, she can proceed with the tracheostomy procedure.
“If let’s say we extubate her without tracheostomy, any chances that she will not be able to breathe during extubation? If yes, will the doctor intubate her back? Is it safe?”
Yes, there will always be the risk of being able not to tolerate the extubation especially for her case that she has been ventilated for 14 days, so she is prone to reintubation which is dangerous.
Before the doctors decide to extubate your mom, they should be doing the weaning process first wherein your mom’s ventilator settings will be reduced gradually (takes days) until off. During this process will they know if she is tolerating breathing on her own and would be safe for extubation. Along with this, they should also be looking at different parameters as well, like for the blood gases, chest X-rays and her level of consciousness.
Kind regards,
Patrik
RECOMMENDED:
Hi Patrik,
Thank you for the perfect explanation. Really thankful for the info.
Regards,
Lalaine
Kind regards,
Patrik
