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
Why Does the ICU Team Intend to Remove My Mom’s Breathing Tube and Disconnect Her from the Ventilator to Die?
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 Bong as part of my 1:1 consulting and advocacy
service! Bong’s mom is critically ill in ICU and Bong is asking why the ICU team is telling that her mom has limited time on a ventilator.
Why Does the ICU Team Say that My Mom Has Limited Time on A Ventilator?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Bong here.”
Part 1
Hi Patrik,
If IPV (Intrapulmonary percussive ventilation) therapy had been used 2 weeks ago it would have enabled mom to recover faster as it would have cleared her lungs earlier and reduced exhaustion from coughing and irritation to her throat from coughing with the breathing tube. Thus increasing her tolerance for
the tube.
Treatment has brought up more mucus but it leaves mom tired and unresponsive. I suspect it temporarily interrupts her air passages and her breathing.
Before IPV I was told about pockets of mucus that had settled in her lungs. But mom was at her highest awareness. IPV temporarily changed that sending her back to sleeping.
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I suspect that will pass. When mom first checked in and the one lung was collapsing she was hard to arouse. The nurses recognized she was not getting enough O2 as the cause. The problem is to conduct PE. Mom has to be alert and we have only 7 days.
The nurse has never seen anyone on the ICU receiving PE. He says it is not performed on the ICU.
That reflects the hospital’s policy you are either capable of recovering from the ventilator on your own or do a tracheostomy and move
the patient to an acute care facility. Poor performers are given no help.
I am told 21 days is the limit to have someone on the ventilator with a tube in the throat.
Regards,
Bong
Hello Tom,
1. These are additional info regarding the use of IPV or Intrapulmonary percussive ventilation (IPV)
IPV or Intrapulmonary percussive ventilation (IPV) is a form of chest physical therapy administered to the airways by a pneumatic device. IPV is designed to both treat active pulmonary disease and to prevent the development of disease caused by secretion retention.
Specific goals of therapy include promoting the mobilization of bronchial secretions, improving the efficiency and distribution of ventilation, providing an alternative delivery system for bronchodilator therapy, providing intrathoracic percussion and vibration, and providing an alternative system for the delivery of positive pressure to the lungs.
The Phasitron may be set to continuous percussion for use in intubated patients. IPV may be applied via mouthpiece, mask, artificial airway, or through a ventilator. To many, IPV is seen as a superior method of secretion removal compared to traditional chest physical therapy, vibratory therapy and other forms of oscillatory airway clearance.
Contraindications
Precautions
- Patient should not receive IPV therapy immediately after eating. A period of at least one hour should be observed after meals before the initiation of therapy to minimize the risk of aspiration.
- Vital signs must be monitored, and the patient must be continuously assessed during IPV therapy. Observe the patient’s heart rate, respiratory rate, blood pressure, and pulse oximetry closely for signs of intolerance.
- Tube feeding should be stopped for one hour prior to IPV therapy, and patients should remain at a 45º angle during therapy to minimize the risk of aspiration.
- Supplemental oxygen must be provided for patients requiring it, and the O2 saturations should be monitored.
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- Suction equipment should be immediately available at the bedside during IPV therapy in case of airway compromise due to copious secretion mobilization.
- To minimize the risk of barotrauma (lung injury because of high pressure), a pressure pop off must be utilized when using IPV for mechanically ventilated patients. Monitor peak airway pressures closely.
- Driving pressure of 30-45 psi must be used during IPV to achieve therapeutic effects. Always assess the patient’s chest excursion to determine the appropriate driving pressure.
- An IPV treatment should be discontinued if a patient experiences any of the following: increased shortness of breath, chest pain, or an increased FiO2 requirement evidenced by transcutaneous desaturation, significant changes in heart rate or rhythm, blood pressure, or skin color, marked diaphoresis, fatigue, or emesis. Notify the physician and the RN, and continue to monitor the patient for progression of symptoms. Reevaluate the
indications for therapy.
- If a patient experiences difficulty in clearing secretions during therapy, assist the patient as needed with naso/orotracheal suctioning.
Documentation:
The respiratory therapist / RN needs to document the pre-and post-treatment clinical assessments, sputum production, medication and dosage (including diluent volume and total solution volume), and therapeutic driving pressure on the electronic medication record (MAR).
2. Physiotherapy Vs Physical Therapy
Physiotherapy indicates more of a hands-on manual therapy approach to rehabilitation, while physical therapy indicates a more exercise-based approach to rehabilitation. But according to research, both of these terms are synonymous.
The very first thing your mom needs is to be referred to a PT (certified physical therapy / physiotherapist) to assess what type of PT (physiotherapy or physical therapy) tailored to what your mom needs or if not, why they won’t be able to perform it to your mom?
They should be explaining their reasons to you as to why. I just wonder why they were telling that they cannot do PT to your mom when they can move her up to a chair? That is part of physiotherapy.
The physiotherapist should be responsible for implementing mobilization plans and exercise prescription, and make recommendations for progression of these in conjunction with other health team members.
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3. Likely the sleeping is because Mom is not getting a lot of oxygen or is not expelling CO2?
Again, it all boils down to the current result of her arterial blood gas to see her current blood oxygenation and CO2 levels. They should be performing blood gases as they see it fit but these assessments should be reported to the doctor immediately to treat the underlying
condition.
I hope this helps.
For any questions still, please let us know.
Kind regards,
Patrik
Hello Patrik,
The hospital is proceeding with removing mom from the ventilator at 3:00 today, I will try again with the court for an injunction.
I have a 7-day grace from the court to delay tube removal which if I take full advantage will exceed the 21 day limit for mom to have a tube in her throat.
We are already seeing new blood likely from the cuff. So I will be working tomorrow with the new doctor on the ward to condition mom. Not a day can be wasted.
Dr. Well is familiar with all treatments, he was sighting them as he attempted to find justification to remove mom’s tube.
Mom’s blood for today is as follows: WBL 4.8, HGB is 9.1, HCT 28.9, Platelet 208, Glucose 101.
Regards,
Bong
Hi Tom,
Ask the hospital to give you their withdrawal of treatment policy as a starting point. They need to follow that.
Every hospital has protocols for everything, starting from mopping the floor, cleaning windows to detailed clinical protocols.
Therefore they must have a weaning protocol. The blood results are OK, HB is low-ish. We still need an arterial blood gas, that hasn’t changed.
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If we can set up a phone meeting with the doctor we can propose a treatment plan.
If they can’t formulate a treatment plan, I believe that we can and we can advocate for it on a clinical level.
Let me know your thoughts.
Kind regards,
Patrik
