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
The ICU Team Says my Dad Won’t Come off the Ventilator But I want to Give My Dad a Fighting Chance. Please Help!
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED”, I am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all time. And today’s live stream is about avoiding
tracheostomy in ICU.
Your Questions Answered Live: Avoiding Tracheostomy in ICU!
It’s Patrik Hutzel from intensivecarehotline.com and today the topic is about avoiding a tracheostomy in ICU. A lot of families in intensive care come to us when they have a loved one in an induced coma in ICU, and they are having a loved one in an induced coma on a ventilator with a breathing tube or an endotracheal tube. And they want to know what are the next steps, and they often don’t realize that if their loved ones can’t come off the ventilator and the breathing tube or the endotracheal tube in their mouth, that one of the next steps is often a tracheostomy or a trach.
So let’s just very quickly look at the terminology. What is a tracheostomy? A tracheostomy is a breathing tube, that’s being inserted into the windpipe often surgically, and it takes a cut in the throat and the tracheostomy is inserted. A tracheostomy as opposed to a breathing tube is much easier to tolerate, however, it also has a lot of disadvantages. And last week I did a YouTube live about the pros and cons of a tracheostomy so you can actually look at that
video from last week where I did the live stream. But the goal in ICU should never be to have a tracheostomy in the first place. That should not be the goal. The goal should be to get somebody out of the induced coma, get them breathing by yourself and then remove the breathing tube and avoid the tracheostomy.
So before we dive deeper into this topic, I also want to quickly, let you know that you can actually dial into the show and you can ask me questions live on the show. You can actually type in your questions in the chat part, or you can actually call in. I’ll quickly give you the numbers. If you’re in the US you can call 415-915-0090 that’s again, 415-915-0090. If you’re in the UK or in Ireland, you can dial 0118-324-3018. That is again, UK. 0118-324-3018; and if
you’re in Australia, you can dial 041-094-2230.
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So let’s get deeper into this topic. So why do you want to avoid a tracheostomy in the first place? So when you have someone on a ventilator with a breathing tube in ICU, you need to try to avoid that as much as you can. Therefore, you need to take the right steps and what are the rights steps to avoid a tracheostomy in the first place? Well, the right steps are in the first place to ask the right questions. The right steps in the first place are to hold the
intensive care team accountable so that they’re doing everything beyond a shadow of a doubt to avoid the tracheostomy.
Now, the problem there is that you have a limited time window for when to remove the breathing tube and the ventilator. So why is that? The maximum length of time for someone on a breathing tube or an endotracheal tube is around 10 to 14 days. And during that 10 or 14 days window, you should be able to take the breathing tube out if someone or if your loved one can recover, can be woken up, can come out of the induced coma, can do the breathing exercises and has a
brain that’s intact, then you should be working on that goal to remove the breathing tube within 10 to 14 days.
What does that look like in practice? Well, let’s just take a common scenario in ICU. Somebody goes into ICU with a pneumonia. They end up on a breathing tube and then, the next steps are to give IV antibiotics, or if it’s a viral pneumonia, to give antiviral, steroids and so forth. And then, once the infection
is cleared, you should wake them up out of the induced coma, you should be starting breathing exercises, you should be doing physical therapy, and then you should ideally take the breathing tube out eventually in order to avoid that tracheostomy.
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Now what we’re seeing in practice more and more is that ICU’s are getting more and more complacent, unfortunately, and they keep sedating patients for longer than necessary. They’re not doing the breathing exercises, they’re not doing the physical therapy and so forth. And that often then gets people to stay on the ventilator for longer than necessary.
So what needs to happen next then is you really need to start asking the right questions. You need to find out what sedatives is your loved one on, what opiates is your loved one on. When someone has a breathing tube or an endotracheal tube, the reality is that breathing tube is so uncomfortable that people need to be induced
into coma with medications, such as propofol or midazolam/versed. They also need fentanyl, morphine on top of that, and the more of those medications you give, the less likely it is that someone is actually going to wake up and be taken off the ventilator.
That’s why you need to do your research from day one, finding out what is the intensive care team doing in order to get your loved one off the ventilator and extubate them. Extubation means the removal of the breathing tube. There are stages of getting someone off the ventilator. For example, initially, when someone is in
an induced coma, your loved one will be on a ventilator setting, such as SIMV, which stands for Synchronized Intermittent Mandatory Ventilation, which means they’re getting a set rate from the ventilator like 10, 12, 14 breaths per minute, and then they can breathe on top of that if they’re awake enough.
Well, often enough, they’re not awake enough, so they can’t breathe, which then comes back again to weaning them from the induced coma. So they can breathe up more and be on their way to be weaned off the ventilator. It’s a very fine balance and it’s a real skill to wean someone off the ventilator and you need to know what you’re doing. So often when people come out of the induced coma, they sometimes can’t be woken up. They’re fighting against the ventilator and
then you’ve got to re- sedate them. It’s kind of a vicious cycle at times. Helene, I come to your questions in a minute. Let me just finish my train of thoughts here. And then I will come to your questions, Helene.
So it’s a real skill to take someone off the ventilator. And if you don’t know what you need to look for, you might be missing the signs of what to look for, what questions to ask, is your loved one on the right track, because what we often see here at intensivecarehotline.com, people come to us day 10, day 14, and they’re saying, “Oh, the ICU team just told us about that they want to do a trach and we don’t know what it means. Is that the
right thing to do?” But by then, you’ve missed all the signs of what should have happened in the first place, which is avoiding the trach – our today’s topic.
So you need to ask the right questions from day one, because as you’ve heard me saying before, the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for, they don’t know what questions to ask. They don’t know their rights. They don’t know how to manage doctors and nurses in intensive care. And that leads to traps. And one of the traps is that you are not holding the intensive care team
accountable from day one in how to avoid the tracheostomy.
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Picture this, a tracheostomy can be the right thing for someone that can’t come off the ventilator beyond the shadow of a doubt, but most patients in intensive care with the right skill, the right approach, have a very good chance of coming off the ventilator to avoid the tracheostomy, just needs the right approach from day one. It also needs you holding the intensive care team accountable from day one, if they’re doing the right things and how can you do that?
You can hold the intensive care team accountable by obviously doing the research or by getting a professional consultant and advocate involved like myself and our team here at the Intensive Care Hotline, because we can ask the right questions. We can help you holding the intensive care team accountable.
And again, unfortunately there’s a fair bit of complacency in this day and age where intensive care teams know that if they can’t wean some off the ventilator while we always have the tracheostomy on the other end. And I come to the consequences of that in a minute, let’s just very quickly look at Helene, you’ve said that your late mother was forced to receive a tracheostomy in 2012 and 2016. Iatrogenic’s death-murdered. And then you’re saying true manipulated
malpractices for RICOs medical schemes and corruptions elderly and grievous bodily injuries. I’m so sorry to hear that Helene. I’m not sure whether you’ve taken this any further, whether you’ve had a medical record review. A lot of families, if they have those concerns, we’ll take this further. They have the medical records reviewed and potentially go about it in a lawsuit and so forth.
Very sorry to hear that, Helene.
And again, in order to avoid a situation like Helene has encountered here, you need to ask the right questions from day one. You don’t know what you don’t know, and you can’t just trust that the intensive care team is doing everything in the best interest for your loved one. Especially for our viewers in the US where once a tracheostomy has been done, patients go to LTAC or long-term acute care. It’s critically important that you can avoid a trach at all costs, almost because again, if your loved one does end up going into LTAC while they’re critically ill, it’s a disaster area. And that is why not
the only reason, but it’s one of the reasons why it’s so important that you try to avoid the trach in the first place.
So really from day one, when someone is in an induced coma, they need to start physical therapy, they need to start range of motion exercises. They also need physiotherapists that are trained on ventilation, need to do breathing exercises, need to increase PEEP for a little while, increased pressure support, play around with the settings here and there, again, to train a patient to come off the ventilator.
And again, the longer someone is in an induced coma, you will also find that when you try to wake them up, it can be very difficult and challenging. So because of that, you need to be on high alert if they’re doing the right thing. So what are the next practical steps then? So when someone comes out of an induced coma, you ideally want to reduce the set rate from the ventilator.
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If someone gets a rate of 15 breaths per minute delivered by the ventilator, you definitely want to reduce that as much as you can. You want to reduce it down to 10, by the same time, you probably need to reduce the sedation and the opiates, and then you need to see can your loved one breathe on top of the ventilator settings. If your loved one can breathe, are the volumes they are breathing adequate? Let’s just say someone gets 400 mls per breath from the
ventilator, or if they’re in pressure control, they’re getting a set pressure but the volume shouldn’t vary too much either then. But you need to look at the volume that your loved one is breathing with a spontaneous breath, is that adequate based on their weight? So, as a rule of thumb, it’s around 7-10 mls per kilo. If someone weighs for simplicity, 60 kilos, they should be breathing 600 mls per breath. As a rule of thumb, it says 7-10 mls, but for simplicity, 600 mls per breath if someone is
weighing 60 kilos.
So then the next step here is you then need to look at what is their oxygen saturation? What are their arterial blood gases? Is CO2 high? Is CO2 low? Is oxygenation adequate? You also then need to look at how much oxygen is your loved one getting through the ventilator. Just for simplicity,
the room air that you and I are breathing is 21%. So when someone is coming off the ventilator, their oxygen levels on the ventilator should be ideally less than 35%, 30% to 35%, then less arterial blood gases must be a satisfactory. Specifically carbon dioxide, oxygen levels, pH, and so forth. Then they need to be awake and they need to be able to follow commands. If they can’t follow commands, there is no point in doing anything. If they can’t follow commands, it’s very difficult for your
loved one to be extubated, because it’s very unlikely that they can maintain a stable airway.
So there are a number of things that need to come into play in order to extubate someone again, such as they need to be off a set rate from the ventilator. So if they were getting 10 breaths per minute from the ventilator, that rate needs to be down to zero so that your loved one can show that they can trigger every single breath with adequate tidal volumes that the volumes are roughly 10 mls per kilo per breath, that the arterial blood gases are fine, that they
can obey commands, that they have a good strong cough, that they can squeeze hands, wiggle toes, poke out their tongue, and all of that. And minimal secretions because when someone is having a breathing tube or an endotracheal tube, they get suctioned very so often, and once the breathing tube is out, you can’t really suction anymore, so that your loved one needs to be able to clear their own airway, clear their own secretions.
So then when someone has the rate reduced to zero from an SIMV or a controlled rate, it then means they’re going into what’s referred to as a CPAP or pressure control mode, which means your loved one will trigger every single breath from the ventilator. And once they’ve triggered every single breath from the ventilator, and PEEP is less than 7.5, pressure support is less than 10. Again, arterial blood gases are good, PO2 is above 65 or 70 mmHg, CO2 is within
normal range, which is sort of 30 to 45 mmHg, the pH is normal, the bicarbonate is normal, and they’re completely off sedation, they’re obeying commands, they’re coughing, they’re poking out their tongue.
And another good sign is if your loved one is strong enough to take the breathing tube out by themselves. Not that you want to do that because they could injure themselves, but it’s a very good sign if your loved one wants to take out and has the strength to take the breathing tube out by themselves, that is a very good sign as well. But that can often only be achieved by trying to wake somebody out of the induced coma as quickly as possible, and doing all the
breathing exercises, doing all the physical therapy, encouraging them and so forth.
Again, let’s just quickly go back to our example with the pneumonia. If the pneumonia takes long to cure, to heal, if the antibiotics are not working and you’re keeping someone in an induced coma for a week or for longer, and you’re trying to wake them up, they’re confused, they’re breathing against the ventilator, and you have to re-sedate them, then that’s making the likelihood of a tracheostomy higher.
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But again, you need to keep trying. You can also do potentially a trial extubation.
If you’re not quite sure if extubation is going to work or not, a trial extubation might be the way to go. So what that means is if you’re not a hundred percent sure of the signs that are there, but you’re still concerned, maybe blood gases are not a hundred percent accurate or not a hundred percent satisfactory, I should say, should you do a trial extubation? Well, I think you can do one trial extubation, if that fails for whatever reason, you then need to
probably have a tracheostomy.
Another way forward is if a trial extubation or if an extubation is sort of standing on shaky ground, if you will, and you are extubating, you could then try BIPAP or CPAP ventilation with a mask as a next step, but then you have to look if there is aspiration risk. For example when someone is ventilated, at least the
endotracheal tube or the breathing tube has a cuff in place, and at least protects from aspiration to a degree because of the block or the cuff in the back of the throat. Whereas if someone is ending up on BiPAP or CPAP mask ventilation after extubation, there is a higher risk for aspiration, which would be very detrimental if we stick with the example of the pneumonia. You certainly don’t need an aspiration if you are having a pneumonia.
So you can see that certain things need to line up. One of the challenges there is when people come out of an induced coma, even if you have sedation and opiates completely switched off, people still may not wake up, or they wake up slower than expected. And one of the challenges as well is that the longer someone is in an induced coma or can’t wake up, they deconditioned fairly quickly, their muscles get weak, including their breathing muscles, which is one of
the challenges why people can’t come off the ventilator. If their breathing muscles, weaken too quickly, which is again, where it comes back to the inability not to breathe spontaneously. And it comes back to physical therapy is critical, especially now that you understand that deconditioning of the muscles is real and can happen really rapidly.
So that’s sort of in a nutshell, how you can avoid the tracheostomy, but you really need to ask the right questions from day one. And you need to understand what are the implications of certain drugs being given. For example, if you give propofol as a sedative, propofol is short-term acting and midazolam/versed is long acting, which means when someone is having propofol, for example, they can wake up quicker.
One of the main side effects, however of propofol is hypotension, which means low blood pressure. And then you’re having the risk of people ending up on inotropes or vasopressors if they’re having propofol whereas midazolam doesn’t impact so much on the blood pressure, but it’s, long-term acting and
if you switch it off, people don’t wake up quickly. So you got to weigh up or the doctors, ICU team has to weigh up what’s the best sedative for your loved one.
Is it midazolam/versed or is it propofol. And for someone that’s in a long-term induced coma, it’s probably midazolam, it’s the better option.
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But then again, you’ve got to look at side effects, for example, midazolam/versed also is addictive in nature. So if someone comes out of an induced coma, they’re often going through the withdrawal phase.
Helene you’re also saying, I found unwarranted, excessive fluids overloaded that infiltrated your mom’s lungs. And you are saying, secondary drowning. I’m wondering Helene, what was the reason that your mom was fluid overloaded? Was that because of kidney failure? Was it because of a weak
decompensated heart? Was it simply fluid overload where they didn’t keep the fluid balance in check? It would be curious to know whether you know the reason for the fluid overload. It would be good if you can share so we can elaborate on this a little bit more here.
So it is very important for you to understand what sedatives, what opiates as well. So take morphine or fentanyl that are very strong opiates for pain relief, the reason people get pain relief when they’re in an induced coma is simply again, the breathing tube or endotracheal tube is very uncomfortable. And one way for patients to tolerate that is to get the sedatives that we talked about, but also to get morphine or fentanyl. Now, the problem with morphine and
fentanyl is simply that they are, just like midazolam, are addictive in nature. And the more you give, the more likely it is that when people come out of the induced coma, they potentially go through a withdrawal phase because they are now addicted to morphine or fentanyl.
So you can see what negative impact the induced coma can have. And again, that’s why it’s so important to minimize the time spent in an induced coma, which is, when someone is coming into ICU we talked about pneumonia at the moment, especially with the COVID pandemic, with COVID-19, many patients end up with ARDS in ICU with COVID-19 they end up in prone position. They need prolonged induced coma, which then makes it very likely that they can’t wake up quickly and that they can’t wake up within 10 to 14 days and that they then need a tracheostomy.
Other scenarios would be if someone’s coming into ICU after multiple trauma, and they need multiple surgeries potentially, and then, that prolongs the waking up phase as well, makes it more likely for them to having a tracheostomy. Other options or other scenarios are for example, head and brain injuries, especially with neurological conditions where patients then again, because of their head or brain injury, are not waking up, they can’t obey commands. And again, makes it more likely for them to end up with a tracheostomy. But that doesn’t mean the ICU team shouldn’t try, they need to try.
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But your job is to hold them accountable. Your job is to asking the right questions, and your job is to making sure they’re doing everything beyond the shadow of a doubt to avoid the tracheostomy and try and get your loved one off the ventilator with the breathing tube in the first place. And I’ve given you the recipe to achieve that. And again, we can help you with asking all of those questions with the intensive care team to hold them accountable.
I hope that helps in how you can avoid a tracheostomy in the first place, if your loved one is in intensive care, and I want to leave it there. I’ll wait a couple of more minutes if someone has any questions, you can type them in the chat part.
If you have any questions in relation to our topic today, how to avoid a tracheostomy in ICU.
Critically important really for anyone that’s watching this video is ask the right questions from day one. You can’t wait until it’s too late because that’s what we’re finding here in intensivecarehotline.com. Families come to us when it’s too late, they don’t realize that they need to ask the right questions from day one. And they don’t realize that they need to hold the ICU team accountable from day one. It’s critically, critically
important because you don’t want your loved one ending up with a tracheostomy. You don’t want your loved one going into LTAC or looking at services like INTENSIVE CARE AT HOME whilst Intensive care at home is a great alternative for someone with a long-term tracheostomy, and on a long-term ventilation. You don’t want to get there in
the first place and you need to focus on what you can control from day one.
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Well, thank you so much for coming on to the call today and for watching this video. If you have a loved one in intensive care, check out intensivecarehotline.com. Subscribe to my YouTube channel here for more live videos, for more updates for families in intensive care, go to intensivecarehotline.com. If you have a loved one in intensive care, call us on one of the numbers on the top of the website, you can call US
415-915-0090, or you can call UK 0118-324-3018. You can call Australia 041-094-2230, or you can simply send an email to support@intensivecarehotline.com.
Thanks again for watching and I’ll talk to you again next week in another live call. Take care for now.
