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
How Can I Be In Control and Advocate for the Best Medical Treatment for My Ventilated & Critically Ill Brother in ICU?
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 how to
wean off ventilation and tracheostomy in ICU.
Your Questions Answered Live: How to Wean off Ventilation and Tracheostomy in ICU?
Good evening, good morning, good afternoon wherever you are. It’s Patrik Hutzel here from intensivecarehotline.com. I want to welcome you to this live stream today. Today’s live stream is about how to wean a critically ill patient in intensive care off the ventilator and the tracheostomy.
Before I go into this live stream, I just quickly want to mention a couple of housekeeping issues and so if you have any questions regarding today’s topic, please type them in your chat pad. You can also dial in live today if you want to.
If you’re in America, in the U.S. or in Canada, you can call me on (415) 915-0090 and you can call in live into the show. That’s again, (415) 915-0090. If you are in the UK, you can dial 01183243018. That’s again, if you’re in the UK, you can call 01183243018 and you can ask questions again, live on the show. If you’re in Australia, you can call 0410942230. That’s again for our Australian viewers, 0410942230.
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Let’s get into today’s topic, how to wean a critically ill patient off a ventilator and a tracheostomy in intensive care, but it also applies to how to wean off
a critically ill patient in LTAC for example, for our U.S. audience. Even though I am saying that, LTACs are not qualified to wean off critically ill patients and a tracheostomy. And I’ll come to that in a minute, but I still stand by that, that LTACs are not designed to wean critically ill patients off ventilation and tracheostomy.
But really let’s dive right into it so I can give you as much information as possible. The live stream will probably go for about half an hour, unless you obviously have any questions that you wanted to ask in regards to this topic. In the last few weeks I’ve had a couple of other live streams. I’ve done a couple of other live streams around the topic, how to avoid a tracheostomy, how long does it take to wake up after a tracheostomy? And that you can see some
videos there.
If for whatever reason, a tracheostomy is unavoidable and your loved one does need a tracheostomy, then obviously the next question is, how can they come off that tracheostomy and the ventilator? Let’s look at practical steps.
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When someone is having a tracheostomy because they have a neurological condition, let’s just say, and they can’t swallow, or they’re at risk of aspiration, but they are fine otherwise to breathe, when someone is having a tracheostomy for that reason, they should be able to come off the ventilator fairly quickly and breathe spontaneously fairly quickly, have some time off the ventilator here and there. Hopefully, they can stay off the ventilator during the day, and
then go back on the ventilator overnight, and then over a 48 to 72-hour period, they should come off the ventilator fairly quickly.
Just to illustrate that, we are currently working with a client who has had cardiac arrest, has gotten an anoxic brain injury, and is breathing on minimal ventilation settings. Initially, the ICU team wanted to do what’s referred to as a ‘one-way extubation‘ and let them die. Then we were obviously advocating to do a tracheostomy and give the client a chance to wake up in their own time. This is exactly what’s happened.
They had a tracheostomy, and now they’re at the point where they can have time off the ventilator here and there and breathe spontaneously with the tracheostomy. In a few days, they will be off the ventilator and then they can be moved out of ICU. That’s the situation there.
Obviously, the client has been off sedation for many days now, does have a Glasgow Coma Scale of around 4 to 6, not really
showing massive signs of waking up, but that is what often happens after a brain injury. People take their own time to wake up and even if they don’t wake up, it’s still up to the family or a patient’s advanced care directive in terms of what they want, what they find acceptable as it relates to quality of life, or in some instances, quality of end-of-life. This is when it comes to sort of neurological conditions. What can happen there is that the tracheostomy is often only done for airway
protection, not so much for ventilating a patient, because problem with neurological conditions is that the swallowing reflex, the gag reflex is often diminished or absent and therefore the risk for aspiration is real. The tracheostomy will protect or diminish the risk for aspiration because the tracheostomy is cuffed with a balloon and that prevents from secretions or vomit or whatever it is, go down the lungs and cause an aspiration pneumonia.
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Coming back to our topic, how to wean off tracheostomy and ventilation in ICU. Let’s just say someone is coming out of a prolonged induced coma. They couldn’t be weaned off the ventilator and the breathing tube because they were in a prolonged induced coma and for whatever reason, could be after
open heart surgery, it could be after a severe pneumonia, definitely could be after COVID. It could be after trauma. It could be a whole myriad of reasons why
people need a prolonged induced coma. Could be, for example, after an aneurysm repair. As I said, there could be so many reasons why people need a prolonged induced coma.
So then after sort of day 10 to day 14, that’s sort of the cutoff when someone needs to look at a tracheostomy because the breathing tube is simply too uncomfortable and you don’t want to keep ventilated patients sedated for any longer than necessary. So that’s when you do a tracheostomy. Then unless there is any specific reason, you can wake up people pretty quickly. You can take off sedation. You can take off opiates once a tracheostomy has been done because a
tracheostomy can be tolerated much easier compared to a breathing tube or an endotracheal tube in the mouth.
The only reason when sedation needs to be continued after a tracheostomy are conditions such as multiple trauma, if people are still waiting for surgery or they are in severe pain because they had multiple trauma, head injuries, sometimes you need to continue sedation a little bit. But as a rule of thumb, you can minimize or stop sedation and opiates altogether once a tracheostomy has been done, which gives your loved one the ability to slowly wake up, gives your
loved one the ability to hopefully gain strength. That can be challenging because after a prolonged induced coma, they are fairly weak. They’ve been deconditioned and they have to use their arms and legs again. That can take a little bit of time and effort.
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But in any case, when someone has had a tracheostomy and is off sedation, is off opiates, such as morphine or fentanyl, they need to start with physical therapy. They need to start with breathing exercises. They need to start by having ventilator settings changed for example, from a controlled mode. When someone is in an induced coma, they’re not breathing properly. They are often in a controlled ventilation mode, which means they’re getting 10, 15, 20, sometimes
even more breaths from the machine and they can breathe on top of that.
Now, once someone is out of the induced coma and has the tracheostomy, that level of support needs to be reduced. The rate that your loved one is getting from the ventilator needs to be reduced and they need to be encouraged to breathe up more and more by themselves. And if that can be achieved, then the rate needs to be even further reduced until your loved one can breathe by themselves in a mode called CPAP or pressure support. That’s sort of the lowest support
that someone can get on a ventilator with a trach or with a tracheostomy. Then once the support is minimized, they’re with a PEEP of 5, oxygen levels, let’s just say 30% and below, with the pressure support of 10 or less mmHg, then your loved one should be in a position to have time off the ventilator. And I can tell you, even if it’s only five or 10 minutes to begin with, and they’re struggling, that’s fine. At least a start has been made. Then hopefully that time can be increased. Let’s take
them off the ventilator for five or for 10 minutes. See what happens. Can they tolerate that? Are they starting to breathe rapidly or heavily? Do they need to go back on the ventilator? Fine, but at least you know where you stand. And that is so much easier to do with a tracheostomy compared to a breathing tube or an endotracheal tube. It’s just so much easier to tolerate for a critically ill patient.
So, if CPAP/pressure support can be tolerated and is on minimal support, then physical therapy or physiotherapy needs to be started. Arm exercises, leg exercises, mobilization, getting out of bed, getting in a tilt chair, and getting in a recliner chair. You might think, “How is that even possible?” Well, I can tell you, it is possible. Most ICUs that I worked at, the sooner we were mobilizing patients the quicker they were able to be weaned off the ventilator.
Think about this. You’ve been lying in bed for weeks on end in an induced coma. Now somebody’s asking you to take breaths by yourself. It’s near to impossible. If you’re lying down, your respiratory drive is diminished.
Now, the only way you can wean someone off the ventilator successfully is by simply strengthening all of their muscles again, including the breathing muscles. You can only really strengthen the breathing muscles by getting people mobilized, by sitting them up, by encouraging them to breathe, by doing breathing exercises. That is the only way you can successfully wean somebody off the ventilator from what I’ve seen.
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So many people that we are consulting here at Intensive Care Hotline, and also at, INTENSIVE CARE AT HOME they’re telling us, the ICU is not mobilizing patients. They’re not doing physical therapy, or when people are in LTAC, it’s even worse. That’s why the mobilization part is not negotiable. And
unfortunately ICUs seem to be getting more and more complacent. I don’t know why. I’m a bit more old school, but I do believe that old school, especially when it comes to weaning ventilation and tracheostomy, it’s also necessary.
You can’t run a marathon without training for it. You can’t go for a five kilometer swim without training for it. It’s impossible. It’s the same when it comes to weaning off the ventilator. It’s like training for a marathon and very few people come off the ventilator very quickly. Younger people obviously have an advantage there, but even in the older population, I’ve certainly seen people being weaned off the ventilator successfully. It just takes more time and
more effort but it’s definitely doable.
I’ve done an interview with this gentleman, Charlie Atkinson, a few years ago. He’s in Boston, in Massachusetts. At that stage, in 2015, he would have been around 80 years of age. He was on a ventilator for a very rare virus, for some Nile virus. I can’t remember the exact term of the virus. Very rare. Cutting a long story short. He was on a ventilator for 12 months, including ICU, including LTAC and then he eventually even went home on a ventilator by himself
with his wife and his family looking after him. He eventually managed to get off the ventilator. It’s definitely doable, even in the older population. I know that Charlie, to this day, he must be in his mid-80s, he’s still alive. I still see him post family gatherings on Facebook and him walking around in his backyard. He’s an amazing guy, so don’t be discouraged by doom and gloom of the intensive care team. Don’t be discouraged by the negativity. It’s definitely possible and there’s enough
evidence out there to support that. It just takes effort. And unfortunately, again, I can’t stress enough if you have a loved one in ICU or in LTAC and they can’t get off the ventilator, mobilization is critical. Physical therapy is critical. Patience is critical.
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Other things that need to happen when someone is being weaned off the ventilator and the tracheostomy, would be good to do a regular normal saline nebulizer. It would be good to do regular inner cannula changes. Some tracheostomies have inner cannula, some don’t, but it definitely is important to do inner cannula changes regularly so there’s no airway blockage. We talked about nebulizers. We talked about the breathing exercises.
Other things that often physiotherapy, so physical therapists or respiratory therapists do is increase the PEEP for a period of time, increase the pressure support for a period of time. Give them a few breaths here and there through the machine to give them a bit of a break. It’s really important to sort of look at breathing cycles where your loved one can breathe by themselves. Then having maybe some breath cycles where they can have a rest on the ventilator, get
a few breaths, go for a sleep and then start the cycle all over again. It’s mainly a daytime activity or overnight, especially in the beginning when someone is being weaned off the ventilator, get them back on the ventilator overnight. Get them to have a good night’s sleep, get them to have a break overnight and then start the breathing exercises the next day again. It’s very important in ICU specifically to have a regular and healthy day and night rhythm.
Sleeping at night, breathing exercises, mobilization during the day. Also trying to get some daylight during the day. What I mean by that, a lot of people in ICU are stuck in a bed space or in a cubicle where there’s no natural daylight. I believe that’s an inhibitor to recovery. Some ICUs that I worked at, we were trying to get long-term patients specifically to a window, even getting some sunshine, makes a hell of a difference. If you can’t go outside with them,
get them some fresh air, get them to enjoy some wind around their nose, around their face. It makes all the difference in the world. Other things you can do, if there is a disturbed day and night rhythm, you can look at things such as give melatonin overnight.
Melatonin is a natural product and it helps people sleep overnight. It’s not a benzodiazepine that sedates people. It’s just a natural product that helps people sleep. Yes, have a look at melatonin. You can suggest that to the intensive care team if they’re not giving it, if your loved one is struggling with a natural day and
night cycle, and if they can’t sleep at night. Because if they can’t sleep at night, they’re tired during the day and then it’ll be so much more difficult to wean them off the ventilator, or try and wean them off the ventilator during the day.
Now, if they are having time off the ventilator, they usually need either a Swedish nose, a Swedish nose is like an HME (Heat and Moist Exchanger) filter, or they need a trach mask or a trach collar, whatever you want to call them, with humidified oxygen, depending on whether they still need oxygen. This is critically important. When someone is on a ventilator with the trach they get humidification via the ventilator. The minute you take someone off the
ventilator, they need the HME filter, also known as a Swedish nose. That’s providing humidification. Or again, you need a trach collar or a trach mask that’s providing humidified air or humidified oxygen.
Why is this important? When you and I breathe in, without a tracheostomy, we breathe in through the nose and the air is getting humidified through the nose. The same needs to happen when someone is bypassing the nose and the mouth, and is breathing through the tracheostomy, the air still needs to be humidified. That can be done with a humidifier or with a HME filter/Swedish nose.
Then regular suctioning needs to happen. You need to encourage your loved one to cough and then when they cough if they can’t bring up all secretions, you got to suction. Again, suctioning should be done by intensive care nurses and respiratory therapists. It can’t be done just by anyone because the risk for injury is real. Other issues are you may want to know, you may want to ask, “Well, how long does it actually take to wean someone off the ventilator and the
tracheostomy?” Well, the answer to that is that it really depends. I’ve seen patients being weaned off the ventilator within days.
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I’ve seen patients being weaned off the ventilator with a tracheostomy over many weeks, sometimes even over many months. It’s not a one-size-fits-all. It depends on the underlying condition. It depends on why people ended up on the ventilator with a trach, for example, take a patient with Guillain-Barré
syndrome. Guillain-Barre syndrome, when people are regaining their strength, I have seen six months, sometimes even nine months for Guillain-Barre people after trauma can take a few weeks, can take a couple of months. Really depends. People after pneumonia, again, can take a couple of weeks, couple of months. It really
depends.
In any case, another alternative, rather than having people being weaned off the ventilator in ICU long-term, or even worse going into LTAC, especially for our friends in America,
where the LTAC might be they’re on the other end. I mean, again, if you’ve done any research, we strictly advise against LTAC, very strictly advice against LTAC.
Another alternative is simply INTENSIVE CARE AT HOME, and you can check out intensivecareathome.com for more information. Cutting a long story short, what we do at Intensive Care at
Home, we are looking after long-term ventilated patients with tracheostomies at home. We’re doing so successfully with intensive care nurses. You can basically have intensive care treatment at home with intensive care nurses and that includes weaning off ventilation and tracheostomy. And that can be done at home. You can have a ventilator just like in ICU at home. You can have oxygen at home. You can have monitoring at home. It’s a no-brainer for anybody that’s been involved in
that service for anybody that’s seen how it works. That, from my perspective, is the best alternative.
But even at home, it doesn’t matter where you are, whether you’re in ICU, whether you’re in a step-down ICU, whether you’re in LTAC or whether you’re at home, mobilization still needs to happen. You can’t breathe without strengthening your upper body. You can’t breathe without strengthening your breathing muscles, doing breathing exercises and so forth.
Other things that can aid the process in weaning patients off the ventilator is like a cough assist machine or hyperinflation. That can help with increased PEEP, with helping coughing, with clearing secretions, with expanding lungs, strengthening breathing muscles. Again, you know that can help as well, and a good physical therapist and a good respiratory therapist will help you with that and can show you that, or can do it for your loved one. And that really
helps as well.
There are also many patients, either in ICU, but also living in the community for example, that we look after at Intensive Care at Home where they have ventilation with a tracheostomy overnight, and then they can breathe independently during the day. How can that happen? That can happen because simply overnight when they go to sleep, they’re not strong enough to breathe by themselves overnight. They might even be able to talk during the
day and might be even able to eat with a tracheostomy. We’ve certainly seen some patients and clients that can eat and talk with a tracheostomy while they’re off the ventilator with a speaking valve. That definitely depends on the individual’s situation.
Then if your loved one can stay off the ventilator for 24 hours a day, for a few days in a row, then there definitely needs to be an assessment made of whether the tracheostomy can be removed as well. That would be the ideal scenario having the ventilator and the tracheostomy removed. So, what checks need to happen when the ventilator can be removed? Well, the checks that need to happen is obviously looking for signs of distress, looking for signs of discomfort or
on the other end, looking for signs of comfort, of breathing normally, of having minimal secretions and if there are secretions, can your loved one bring up the secretions and doesn’t need any suctioning? Are they strong enough to bring it up? That is what needs to happen.
Other checks that can be done are arterial blood gases. Making sure that if your loved one is breathing without the ventilator, without any oxygen, are arterial blood gases normal? Are chest X-rays normal? Other things that can be done. Let’s just say your loved one has a size eight tracheostomy, can that be slowly downsized to a size seven, size six, and potentially to a mini trach? Then decannulation can happen.
So, there’s various approaches how someone can be weaned off the ventilator. Again, it’s not a one-size-fits-all. It’s more the individual approach that matters. That’s sort of what needs to happen. As soon as your loved one doesn’t need any more suctioning, they should be able to have the tracheostomy removed, assuming they have been off the ventilator for a few days.
And one of the things to be looked at if someone can have the tracheostomy removed are swallowing. Can they swallow? Are they not at risk of aspiration because the minute the tracheostomy comes out, your loved one needs to be able to swallow into the stomach, not into the lungs. Do they have a good cough reflex? Can they cough? Can they clear their airway? Can they maintain a stable airway? Can they talk? Were they able to talk with a speaking valve before the
tracheostomy was still in or while the tracheostomy was still in? That can be checked. The tracheostomy is usually kept in the back of the throat with a cuff. Basically there’s a balloon at the lower end of the tracheostomy and that’s inflated with air. Therefore, there is minimal risk for aspiration. Then you can take the cuff down. You can take the balloon down. Then if someone doesn’t aspirate, if someone can cough, that’s a very good sign. If someone doesn’t swallow secretions in the wrong
places, down into the lungs, that’s a very good sign.
If they’re strong enough to cough the tube out, again, that’s a very good sign that someone can have the tracheostomy removed.
It might take a little while after the tracheostomy has been removed until someone has their voice back. They might have a hoarse voice. They may not be able to talk straight away. Bear in mind, the vocal cords have been paralyzed for the period of time where your loved one had a breathing tube and a tracheostomy. Also, there may be numerous issues around talking. There may also be issues to begin with, with swallowing. Many patients in ICU after they have the
tracheostomy removed are very thirsty and they want to drink water. Again, you got to go very slowly there because you don’t want to end up again with an aspiration where your loved one can’t swallow properly. You might have to just start with some ice chips. You might just have to start with some jelly or some custard where they can swallow or start to swallow slowly and gently. The last thing you want is a step back where they end up again with an aspiration pneumonia, and next thing you
know they’re back on a ventilator and need the tracheostomy back in and potentially the ventilator back in. It’s a bit of a tricky situation, but many patients get over it, but it does take a little bit of time and effort. It also takes a committed intensive care team to follow through and making sure that critically ill patients can go from tracheostomy to be weaned off the tracheostomy successfully. That’s it in a nutshell.
Again, if you have any questions, type them in your chat pad, or give us a call and I can get you on the call. I mentioned the numbers earlier before. If you’re in the U.S. you can dial (415) 915-0090. If you’re in the UK, you can dial 01183243018, and if you’re in Australia, you can dial 0410942230.
Just want to quickly also talk about pediatrics or kids when it comes to weaning of kids. Now, it depends on the underlying condition obviously, if they can come off the ventilator and tracheostomy at all. It depends on their age. On the one hand, the younger they are, that gives them the chance to be weaned off the ventilator but cognition is an important aspect as well for kids. If they’re not cognitive, if they can’t follow commands yet, because they don’t
understand yet, that can be a little bit of an obstacle.
But as soon as their cognition is intact and as soon as they can relate to you and as soon as they can understand what you’re saying, then it’s much easier to instruct kids as well, in terms of do they need coughing? What do they need to do to get off that ventilator and the trach? How should they be breathing? And so forth.
We also have at Intensive Care at Home, we’ve successfully decannulated and weaned kids off the ventilator at home and we’ve done that too. It can be done at home with our kids or adults.
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Someone’s had a question there, just give me a second. Team Sicard, “Hi, I love watching all your videos. My mom had COVID and spent 30 days intubated and spent 30 days intubated. 15 it was with tracheostomy. She is home now and getting better but your videos helped me a lot. I know what to ask.” Oh, you’re very welcome.
You’re very welcome Team Sicard. I’m very grateful to hear that your mom is getting better and I’m very grateful to hear that my videos are helping you and knowing what questions to ask. That’s the whole purpose why I’m doing what I’m doing to help families, because I know it’s a very difficult situation. I’m really pleased to hear that your mom is on the mend by the sounds of things. That is really great. Just wondering, just out of curiosity, Team Sicard, is your mom still having the
tracheostomy or is the tracheostomy removed? Do you want to just type that into your chat pad? It’ll also help our other viewers to find out how can they go about it? Then, is there hope on the other end? Well, I believe there is hope, but it would be good to hear from you, Team Sicard, if your mom had the tracheostomy removed and if she’s home now without the tracheostomy.
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While I’m waiting for you to type that into the chat pad, I’ll just carry on for now. So, patience is critical, coming back to the commitment of the intensive care team, it’s a huge commitment for an intensive care team to get somebody from A to B, getting somebody from breathing to induced coma, tracheostomy, ventilation, and then back to ‘normality’. It’s a huge commitment. It takes a lot of time. It’s not easy at all, and it can take weeks and many months
sometimes and your patience will be tested.
Oh, and Team Sicard is saying, “My mom got removed from the tracheostomy and she’s now on oxygen.” Thank you so much for sharing that with me and our viewers, because again, I think that’s really critically important for our viewers to know that, yes, you can definitely have a tracheostomy and you can get rid of the tracheostomy eventually. I’ve seen it again many times, but you need to be patient and you need to have a committed intensive care team. Or if you’re
choosing INTENSIVE CARE AT HOME, we are committed too to help our clients get off the ventilator at home.
Last but not least, I just want to have a final word about LTAC. Again, my advice or our advice here at Intensive Care Hotline is strictly against LTAC, no matter the rhetoric of ICUs that the next step for your loved one is LTAC, that LTACs are specialized on weaning people off the ventilator. Well, from my experience, nothing could be further from the truth. It’s anything but the truth. We have literally people in LTAC that come
to us and beg us to help them get out of LTAC. You got to keep that in mind just as a final thought.
When someone is in intensive care, they have intensive care doctors, intensive care nurses, respiratory therapists, they have allied health like physical therapists that are specialized on intensive care. Most of the time you have a one-on-one nurse to patient ratio. Imagine you’re going from that level of expertise to LTAC, where you have one nurse and they’re not critical care trained, they’re not ICU nurses, going to LTAC where you have one non-critical care RN
looking after five patients, after five ventilated patients, that in my mind is insanity and it’s dangerous. That’s why many people bounce back into ICU because they’re being transferred whilst being critically ill. That is negligent in my mind. A patient that’s critically ill needs consistency of care. Doesn’t need to be moved around from one place to another. That’s negligence. That’s stupidity in my mind. LTACs are simply designed to save money. They’re not designed around clinical need and
that’s simply dangerous. That is my sort of last word.
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If you are at the cusp in ICU where the ICUs in America specifically, are asking you to go to LTAC, you need to contact us here at intensivecarehotline.com so we can advise you what the next steps are so you can keep your loved one in ICU. We have plenty of experience with that and we can help loved ones and families to stay in the right places with our advocacy.
Again, another alternative to LTAC is definitely Intensive Care at Home. Again, you can check out intensivecareathome.com for that, where we provide a genuine alternative for critically-ill patients in intensive care with long-term ventilation to leave ICU and be looked after at home. I think that’s it for me for
today.
Check out intensivecarehotline.com for consulting and advocacy for families in intensive care, and also check out intensivecareathome.com where we provide an intensive home care nursing service for long-term ventilated patients in ICU, adults and children with tracheostomies. We have also weaned patients successfully off the ventilator at home.
Thank you so much for watching this video today and for joining the live stream. If you have any other questions, I’ll just stay on for another minute so you can type in your questions into the chat pad, if you have any other questions. If not, I want to thank you again for coming on to the live stream and I hope I’ll talk to you all next week again. Next week’s topic will be around waking up after head and brain injuries. That’ll be my topic next week, next
Saturday night, Eastern Standard Time, Sunday morning time in Melbourne and in Sydney.
Yes. The topic next week will be around waking up after head and brain injuries. I hope you enjoyed that today. I hope I was able to help you. I hope that your loved ones get out of intensive care very soon. Don’t let negative intensive care teams discourage you.
Thank you for all your support and I’ll talk to you next week. Take care, everyone.
