Why would a critically ill Patient in an induced coma need a tracheostomy in Intensive Care?

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 last week was

My 39 year old brother had a TBI! Now he’s back to Intensive Care with hydrocephalus and he needs a VP-shunt! Is this the best option?

You can check out the answer to last week’s question by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED” I want to answer another more general question from our readers that I get all the time.

Why would a critically ill Patient in an induced coma need a tracheostomy in Intensive Care?

So this is an answer to a more general question that we get all the time and I want to shed more light on this today.

Most families of critically ill Patients in Intensive Care coming to our website come because their loved one isn’t “waking up” after an induced coma. They want to simply know “when is my loved one going to “wake up” after the induced coma.

Often there is no “one size fits all answer” to this and then families in Intensive Care realise that if their critically ill loved one isn’t “waking up” in a time frame that they expect that they may need a tracheostomy.

That’s basically what this episode of “YOUR QUESTIONS ANSWERED” today is all about.

So if your loved one is critically ill in Intensive Care and they are in an induced coma they will also be mechanically ventilated with a breathing tube or an endotracheal tube.

There is no such thing as an induced coma without mechanical ventilation and a breathing tube or an endotracheal tube.

The same is true for mechanical ventilation with a breathing tube or endotracheal tube, it just doesn’t happen without an induced coma.

Therefore one goes with the other.

Mechanical ventilation with a breathing tube or an endotracheal tube is just too uncomfortable to tolerate, therefore an induced coma is the only way for a critically ill Patient to tolerate mechanical ventilation with a breathing tube or endotracheal tube!

Imagine somebody puts a tube down your throat and starts ventilating your lungs with lots of pressure and flow, you couldn’t cope… therefore an induced coma is the only way to safely ventilate your critically ill loved one.

Also keep in mind that starting to ventilate a critically ill Patient with a ventilator and a breathing tube or an endotracheal tube is preceded by a critical illness where some major bodily functions such as the heart, the lungs, the liver, the brain and or the kidneys are unable to function 100%, hence the induction into a coma and the mechanical ventilation with a breathing tube or an endotracheal tube.

Other conditions such as a major trauma or heavy blood loss may lead to an induced coma and mechanical ventilation with a breathing tube or endotracheal tube as well.

Therefore, the critical illness of your loved one is often only the starting point for your loved one’s induced coma and the mechanical ventilation with a breathing tube or endotracheal tube.

For more information about why your critically ill loved one needs an induced coma and what an induced coma exactly is check out this article/video here

Related article/video:

What is an induced coma and why is my critically ill loved one in an induced coma?

In this episode of “YOUR QUESTIONS ANSWERED” I just want to focus on why your critically ill loved one may need a tracheostomy when they are in an induced coma.

In case you are new to this blog you may wonder what makes me qualified to write about this subject.

In more than 15 years Intensive Care nursing in three different countries I have seen over and over again that critically ill Patients go from an induced coma to a tracheostomy. During those more than 15 years in Intensive Care, I have literally worked with thousands of critically ill Patients and their families!

I have also worked for more than 5 years as a Nurse Unit Manager in Intensive Care and I have gathered tons of insights into the world that is Intensive Care.

Tracheostomy or no tracheostomy in an induced coma?

When critically ill Patients in Intensive Care are in an induced coma it often comes with undesired side effects such as the mechanical ventilation with a breathing tube or an endotracheal tube.

An induced coma also comes with medications such as Propofol(Diprivan), Midazolam(Versed), Fentanyl and/or Morphine* being given for the induced coma.

*Propofol(Diprivan), Midazolam(Versed), Fentanyl and/or Morphine are the most commonly used sedative and opioid(=pain killer) drugs in an induced coma. Other drugs that can be used for an induced coma are Ketamine, Dexmedetomidine(Precedex), Phenobarbital(mainly for head and brain injuries including seizures), Oxycodone, Remifentanil.

In some instances muscle relaxant substances such as Rocuronium, Vecuronium, Cisatracurium, or Suxamethonium- just to name a few- are given in case a critically ill Patient can’t be ventilated during the induced coma. This completely paralysis a critically ill Patient and it should only be done temporarily and it should only be done as a last resort or at the beginning of an induced coma as it completely paralysis a critically ill Patient.

In some instances muscle relaxant substances are also given if a critically ill Patient is too unstable in order to minimise bodily functions and any resistance in order to maximise blood flow to major organs such as the liver, the kidneys, the heart, the lungs and the brain.

If any of those substances like Propofol(Diprivan), Midazolam(Versed), Fentanyl, Morphine and/or muscle relaxant substances are given for a prolonged period of time, there is a chance that your critically ill loved one will stay in an induced coma for longer than anticipated.

It’s always difficult to say at the beginning of an induced coma how long the induced coma and the mechanical ventilation with a breathing tube or endotracheal tube is needed for, however the more sedative drugs(Propofol or Midazolam), the more Opioid drugs(Fentanyl or Morphine) and the more muscle relaxant drugs are given the higher the chance that the induced coma and the mechanical ventilation with a breathing tube or endotracheal tube will be needed for at least a few days, sometimes many weeks.

On top of that, if the nature of the critical illness for your loved one requires them to be in an induced coma and therefore requiring mechanical ventilation with a breathing tube or an endotracheal tube for prolonged periods(days or even weeks), again there is a higher risk for not “waking up” quickly after the induced coma.

Therefore, the combination of a prolonged induced coma with prolonged mechanical ventilation often triggers the considerations for a tracheostomy instead of a breathing tube or endotracheal tube.

Clinical situations such as severe head and brain injuries, ARDS(lung failure), major trauma, Guillan Barre syndrome, Cardiac arrest, ECMO for heart and/or lung failure, lung transplants, COPD, acute severe asthma just to name a few are all clinical situations that may require a tracheostomy during an induced coma.

The reasons for performing a tracheostomy in an induced coma are manyfold and can’t be reduced to simply one reason.

The main reasons for a tracheostomy in an induced coma are

Minimisation or even exclusion of sedative and opioid(=pain killer) drugs such as Propofol(Diprivan), Midazolam(Versed), Fentanyl and/or Morphine. Some of those drugs all have undesired side effects such as being addictive and therefore minimising or even excluding those side effects is often crucial during the recovery of a critically ill Patient

The longer critically ill Patients in Intensive Care are on medications such as Propofol(Diprivan), Midazolam(Versed), Fentanyl and/or Morphine, the higher the chances are that your critically ill loved one becomes addicted to these drugs. Therefore a withdrawal from these drugs can also become an issue when your critically ill loved one is being woken up after the induced coma. The quicker your loved one gets off these addictive drugs the better it is, therefore a tracheostomy and then a minimisation or even an exclusion from these addictive drugs is often desirable. Being in an induced coma and battling a critical illness presents a multitude of challenges already and therefore your critically ill loved one doesn’t need another one of those challenges by withdrawing from addictive drugs

A tracheostomy, unlike a breathing tube or an endotracheal tube is easier to tolerate and is almost painless. Therefore, sedative and opioid(=pain killer) drugs such as Propofol(Diprivan), Midazolam(Versed), Fentanyl and/or Morphine can often be ceased immediately after the tracheostomy has been performed and therefore “waking up” after an induced coma can often be started immediately after the tracheostomy has been done

Related:

The 5 Mistakes you are unconsciously making if your critically ill loved one is in an induced coma and is not “waking up”!

The 10 answers to the 10 most frequently asked questions when your loved one isn’t “waking up “ after an induced coma!

Depending on the nature of the critical illness, sometimes “waking up” and weaning off sedative and opioid drugs can’t be commenced straight away as sometimes critical conditions such as haemodynamic or neurological instability require sedation and opioid(=pain killer) drugs, however usually a tracheostomy is leading to a reduction of sedative and opioid(=pain killer) drugs within hours

Again, a tracheostomy is a tube inserted into the windpipe(trachea), whereas a breathing tube or endotracheal tube is inserted through the mouth. A tracheostomy is therefore so much easier to tolerate

Once a tracheostomy is inserted and your critically ill loved one is more awake, your loved one can be weaned off the ventilator gradually by having time on and off the ventilator(this approach can’t be done with a breathing tube or endotracheal tube)

Many, many critically ill Patients in Intensive Care are not “waking up” quickly after an induced coma, therefore a tracheostomy is giving them more time to “wake up” in their own time whilst having sedation and opioid(=pain killer) drugs minimised

They are the main reasons why a critically ill Patient in an induced coma might need a tracheostomy in Intensive Care.

Here are more related articles/videos for you to get more information about induced coma, breathing tube/ endotracheal tube and tracheostomy.(click on the links below)

HOW LONG CAN YOU KEEP A CRITICALLY ILL PATIENT IN INTENSIVE CARE IN AN INDUCED COMA?

How long can a breathing tube or an endotracheal tube can stay in?

HOW LONG SHOULD A PATIENT BE ON A VENTILATOR BEFORE HAVING A TRACHEOSTOMY?

Why does my loved one need a Tracheostomy in Intensive Care?

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