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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip and question answered for families in intensive care.

So I had an email from Dale and Dale writes, my wife has been in intensive care for eight weeks for a VP shunt valve failure and multiple shunt revision surgeries. She’s been on the ventilator for all but three days of, that they did ventilator weaning a little over a week ago and got her onto a tracheostomy collar. She was moved out of ICU, but was immediately moved back within a day. She has had MRSA pneumonia twice, once before the weaning and again when they moved her back.

To be honest, I’m not sure if she was over the pneumonia in the first place when they weaned her from the ventilator. Anyway, she underwent another 7-day course of antibiotics for MRSA mainly Vancomycin, now, she’s doing much better. Her lung x-rays says it appears she’s clearing after an infection and the blood test they did for determining if she still infected came back normal. They are trying to wean her from the ventilator once again and today she’s down just to pressure support and PEEP of five. She’s tolerating this very well.

They will rest her tonight and try the tracheostomy collar trials again tomorrow. I also have a multidisciplinary team meeting with neurosurgery ICU palliative care the case manager and the social worker on Monday. They have been pressuring me to move her to LTAC. The neurosurgeon said, you don’t want her in here. This is where she was infected. You want to get her out of this environment to a place that specializes in ventilator weaning. I was under the impression that MRSA and C. Diff are even more of a problem at LTAC. Am I wrong? It seems to me that we’re so close to weaning her from the ventilator moving her now doesn’t make any sense. I need talking points for the meeting on Monday. Can you help?  From Dale.

Now Dale, I’m very sorry to hear about your wife’s situation. Now here is the thing, if your wife is on pressure support and on a PEEP of 5, you know, that’s good information have that means she’s breathing spontaneously that means she’s taking every single breath from the machine herself so she’s triggering a breath and then flow is following. So it really depends how much pressure support she’s on, it’s usually 10 or less where people can be taken off the ventilator and it sounds to me like she’s taking the first steps, especially if she’s been on tracheostomy collar during the day.

So it also depends how much oxygen she’s on, generally speaking, 30% of oxygen and less, you know aligned with ventilator weaning. So let’s just say for argument’s sake, 30% of oxygen and less PEEP of 5 and pressure support less than 10, I would argue your wife is ready to come off the ventilator if the chest x-rays are clear and if the arterial blood gases are good as well.

So I completely agree with you that your wife is very close to coming off the ventilator and that she should not go to LTAC. Why should she not go to LTAC, I’ll tell you why. In LTAC, patients generally speaking are not looked after by intensive care nurses, they are looked after by general nurses or by LNP’s which are not ventilator and tracheostomy competent. So LTAC’s are really designed to save money and get patients out of ICU fast, but they’re not designed to specialize on ventilator weaning which is what ICU’s are often saying.

So, now that your wife is close to come off the ventilator, it would be crucial for you to buy time in ICU because once she’s off the ventilator, she can go onto a general ward or to a step-down unit, which is much better than LTAC or long-term acute care.

Now, if you think about it Dale, LTAC or long-term acute care implies that your wife is going into long-term care. That is ridiculous. Why would somebody go into long-term care if somebody can take a short term care approach, especially when your wife is off the ventilator? The recovery time will be much quicker if your wife is off the ventilator, and it looks like that’s going to happen in the next few days.

And as far as infections are concerned, ICU is a high infection environment. There’s no doubt about that, but so is LTAC, you know, whenever there’s critically ill patients, patients with infections, you know, the risk is always there to catch an infection. So from my perspective and experience whether she stays in ICU or in a hospital or she goes into LTAC, the risk for an infection is simply there.

Here is another tip. You know, I mentioned to you, your wife should be ready to come off the ventilator with everything that you shared. Another thing to look for is how often does your wife need suctioning through the tracheostomy tube and is her cough strong enough to clear her secretions herself.

So go and you know, look how often does she need suctioning from the nurses and if it’s, you know, three times a day, again, there’s a very good chance your wife can come off the ventilator soon and doesn’t need to go to LTAC and can go onto a short-term recovery plan.  So that is my tip in terms of when it comes to ventilator weaning.

One last thing, I want to say, if your wife, God forbid can’t come off the ventilator, have to think about intensive care at home rather than LTAC because intensive care at home can do what ICU’s are doing especially when it comes to medically stable long-term ventilated patients and they can look after your wife at home with intensive care nurses.

If for whatever reason she can’t come off the ventilator long-term, so go and check out intensivecareathome.com for that.

So, that’s my tip for today. All the best for now Dale and I’ll talk to you in a few days. Check out our case studies at intensivecarehotline.com and if you have any questions, just call us on one of the numbers on the top of the website or simply send me an email to [email protected].

This is Patrik Hutzel from intensivecarehotline.com. Take care for now.