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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.
So I have a question here from Angie, and Angie says,
My dad’s been in intensive care for two weeks now with COVID pneumonia, his oxygen levels are at 80% and his PEEP (Positive End-Expiratory Pressure) is at 15. Now I know after doing my own research, he should be having a tracheostomy by now because there’s no end in sight for him needing a ventilator with a breathing tube, they have started to prone him. But as far as I’m aware, they haven’t done anything else besides giving him remdesivir and steroids. And that hasn’t worked so far with the proning to get his oxygen levels down. What should they be doing to get his FiO2 (Fraction of Inspired Oxygen) levels and his PEEP down in order to enable a tracheostomy? Thankfully, all his other organs have been stable, so it’s just really the lung failure that we’re dealing with. Please advise.
Well, what a great question, Angie, especially in the current environment, because I did make a video the other day about why there are delays with the tracheostomy at the moment when it comes to COVID pneumonia or COVID ARDS. Let me explain.
So, a lot of patients with COVID pneumonia or COVID ARDS have high FiO2 requirements and high PEEP requirements. Now, to move safely to a tracheostomy, FiO2 levels, generally speaking need to be below 60%. And PEEP generally speaking needs to be below 8, to safely do a tracheostomy and not jeopardize the patient’s safety. Now, a tracheostomy would definitely help, especially with a proning side of things. It’s just a more stable and a more comfortable airway compared to a breathing tube or an endotracheal tube.
Now what can they do to bring FiO2 down and bring PEEP levels down? Good question. So if he has COVID pneumonia, they need to look what other issues are there? A lot of patients we’re seeing at the moment go from COVID pneumonia to a bacterial pneumonia and also to a fungal pneumonia, which means, antibiotics need to be started, antifungal medication needs to be started to manage the bacterial pneumonia and the fungal pneumonia.
Now, what else needs to happen is the proning needs to be continued, but also other treatment options such as potentially nitric oxide or epoprostenol need to be considered, especially with prolonged pneumonia or prolonged ARDS.
Other options that can be considered is potentially ECMO, if FiO2 levels and PEEP levels keep going up. ECMO is a bypass machine that can take over the function of the lungs for a period of time. Often it is a waiting game, and I know it can be very daunting and it can feel very lonely.
And while waiting, while your loved one is improving, and absolutely like you said, in your email, the risk for things to go wrong. The longer someone is on a ventilator with the breathing tube is definitely real, but unfortunately there’s not much else that can be done at the moment from what I described to you a minute ago. I hope that answers your question. I hope that helps.
Now, if you have a loved one in intensive care, go to intensivecarehotline.com, call us on one of the numbers on the top of the website, or send us an email to [email protected].
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This is Patrik Hutzel from intensivecarehotline.com, and I’ll talk to you in a few days.