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

So today’s tip is about, what if a tracheostomy is delayed, especially at the moment with COVID-19 pneumonia or COVID-19 ARDS, what happens? And I have done a video about this recently in a more broader sense that currently tracheostomies are being delayed with COVID-19 pneumonia and COVID-19 ARDS. Go and check it out on my YouTube channel or on my blog, intensivecarehotline.com.

Now to today’s question, which comes from Angie.

Hi Patrik,

My question is that my dad can’t have the tracheostomy at the moment because his oxygen levels are too high at 80% with COVID pneumonia. What are the next steps? I know there is risk involved in leaving him on the ventilator with a breathing tube too long, but waiting is the only choice I have at this time.

What can the ICU do to help my dad’s oxygen levels go down besides proning him? Thankfully, his body has been strong enough so far and no extra organs have been damaged.

From Angie

 

Now I need to give you a little bit more context here about the situation. So Angie’s dad has been in ICU for about close to a month now, with COVID pneumonia. And initially he was on a non-invasive BiPAP with a mask, then he ended up on the breathing tube, ended up being proned for the COVID pneumonia, but not with much successes. FiO2 (Fraction of inspired oxygen), his oxygen level on the ventilator are still around 80%, he’s on high PEEP levels, which is a contraindication for a tracheostomy at this particular point in time. And Angie’s obviously asking what can be done.

We’ve educated Angie that a tracheostomy normally is done after 10 to 14 days of mechanical ventilation and the inability to wean off the ventilator. But her dad is on too much support at the moment to have the tracheostomy done. So what can be done?

A) what can be done, is continuing the proning B) what can be done, is potentially look at treatment options, such as nitric oxide, epoprostenol and also potentially ECMO. Now, if ECMO is an option, patients on ECMO, most of the time end up on heparin, which is a blood thinner, which then might be a contraindication for a tracheostomy as well. So it can be a tricky situation what you’re facing at the moment, but most ICUs are not transparent with what treatment options might be available if proning isn’t working.

Obviously, when there’s COVID pneumonia, what we’re also seeing, sometimes there’s also another infection coming on top of that, either fungal infection or a bacterial infection on top of the COVID infection, which then needs antibiotics or antifungal medication, depending on what infection is on top of the COVID.

I do understand from our conversations we’ve had Angie that, your dad already had the standard COVID treatment with remdesivir and steroids. So, the next steps really would be nitric oxide depending on chest x-rays, depending on what else is going on and potentially epoprostenol.

So that is my quick tip for today.

I hope it’s all going well for you, Angie, and for your family. Hopefully your dad can come out of this and leave intensive care alive very soon, potentially with a tracheostomy.

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. Like this video, comment below what you want to see next, or what insights you have from this video, subscribe to my YouTube channel and click the notification bell.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days. Take care.