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

So when someone is doing their research at the moment, if they have a loved one in intensive care, especially with COVID at the moment, they’re trying to find out, how long can someone stay on a breathing tube or an endotracheal tube? How long can someone be on a ventilator before they need a tracheostomy? And when you look at research pre-pandemic, pre-COVID, you will find that the standard time for someone to be on a breathing tube or an endotracheal tube before they can have a tracheostomy is around 10 to 14 days. Now that has probably gone out of the window with COVID. And I’ll tell you why, let me explain.

So when someone goes into ICU with COVID, they often end up with a COVID pneumonia or with COVID ARDS also known as lung failure. When someone is going into ICU with COVID pneumonia or COVID ARDS, the oxygen requirements that they need on a ventilator, as well as PEEP and other supports from a ventilator are very, very high. And we’ve known now, we can see from experience now, that it takes a long, long time for oxygen requirements to come down. Patients are often being proned, or they end up on ECMO and that further complicates things. And it also delays the time when someone can have a tracheostomy.

Now, this is simply a safety issue. So when someone is on 100% of oxygen, also known as FiO2 in intensive care and has a very high PEEP, let’s just say a PEEP of 10 to 15. They can’t have a tracheostomy because it’s simply unsafe to do a tracheostomy. Oxygen requirement for a tracheostomy to be done, need to be generally speaking below 40% and PEEP needs to be less than 8. Some people might say 10, but it usually needs to be less than 8. And that often can’t be achieved very quickly for patients with COVID pneumonia or with COVID ARDS.

Now, some COVID ARDS patients may also be on ECMO. And when patients are on ECMO, they’re also on heparin, which is a blood thinner. That again, can be a contraindication for a tracheostomy because patients could bleed to death. So heparin needs to be stopped before a tracheostomy. And again, if someone is on ECMO, you can’t really stop heparin. So, it’s a fine line there that needs to be walked. So therefore you will see that the 10 to 14-day timeline for a tracheostomy be done when someone is on a ventilator with a breathing tube is often not adhered to, just simply because of the risk factors attached and the high oxygen and PEEP requirements. I have now seen that some patients in ICU unfortunately, have been on a breathing tube with a ventilator for two months before they had a tracheostomy before it was safe to do so.

So the timelines have changed. The principle hasn’t changed but the timelines, unfortunately, have changed. And there are side effects with that, because if someone can’t have a tracheostomy, they need to be in an induced coma  for much longer because the breathing tube is so uncomfortable, but that most patients need to be sedated with midazolam or versed, propofol, precedex and they also often need to have morphine or fentanyl for pain management. So it has many undesired side effects that someone can’t have the tracheostomy after 10 to 14 days, if oxygen requirements and PEEP requirements are high.

So that is my quick tip for today.

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.