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If you want to know if your loved one after 10 days of ventilation with a breathing tube and now in pressure support can be extubated, stay tuned. I’ve got news for you.

So today, I have an email from Vicky who says, 

“Hi Patrik,

My mother is in ICU without any neurological problems, and she’s on pressure support ventilation. Now, she has a cough with suction, arterial blood vessels are good. She has been on the ventilator 10 days. This is the 3rd day on pressure support. All sedation has been off. She is, however, not following commands.

Do you think my 84-year-old mom just needs more time clearing propofol and fentanyl? Her renal function took a hit due to a hypertensive crisis and then being on Bactrim. What do you think?

You are fantastic and by the way, I agree with mobilization. Thank you.

From, Vicky.”

Well, Vicky, there’s a little bit of a contradiction in your email. You’re saying, “My mom has no neurological problems”, and then you’re saying, “She’s not waking up”. So, if she’s not waking up, there must be a neurological problem for now. It may not be a stroke, God forbid, it may not be seizures. It could just simply be, she’s not waking up because she still has too many sedatives on board. But let’s look at this a bit closer.

By the way, my name is Patrik Hutzel from intensivecarehotline.com and this is another quick tip for families in intensive care.

So, she has a good cough, which is good, arterial blood gases are good. She’s been on the ventilator for 10 days. This is the 3rd day on pressure support. What does it come down to? It pretty much ticks all the boxes with the exception of she is not waking up. That is a red flag.

The other red flag that I’m having is, I don’t know how much pressure support. So, is she on 20 of pressure support, 16 of pressure support, 14 of pressure support, 12 of pressure support, what pressure support is she on? Anything more than 12, extubation is probably going to be difficult.

But then it also comes down with the pressure support. What are her tidal volumes? If she’s on the pressure support of 12 and she’s breathing, let’s just say 500 mLs, which may be adequate, depending on her weight. Then, maybe, a trial extubation is okay if she’s between 8 and 12. If she’s on a pressure support of 14 and she’s breathing less than 400 mLs, and then she’s probably not ready for extubation. If you’re dropping it down even further, let’s just say you’re dropping it down to 8, and her tidal volume is 200 mLs, she’s definitely not ready for extubation.

Then it also comes down to, what is her breathing rate? Is her breathing rate normal? Is it shallow? Is it fast? Is it slow? And how does that correlate with the tidal volume? How does that correlate with the tidal volume, with the minute volume, with the arterial blood gases and so forth?

So, with her renal function taking a hit, there’s also a question, is she potentially fluid overloaded. Does that impact on not being able to extubate?

Now, if she’s not waking up and she can’t protect her airway, however, she is ready to be taken off the ventilator, then a tracheostomy might be needed, but then she should be able to come off the ventilator. 

But in the ideal world, she wakes up, is on minimal amount of pressure support, normal breathing rate, normal tidal volumes are adequate for her weight, normal blood gases, chest X-ray looks fine, she can obey commands, she can cough, then let’s extubate. But if she’s not waking up, but pressure support is low, but she can’t protect her airway, then a tracheostomy might be the next thing to do.

However, if she’s coughing, she does have a good strong cough, and she’s not waking up, she might also be ready for extubation. She might, if she can protect her airway.

So, I hope that really explains to you whether she’s ready for extubation or not. But another thing that needs to happen, she needs to be mobilized she needs to have physical therapy if she can’t wake up because if she’s been lying in bed for 10 days in an induced coma, it’s going to be very challenging for her to wake up if she’s not getting stimulation, mobilization, and patients, even on a breathing tube can be mobilized in special chairs in ICU. There should be no excuse whatsoever.

So, I hope that answers your question. If pressure support is at a low level between 8, 10, 12, let’s just say, tidal volumes are fine, breathing rate is normal, arterial blood gas is fine, she is coughing and can protect her airway, chest X-ray is clear, maybe a trial extubation is warranted here. If not, then maybe a tracheostomy but take her off the ventilator. She should be able to pass the spontaneous breathing trials there fairly quickly and mobilization, mobilization, mobilization.

So, I have worked in critical care nursing for 25 years in 3 different countries where I worked as a nurse manager for over 5 years in intensive care, and I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care. You can verify that on our testimonial section and you can verify it on our intensivecarehotline.com podcast section where we’ve done client interviews.

Our advice is absolutely life changing. Once again, you can verify that on our testimonial section and on our intensivecarehotline.com podcast section. It’s life changing, we have saved many lives. You can join a growing number of hundreds of hundreds of members and clients that we helped over the years to improve their lives instantly when they have a loved one in intensive care, so that they can make informed decisions, have peace of mind, control, power, and influence, making sure their loved ones always get best care and treatment in ICU.

That’s why I do one-on-one consulting over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I talk to doctors and nurses directly on your behalf. I handhold you through this once in a lifetime situation that you can’t afford to get wrong. When I talk to doctors and nurses directly, I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. I also represent you in family meetings with intensive care teams.

We also do medical record reviews in intensive care, so that you can get a second opinion while your loved one is in intensive care. We also do medical record reviews after intensive care, in case you have unanswered questions, you need closure or if you are suspecting medical negligence.

All of that, you get at intensivecarehotline.com, where we also have a membership for families in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly.  In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 e-books and 21 videos that I’ve personally written and recorded. All of that will help you to make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment, always.

All of that, you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care, click the like button, click the notification bell, comment below what you want to see next, what questions and insights you have from this video.

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Thank you so much for watching.

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

Take care for now.

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