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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another tip for families in intensive care. Normally I say a quick tip, but today might be a little bit longer because I want to share question from a client and that might take me a little while to go through this today.

Also, if you’re finding these videos valuable, subscribe to my YouTube channel so you get the regular updates, click the like button and notification bell, also share the video with your friends and families, and comment what you want to see next or what questions you have from this video.

Anyway, without further ado, I’m going to read out an email from a client that we’ve been working with for the last couple of months and then I will get right into it.

So, this is one of our U.S.-based clients.

“Hi Patrik,

My dad has been at the LTAC (Long Term Acute Care) since the end of April. He has been off the ventilator for about a month now but has primarily been on the tracheostomy collar since then. He continues to have fevers, mostly low grade, and high white cell counts.

They continue to say its aspiration. Although he has had no need for an increase in oxygen. He’s been on 28% FiO2 (Fraction of Inspired Oxygen) consistently. His chest X-rays do not show anything significant, depending on whom you ask. He has had no respiratory distress. Arterial blood gases have been done a couple of times with no findings.

The issue is his secretions. He gets a different respiratory therapist every day or two. It really frustrates me how they have such a direct influence on his trajectory. Depending on who we get, he has no secretions, minimal secretions, and copious secrets. It’s all over the map with no rhyme or reason. It has been capped several times and then uncapped and put back on the tracheostomy collar due to an increase in secretions.

Still, sputum results are negative chest X-ray findings are minimal, and no increase in need for oxygen. Basically, they’re saying he can’t manage his own secretions. The speech therapist says his swallow is very weak and won’t let him eat. He doesn’t receive much therapy besides with me.

I was hoping to have a call with you and help me understand why they’re saying he has copious secretions one day and no secretions the next day. What can I ask them to do?

I have already asked them for mucomyst, and nebulizer, and he has received those for many weeks. Still moderate or thick secretions. I have asked for chest physiotherapy, and increased mobilization, and they do it when they feel like it.

I have asked for a smaller inner cannula so that he can cough the secretions out through his mouth. They say no in case he needs to go back on the ventilator. I don’t know what else to ask. They said two weeks ago that decannulating is off the table.

We continue to try to push ahead and wean towards decannulation but are fighting the system and doctors and nurses and respiratory therapists who want to be extremely conservative and safe rather than a little aggressive and safe.

If you can provide any advice on what to do here, how to get the secretions to thin out or go away? How to convince them to go forward with decannulation and weaning how to get them to look elsewhere for the cause of these fevers? I would love to have a call with you.

Dad is going to be discharged home at some point and I’m sure it will be on the tracheostomy collar because of how this LTAC stay is going. We don’t know how to get him weaned off the tracheostomy collar at home, and I’ve asked several people several times.

Thank you.”

This is a great email and I’ve had a consulting session with this client this week on the phone. I’m going to answer the questions here again.

So first off, for those of you that don’t know what LTACs are, LTACs are long-term acute care facilities. A lot of patients in the U.S. that end up with a tracheostomy and a PEG (Percutaneous Endoscopic Gastrostomy) tube in the ICU end up in an LTAC. LTAC stands for Long-Term Acute Care. It’s basically the better version of a nursing home, if that, from our experience.

I’m not overly surprised that things are not going great in there because from our experience, LTACs don’t know what they’re doing quite frankly and they don’t know how to manage tracheotomies, let alone ventilators. They obviously must have managed to wean this gentleman off the ventilator, but now they’re stuck with decannulating.

So, let’s go through this step-by-step.

“Why does he keep having a low-grade fever and white cell count high, especially if they can’t find anything in the sputum?” Look, that’s hard to say. Other things they need to check are obviously urine, whether he’s got a UTI, or a urinary tract infection. They need to check for blood infection and it’s often, from my perspective, having worked in intensive care for over 20 years in three different countries, patients in ICU always seem to have a low-grade fever very often.  So, it’s just the environment, I guess. It can be warm in there. There are so many bacteria floating around, which is why I believe home care is the best option even in a situation like that, and if you are interested in that, have a look at intensivecareathome.com, one of our sister sites intensivecareathome.com. But I will talk about Intensive Care at Home a little bit later.

“So, x-rays don’t show anything significant, and he has had no respiratory distress. ABGs (Arterial Blood Gases) are fine as well. The issue is his secretions. He gets a different respiratory therapist every day or two and it really frustrates how they have such a direct influence. Depending on who we get, has no secretions, minimal secretions, and copious secretion. It’s all over the map. He has been capped several times.” So, what that means is they’re capping the tracheostomy, have the cuff down, and then see whether he can breathe through the nose, bypassing the tracheostomy.

Then, they’re saying, “Then, they put him back on the trach collar because they’re saying he has an increase in secretions, and even though sputum results are negative. Now, basically, they’re saying he can’t manage his own secretions. Speech therapy says his swallow is very weak and won’t let him eat. He doesn’t receive much therapy besides me.” The critical point here, they’re saying he can’t manage his own secretions.

Now, why can’t he manage his own secretions? When I spoke to the client, she said that her dad has a very good strong cough and can bring up his secretions. If you can do that, that means he can protect his airway. That also means he can potentially swallow but this is obviously something that the speech therapist needs to decide, and they need to do a swallowing test.

Now, funnily enough, it turns out that this client has the cuff down. So, what that means is, I’ll just quickly show you what that looks like, tracheostomy. You can see that you can see at the end here, there’s a balloon, that balloon. If that balloon is deflated, which it is at the moment, it means that the airway is open, and then someone, if they can’t swallow, they would get their own saliva into the lungs, and they could end up with a chest infection. But if he doesn’t have a chest infection, possibility that he can actually swallow, but they haven’t tried it yet, that’s the problem.

So, with the “copious secretions”, here is the deal. As long as he has them and he can’t bring them up, he will need some suction. But again, talking to the client, she says, “Well, he’s got a good strong cough.” It’s her dad, by the way. Then, if he can manage those secretions, he might as well have the tracheostomy removed, especially if they cap him.

But here is another tip, they should absolutely downsize the tracheostomy. At the moment, I believe he’s got a size six. They should downsize it, and if he can still manage with a smaller tube to take it out completely. But a swallow test would certainly be advantageous.

Furthermore, like the client says, physical therapy, and mobilization, every day, because the more mobile her dad is, the higher chance he can cough, he can breathe, he can clear his airway, he can start swallowing, and start eating and drinking.

Not trying to eat and drink seems like madness simply because he’s got the cuff down all the time now. You’ve heard them say he will need a cuffed tracheostomy in case he needs to get back on the ventilator. Well, he’s been off the ventilator for the last month. Why would you not try and take the tracheostomy out and do a swallow test? They’re saying that decannulation is off the table and that is just ridiculous.

Furthermore, if he has copious amounts of secretions, there’s a high chance that secretions accumulate around the deflated cuff, which is also an infection risk, by the way. If they’re not being suctioned, so you could therefore use a subglottic tracheostomy.

You could look that up if you type into Google, subglottic tracheostomy, what that is. It gives you the opportunity to suction around the inflated or deflated cuff to get rid of those extra secretions. Again, it’s a cleaner option and it decreases the risk of infection.

So, I hope that helps.

If the speech therapist says he can’t swallow and the cuff is down, that’s a huge risk for aspiration. If he doesn’t have a chest infection, there is a high chance he can swallow. It illustrates my whole point that LTACs are really not good at what they’re doing. Look up the online reviews of LTAC. You get the picture, I don’t need to say much more than that. But similar to this client, we literally have clients begging us to help them to get their loved ones out of LTAC.

But then, she’s also saying in the last paragraph of the email, “Dad is going to be discharged home at some point. I’m sure it will be on the tracheostomy collar because of how this LTAC stay is going. We don’t know how to get him weaned off the tracheostomy collar at home, and I’ve asked several people several times.” No, they wouldn’t know how to wean the tracheostomy at home.

So, I mentioned briefly Intensive Care at Home earlier. So, with Intensive Care at Home, if you have a look at intensivecareathome.com, we are currently providing Intensive Care at Home services for our clients, adults and children with tracheotomies including ventilation with tracheostomy, but also noninvasive ventilation such as BIPAP, CPAP, seizure management, home TPN (Total Parenteral Nutrition) home IV fluids.

So, very specialized service, very unique service where we help patients and families to leave intensive care earlier and wean tracheostomies or ventilation at home if they’re a slow wean. So, yes, very few organizations can do that, wean a tracheostomy at home. We’ve done it at home numerous times including for children. It’s all possible but you need to know what to do, and you need to know what you’re doing.

You could go home but you would need 24-hour nursing care with intensive care nurses.  I don’t know where the area that you’re in. At the moment with Intensive Care at Home, we are operating all around Australia in all major capital cities and all rural and regional areas as well. If you’re in the U.S., we don’t have a physical presence yet, but it’s coming very soon. You should contact us as well.

If you’re watching this, if you’re in Australia, you’re a NDIS support coordinator, or you have a family member in intensive care, or you are a patient in intensive care yourself, a long-term patient in particular, please contact us at intensivecarehome.com and we can help you go home sooner.

If you’re a hospital CEO watching this or an ICU consultant, we can help you manage your beds more effectively while improving the quality of life and in some instances, quality of end of life for patients and families.

Anyway, that’s enough for today, I think. I hope I gave you enough insights there, what to do with the tracheostomy. You know what to look for when it comes to the decannulation.

One last tip, if secretions are excessive, which it doesn’t really sound to me like they are, they might be for short periods. But if secretions are excessive, if you have a loved one in intensive care for a tracheotomy patient or breathing tube, medications such as glycopyrrolate might help and also a restriction in fluid balance.

Sometimes other issues that can lead to having more secretions are things like heart failure and kidney failure because then it’s easier to get fluid overloaded, and fluid accumulation in the lungs, and that could contribute to having increased amount of secretions.

So that’s my tip for today.

If you have a loved one in intensive care and you need help, go to 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.

Also, if you have a loved one in intensive care and with a tracheostomy or long-term ventilation with a tracheostomy, BIPAP, CPAP TPN, and you want to go home, please contact us at intensivecareathome.com. Call us on one of the numbers on the top of our website or send us an email to [email protected].

Also, have a look at our membership for families in intensive care at intensivecaresupport.org. There, you have access to me and my team, 24 hours a day, in a membership area and via email and we answer all questions, intensive care and Intensive Care at Home related.

If you need a medical record review in real-time and a second opinion, please contact us as well. We provide medical record reviews and second opinions in real-time. I also offer one-to-one consulting and advocacy for families in intensive care including talking to doctors and nurses directly and representing you in a family meeting, for example. If you need a medical record review after intensive care, we can help you with that as well.

Subscribe to my YouTube channel for regular updates for families in intensive care, click the like button, click the notification bell, share the video with your friends and families, and comment below what you want to see next or what questions and insights you have from this video.

Thank you so much for watching.

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

Take care for now.