Podcast: Play in new window | Download

Subscribe: Apple Podcasts | RSS

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

I have an email from Jin who says,

“Hi Patrik,

We would like to get some help. My 89-year-old dad was supposed to discharge last Sunday and the moment we moved him into the car, still at the hospital lobby, he suddenly collapsed. We then immediately rushed into the emergency room. They did CPR (cardiopulmonary resuscitation) for him and got his heartbeat back after 26 minutes and he was under sedation and intubation. 

He has been coughing and had aspiration pneumonia the first time he was admitted. Lots of phlegm, and we are still not sure the reason he collapsed. He had multiple strokes previously and the last one happened last Christmas and caused his right hand and right leg could not move. He also had dementia and Parkinson’s. The throat is not sensitive, he always chokes on liquid, but he’s still able to take porridge before he got admitted.

Back to now, he’s intubated for a week. Sedation was off 6 days ago. So far, he has not woken up. He has been having some self-breathing. He’s at PEEP (positive end expiratory pressure) of 10 and breathing can go up till 24 – 25 breaths per minute. However, just last night they tried to have a CT scan for him, not sure what happened after that. The expiratory rate decreased.

The doctor did a new round of intubation for him saying that the tube connections wasn’t good enough and caused an air leak. They sedated him a bit for him again. Now, PEEP is at 10 and ventilator rate number is at 14. His kidney creatinine is increasing every day. Now, up to 320 from Day 1-70. He’s got an enlarged heart.

The doctor said we can keep him as far as we want but also worry the complications that may happen along the way. Tracheostomy is mentioned, as well as end-of-life. My family decided to keep him in the hospital till the very last minute. We are very worried and scared.

My questions are:

Number 1, can they extubate him if he can self breathe? As I searched saying, ventilator too long may cause kidney failure as well. Dad’s body is swelling. Do we need the patient to be conscious before extubating him? The doctors also worry his airway got stuck back if extubated.

Next question, the doctor is not suggesting dialysis anymore due to his age and very weak heart. What should we do?

Number 3, can we keep the tube ventilator for him without going for a tracheostomy?”

Those are all great questions, Jin. 

Let’s go through them one by one. Can they extubate him if he can self breathe? Not necessarily, and I’ll tell you why.

So, I’ve written an article, how to wean a critically ill patient off the breathing tube and the ventilator?” and that’s a step-by-step explanation what needs to be done before someone can be extubated and have the breathing tube removed.

Here is what I can see. Your dad might be able to breathe spontaneously. He might. However, with a stroke, there’s no guarantee he can swallow and he’s coughing. If he’s not swallowing and coughing, the issue is that he would aspirate.

If he aspirates, even though he can spontaneously breathe, he will need a tracheostomy to protect his airway so that (A) he will not aspirate saliva in his lungs and cause an aspiration pneumonia because the tracheostomy will have a block and have the cuff up and therefore, aspiration is minimized if not excluded.

So, to answer your question, “Can they extubate him if he can self breathe?” Only if he can swallow and if he can cough.

“Do you need a patient to be conscious before extubating him?” Yes, absolutely, you do. Another missing link here is he needs to be more awake. He needs to be able to follow commands. But for more and more detailed information, check out the article and video, “How to wean a critically ill patient off the ventilator and the breathing tube?”

Next question, “The doctor is not suggesting dialysis anymore due to his age and very weak heart. What should we do?” 

Well, if dialysis is potentially too aggressive for him, then I would go down the track of hemofiltration. Hemofiltration is a more gentle approach to kidney dialysis. Dialysis is short up on set of lots of fluid removal. Whereas hemofiltration is a more gentle approach. You go over 24, 48, even 72 hours and you remove, 50 ml an hour, 100 ml an hour. That is a much gentler approach and can be done. So, you should be asking for that.

Now, this is once again, the biggest challenge for family in intensive care is that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights and they don’t know how to manage doctors and nurses in intensive care, and that’s exactly what you’re dealing with.

Last question for you is “can we keep the tube ventilator for him without going tracheostomy?” Look the cut off for leaving a breathing tube instead of a tracheostomy is around Day 10 to Day 14. What that means is, you’re now 6 days in, you still have a little bit of time and see whether your dad can wake up. But after Day 10 to Day 14 of showing the inability to be weaned off the ventilator or him not waking up him, not being able to cough, then the answer is no, because it’s extremely uncomfortable and it could harm the vocal cords irreversibly and therefore, I wouldn’t recommend it. 

So, I hope that answers your questions.

I have worked in critical care for nearly 25 years where I have worked as a nurse manager in intensive care for over 5 years. I’ve been consulting and advocating for families in intensive care all around the world since 2013 here at intensivecarehotline.com.

I can confidently say we have saved many lives for our clients. You can verify that on our testimonial section or on our intensivecarehotline.com podcast where we have interviewed our clients.

That’s why we created a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership 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, sharing all my vast intensive care nursing experience with families in intensive care, making sure they can make informed decisions, have peace of mind, control, power, influence so that you can influence decision making fast making sure your loved one gets the best care and treatment, and you can join us in the membership. We have helped hundreds of paying clients over the years. Like I said, we have saved many lives, and I can say that without the slightest hint of exaggeration.

I also do one-on-one consulting and advocacy over the phone, Zoom, WhatsApp, Skype, whichever meeting works best for you. I talk to you and your families directly. I talk to doctors and nurses directly. I also represent you in family meetings with intensive care teams and I handhold you through this once in a lifetime situation that you simply 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.

We also do medical record reviews in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

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, share this video with your friends and families, comment below what you want to see next, what questions and insights you have.

I also do a weekly YouTube live where I answer your questions live on a show and you get notification for the YouTube live if you are a subscriber to my YouTube channel or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

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.