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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 a question from Tom who says, “My dad’s been in ICU for 30 days and he’s been on the ventilator for 30 days. What can be done to get him off the ventilator?” Well, that’s a great question, Tom. Now, it’s a very generic question, but I will break it down in a much detail for you so that you can understand what can be done.

Now, first things first, you have not shared with me whether your dad is on a ventilator with a tracheostomy or on a ventilator with a breathing tube because the answer to your question depends on whether your dad is on a ventilator with a breathing tube or with a tracheostomy.

Once again, the biggest challenge for families in intensive care, is simply 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.

So what can be done after 30 days on a ventilator, Tom?

Let’s just say your dad still has a breathing tube and can’t be weaned off the ventilator. The first thing that needs to be done, is do a tracheostomy. And I don’t have anything else to add because a tracheostomy should be done after about 10 to 14 days on mechanical ventilation with a breathing tube, also known as an endotracheal tube, and the inability to wean off the ventilator. If your dad is at day 30 with a breathing tube, he is beyond the shadow of a doubt, that beyond weaning, because otherwise he would be extubated and he would be off the ventilator.

So let’s look at scenario two that your dad has been in ICU and on the ventilator for 30 days with the tracheostomy. So what can be done?

So, first thing when a patient has a tracheostomy; going from a breathing tube to a tracheostomy, one of the main goals of the tracheostomy is to stop and eliminate sedation. When someone is having a breathing tube, the need for sedation and opiates is there. Opiates are strong painkillers such as morphine or fentanyl. And as soon, because the breathing tube in the throat is very uncomfortable and can most of the time only be tolerated with sedatives and opiates.

Now, once the tracheostomy has been done, the need for sedation and opiates should stop immediately. So that’s number one. Ask if your dad is completely off opiates and sedatives because you should no longer need them. Rather, a tracheostomy is much easier to tolerate in comparison to a breathing tube.

Number two, has he passed in his spontaneous breathing trials yet? Is he breathing on CPAP or pressure support? Now, I’m not doing a deep dive today into ventilation modes, but the goal for your dad should be to get on a CPAP (Continuous Positive Airway Pressure) or pressure support mode from a controlled mode where your dad is having a set rate breath per minute from the machine every minute. He should now be weaned off that rate and he should be able to initiate every single breath so that he gets a flow delivered by a CPAP or pressure support. Look out for that.

If he’s passing spontaneous breathing trials on the ventilator with CPAP or pressure support, he should then move on to be taken off the ventilator even if it’s only for a few minutes a day to begin with, right, and get on a trach collar or a trach mask.

Next, he can only really pass spontaneous breathing trials on CPAP or pressure support and move on to a trach collar or a trach mask if his pressure support is less than 10. If his PEEP (Positive End-Expiratory Pressure) is less than seven, let’s just say, ideally five, if his tidal volumes are adequate to his weight and tidal volumes adequate to a patient’s weight should be 7 to 10 mls per kilo. For example, if your dad weighs 80 kg and he takes 10 breaths per ml. That should be around 800 mls per breath right between 6 to 800 MLS, 600, 800 mls per breath. That would be a good indicator.

Next, his breathing rate should be within normal limits. Let’s just say 10 to 30 breaths per minute at the most with good tidal volumes per breath. His oxygen levels should be above 94, 95% oxygen saturation and his arterial blood gases should be within normal limits. I.e. pH should be normal PO2 (Partial pressure of Oxygen) should be above 70 to 80 millimeter per mercury, PCO2 (Partial pressure of Carbon Dioxide) or carbon dioxide should be within a normal range, 35 to 45 mmHg. If those boxes are ticked, then he should have spontaneous breathing trials. I don’t see high pressure support and then the next step is to go on to a trach collar or a trach mask.

Next, if your dad is not moving towards that, the next thing that needs to happen and should have happened already is, to get mobilized and get physiotherapy and physical therapy, get breathing exercises, coughing exercises, with the nurses with the respiratory therapist. If you’re in the U.S. or with experience ICU nurses can do that, respiratory therapists in the U.S. and ICU nurses do it in most other countries.

Mobilization with a physical therapist, potentially using a cough assist machine depending on why your dad is in ICU. You haven’t mentioned why your dad is in ICU.

Next good nursing care. What I mean by that is, making sure there’s good mouth care, there’s good skin care, and regular pressure area care. In a good ICU, your dad will have a shower. They will get your dad into a shower in a good ICU even on a ventilator. We’ve done that in most ICUs that I work in, we’ve showered our patients. There was no issue, with not showering the patient, you could get them to a shower trolley even if they were bed-bound. So, have a good look at whether they are giving good nursing care.

 

Most families in intensive care have no idea what to look for when it comes to good nursing care, but good nursing care is absolutely vital. Imagine you’re confined to a bed, critically ill and you’re getting a bed bath, you’re getting a wash, you’re getting a shower, that’s the highlight of your day. And imagine how much better you feel. It’s not rocket science. And yet many ICUs are dropping their standards when it comes to good nursing care. A lot of patients in ICU nowadays end up with pressure sores and that’s clearly negligence. No one should have pressure sores in the ICU if the nurses know what they’re doing. So what else can be done?

Optimizing a good day and night rhythm. Being awake during the day, being asleep at night. And that could also include, maybe off the ventilator during the day and then back on the ventilator overnight to give your dad a good rest. So he can be off the ventilator the next day and then slowly and gradually move towards being off the ventilator 24 hours a day. And once that’s achieved, then the next step is to ideally remove the tracheostomy.

But we’re not talking about that today, we’re just talking about, to get your dad off the ventilator because he’s been on it for 30 days, right? So those are the most important things to look out for, to get your dad off the ventilator as soon as possible. I’ll tell you another thing that’s important that is often neglected.

Regular people looking after your dad, i.e. if he has a different nurse every single day, that wouldn’t be good. So, having a team built around him that gets to know him that can work with him, that understands his preferences, that can work with him, on a regular basis, that would also help to get your dad off the ventilator.

And if God forbid all of that fails, there’s always the option to take your dad home on a ventilator with the tracheostomy and you can take your dad home with Intensive Care at Home. So have a look at intensivecareathome.com there you can take your dad home.

So go to intensivecareathome.com if you’re really, really stuck with not getting your dad off the ventilator. Intensive Care at Home provides a win-win situation for all stakeholders. Improves the quality of life for your dad, improves the quality of life for you and your family. Freeze up the ICU bed, cuts the cost of the ICU bed by about 50% of the cost, and weaning at home is still possible.

So that is my quick tip for today.

Now, we have a membership for families of critically ill patients in intensive care at intensivecarehotline.com. If you click on the membership link or if you are going 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 emails and we answer all questions intensive care related.

I have worked in intensive care for over 20 years in three different countries where I also worked as a nurse manager for over five years. And I’ve been consulting and advocating for families in intensive care for over 10 years all over the world as part of my intensivecarehotline.com, professional consulting and advocacy service. I can say without any exaggeration that we have saved lives for families in intensive care with our consulting and advocacy. We have saved lives. We improved outcomes. We’ve done it all really and got the results for the clients that they wanted. Have a look at our testimonial section and have a look at our podcast section for some client interviews to verify what I’m saying.

I also offer one on one consulting and advocacy for families in intensive care over the phone, Skype, Zoom WhatsApp, or whichever medium works best for you and I talk to you and your families directly and I will help you navigate this incredibly difficult landscape that is intensive care through proven tips, tricks, strategies. And I will help you to understand what’s going to happen next, what to anticipate what’s going to happen next, how to manage intensive care, what questions to ask, but I also talked to doctors and nurses directly on your behalf and with you of course, and I ask all the questions that you haven’t even considered asking, but you must ask in order to make informed decisions, have peace of mind, control, power and influence.

Also, we represent you in family meetings with intensive care teams. Once again, you will need clinical and advocacy representation in family meetings with intensive care teams. You need a strategy when dealing with intensive care teams, 99.9% of families in intensive care have no strategy whatsoever and they’re running towards the fire, they’re walking into these situations blindly. Only to find out that they get walked all over. You need to have a strategy when it comes to intensive care teams and that’s where I can help you fast.

Now, we also offer medical record reviews in real-time so that you can get a second opinion in real-time. We also offer medical record reviews after intensive care so that you can get closure. If you’re suspecting medical negligence or if you have any other answer, unanswered questions, we can do that for you as well.

And all of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or 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 the video with your friends and families, and comment below what you want to see next or what questions and insights you have.

Thanks for watching.

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

Take care for now.