My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives of families of critically ill patients in intensive care so that you can make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always, even if you’re not a doctor or a nurse in intensive care.

Now watch this video until the end to get all your questions answered and if you need my help, you can book a consulting call by clicking on the phone icon on the top right of your screen, or directly call me on one of the numbers on the top of our website at intensivecarehotline.com.

So today, I have a question from Esther who says,

“Hi Patrik,

My husband remains on the ventilator and breathing tube for ARDS.

So, for those of you who don’t know what ARDS is, ARDS stands for acute respiratory distress syndrome, also known as lung failure, and its lung failure. It’s usually a complete shutdown of the lungs.

And my husband has not been proned because they said he doesn’t improve when they prone him, so they stopped proning him to avoid abdominal damage. He is on blood pressure medication as his blood pressure is low, heavily sedated on paralytic drugs, and plenty of other drugs I don’t know. His lungs are still on daily dialysis, and he’s been given blood several times. He’s been on the ventilator for 4 weeks now. When is it possible to wean him off the ventilator?

From Esther”.

Now, Esther, thank you so much for your question, and I’m sorry you and your husband are going through this incredibly difficult time right now but the good news is there’s help for you.

Your husband has been on the ventilator and breathing tube for nearly 4 weeks now with ARDS. He’s on heavy sedation, paralytic drugs, blood pressure support, which is inotropes or vasopressors, daily dialysis, multiple blood transfusions, and they’ve stopped proning him because they said it wasn’t helping and they’re worried about abdominal damage.

Now, proning means that they’re turning a patient onto their tummy to help drain secretions from the lungs, let gravity work, and put a patient head-down while they’re lying on their tummy.
That can be very challenging, but it can also be very effective for some patients in ICU and I’ve certainly seen that.

Now you’re asking the critical question, when is it possible to wean him off the ventilator?
Well, let me walk you through what’s happening here and what your options are.

First off, you need to understand where your husband is right now. Your husband is in a very critical situation. ARDS is one of the most severe lung conditions we see in intensive care.

The fact that he’s been on the ventilator for 4 weeks, still heavily sedated, still paralyzed, still requiring blood pressure support, and still on daily dialysis tells me his lungs and other organs are struggling significantly.

The fact that they’ve stopped proning him is very concerning. Proning is one of the most effective interventions we have for severe ARDS because it helps recruit collapsed lung tissue and generally improves oxygenation, also by draining secretions naturally via gravity. If proning isn’t working or if they’re saying his abdomen can’t tolerate it, it suggests either his ARDS is extremely severe, or there are other complications we need to understand better.

Here’s what you need to know. Weaning from the ventilator is only possible when his lungs start to heal and recover and it doesn’t look like that’s happening right now.

So, what needs to happen before weaning can start? Before anyone can even think about weaning your husband from the ventilator, several things need to happen.

1. His oxygenation needs to improve significantly. His lungs need to deliver enough oxygen to his body without the ventilator doing all the work.
2. His sedation and paralysis need to be reduced. You can’t wean someone who’s heavily sedated and paralyzed because you need them to trigger their own breaths and eventually breathe on their own.
3. His blood pressure needs to stabilize without high doses of blood pressure medications such as inotropes and vasopressors such as adrenaline, noradrenaline, epinephrine, norepinephrine, dopamine, dobutamine, depending on his cardiac function as well. Because the cardiovascular system and respiratory system work together and if his heart and blood vessels can’t maintain adequate pressure, his body won’t tolerate the work of breathing.
4. His other organ systems need to improve. The fact that he’s on daily dialysis means his kidneys aren’t working. Multiple organ dysfunction makes it incredibly difficult to wean from the ventilator.
5. The underlying cause of his ARDS needs to be treated. Whether it’s pneumonia, sepsis, COVID-19, or any other cause, you can’t successfully wean until the primary problem is under control. So, the timeline question nobody can answer with certainty.

But now, Esther, I know you want to know when this will happen. I understand that desperation completely. But here is the reality, after 4 weeks on the ventilator with this high level of sedation, paralysis, and organ support, vasopressors, and inotropes, nobody can give you a definitive timeline.

Some patients with severe ARDS start to turn the corner after 2 to 3 weeks. Others take 6 weeks, others 8 weeks, or longer. Unfortunately, some patients’ lungs are so damaged that they never fully recover. The key factor is whether his lungs are showing any signs of improvement.

You need to ask the ICU team very specific questions:

Number 1.

What is his PaO2 (arterial oxygen partial pressure)/FiO2 (fractional inspired oxygen) ratio? This tells you how well his lungs are oxygenating. A ratio below 100 is severe ARDS, 100 to 200 is mild to moderate, above 200 is mild, and therefore they need to do arterial blood gases to give you that ratio.

Next, what are his ventilator settings?

Specifically, what is his FiO2 oxygen percentage and PEEP, which is the positive end-expiratory pressure? Are these being reduced over time or staying the same? It’s a very high chance your husband is on 100% FiO2 right now. Keep in mind, room air the air that you and I are breathing is 21%.

Next, what does his chest X-ray or CT scan show?

Are his lungs showing any sign of improvement, any clearing, or are they still completely wiped out and shut down?

Next, what is his compliance?

This measures how stiff his lungs are. Stiff lungs won’t wean easily. Also, what are they doing to treat the ARDS? Are they giving antibiotics, antivirals? Are they giving steroids? Are they giving nitric oxide? Are they giving epoprostenol? Again, nitric oxide and epoprostenol are known to open up some compartments of the lungs if the medications are effective.

Now let’s look at VV ECMO stands for extracorporeal membrane oxygenation, an option that might not have been discussed.

Esther, given how severe your husband’s ARDS is and the fact that proning has been stopped, I need to ask, has anyone even mentioned VV ECMO (Veno-Venous Extracorporeal Membrane Oxygenation)?

It’s basically a bypass machine. VV ECMO is a form of life support that takes over the work of the lungs completely, removing carbon dioxide and adding oxygen to the blood outside of the body.

It’s used for the most severe cases of ARDS when conventional ventilation and treatments like proning, nitric oxide, and epoprostenol isn’t working. VV ECMO can give his lungs time to rest and heal while the machine does the gas exchange work. It’s not available at every hospital, and it requires a specialized team, but for someone who’s been on maximum ventilator support for 4 weeks without improvement, it might be the intervention that saves your husband’s life.

If his current hospital doesn’t offer. ECMO, he might need to be transferred to a specialized ECMO center, but time matters.

The longer he stays on high ventilator settings with heavy sedation and paralysis, the more complications can develop, ventilator-associated pneumonia (VAP), barotrauma, pneumothorax, muscle wasting, and deconditioning, to name a few.

Now, also the VV ECMO can also be a bridge to a lung transplant if your husband qualifies, if your husband qualifies for a lung transplant. Now you can already see that the biggest challenge for families in intensive care, 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 up against because you didn’t know that VV ECMO was even an option.

So why you need all medical records and expert help now, is that here’s what concerns me the most about your situation. You’re telling me about all these interventions and medications, but you’re saying plenty of other drugs I don’t know, and you also didn’t know about VV ECMO.

You need access to all of your husband’s medical records immediately. You have a legal right to these records, and you need to understand exactly what medications he’s on and why. What’s his lab and pathology values? What are they showing? Kidney function, liver function, infection markers, arterial blood gases, and so forth. What are his ventilator settings and whether they are improving? What is the ICU team’s actual plan and what is their prognosis for his recovery? Have they considered VV ECMO? This is where having an independent ICU expert review his case becomes absolutely critical and lifesaving.

We’ve worked with families in exactly your situation since 2013, and I can tell you that having someone like myself or my team at intensivecarehotline.com review your husband’s medical records and participate in a consulting call with you and the ICU team will change everything. We can interpret his medical records and explain what’s actually happening. Ask the ICU team the right questions about his ventilator settings, prognosis, and treatment plan. Identify whether there are treatments like VV ECMO that haven’t been considered.

Advocate for your husband and make sure he’s getting the best possible care and treatment. Help you understand what realistic timelines and outcomes look like. Question decisions that don’t make sense or seem to be giving up too early. You should not be navigating this alone without understanding what plenty of other drugs means or what the actual plan is. The devil is in the detail, and you will see that you have already seen it in this video that the devil is in the detail.

So, what happens if your husband needs long-term ventilation? Now let’s talk about something the ICU team might start mentioning soon if they haven’t already a tracheostomy. If someone has been on a ventilator with a breathing tube through their mouth for 3 or 4 weeks and it isn’t showing signs of rapid improvement, the medical team typically recommends a tracheostomy. This is a surgical opening in the neck that allows for long-term ventilation and is generally speaking more comfortable and safer than an endotracheal tube; it eliminates the need for sedation and opiates most of the time. A tracheostomy doesn’t mean he’ll never come off the ventilator. It’s just a different route for the ventilator. Many patients with tracheostomies can eventually wean off and have the tracheostomy removed.

But here’s what you need to know. If your husband does get a tracheostomy and continues to need ventilator support, you have options beyond staying in ICU indefinitely. This is where intensivecareathome.com becomes incredibly important. With Intensive Care at Home, it’s our specialized service that allows ventilator-dependent patients, with or without tracheostomies, to receive ICU-level care at home.

Instead of your husband being trapped in an ICU bed for months on end, potentially exposed to hospital infections and away from family, he can continue his recovery at home with 24/7 specialized intensive care nursing. Ventilator management, tracheostomy management, all the monitoring and support he needs, similar to ICU, with family and loved ones around him, dramatically improves outcomes and wellbeing. This gets him out of ICU predictably and permanently while he continues to heal and work towards weaning from the ventilator in a much better, safer environment. Many families don’t know this is even possible until it’s too late. They think ICU or a long-term acute care facility are the only options, but Intensive Care at Home is often better for the patient’s physical and emotional recovery, better for the family, and can actually accelerate the weaning process.

So, what do you need to do right now, Esther? Here’s your action plan.

1. Request all of your husband’s medical records immediately.
   You need complete access to his chart, lab values, imaging, and medication list.
2. Ask the ICU team specifically about VV ECMO.
   If they say he’s not a candidate, ask why. If they don’t offer it, ask about a transfer to an ECMO center.
3. Get the ICU team to explain the exact plan and prognosis.
   Not vague statements, but specific goals, timelines, and what improvements they’re looking for.

And next, of course, call me at intensivecarehotline.com or visit intensivecarehotline.com to book a consulting call with me. We’ll review his medical records, participate in a call with the ICU team, and help you advocate for the best possible care and treatment for your husband and start exploring the option of intensivecareathome.com.

If it becomes clear he’ll need long-term ventilation support with a tracheostomy, don’t wait until it’s too late. Four weeks on the ventilator with this level of support means you are at a critical juncture. Decisions being made right now will determine whether your husband has the best chance of recovery or whether opportunities are being missed. You need expert guidance. You need to understand his medical records, and you need someone in your corner who can question and advocate for your husband right now when you don’t know what questions to ask.

And that’s exactly what we do at intensivecarehotline.com. We’ve helped thousands of families navigate situations just like yours, and we have saved many, many lives in intensive care.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over 5 years in intensive care. 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 with our consulting and advocacy because of our insights. You can verify that on our testimonial section at intensivecarehotline.com. You can verify it on our intensivecarehotline.com podcast section where we have done client interviews because our advice is absolutely life changing.

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.

That’s why we help you to improve your life instantly, making sure you make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always. That’s why you can join a growing number of members and clients that we have helped over the years, saving their loved ones’ lives.

That’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you simply cannot afford to get wrong. When I talk to families directly, I also talk to doctors and nurses directly, asking 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 real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if in case you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care, and 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 eBooks and 21 videos that I have personally written and recorded. All of that will help you to improve your life instantly, 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.

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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.