Dad developed a Pneumonia and now needs to be ventilated again, what should we do to make sure he keeps improving?

Hi, it’s Patrik Hutzel from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!

This is another episode of “YOUR QUESTIONS ANSWERED“ and in last week’s episode I answered another question from one of my clients and the question in the last episode was

How Physical Therapy/Physiotherapy Will Help Your Loved One To Get Off The Ventilator And Tracheostomy!

You can check out last week’s episode by clicking on the link here.

In this week’s episode of “YOUR QUESTIONS ANSWERED“, I want to continue answering the next questions regarding James’ and Christine’s Dad in ICU who’s had a haemorrhagic stroke.

James’ and Christine’s Dad had a brain decompression where they evacuated a large bleed from his brain after the haemorrhagic stroke. And their Dad also underwent a craniectomy (removal of skull) to decrease the brain pressures after the bleed.

James’ and his sister Christine were getting their Dad in one of the best hospitals in the USA, the Cleveland clinic in Ohio.

In the meantime, their Dad was getting a tracheostomy because he couldn’t be weaned off the ventilator and the breathing tube. He also had a PEG tube for feeding inserted.

He also had ongoing seizures due to the stroke and his anti-seizure medications needed to be optimized so he could “wake up” and progress to Neurology Rehabilitation.

In today’s 1:1 consulting and advocacy sessions with James and his sister Christine, we look at some setbacks their Dad is going through.

He had to be put back on the ventilator due to a Pneumonia and he also ended up with a central line (CVC) and arterial line again.

So in today’s episode of “YOUR QUESTIONS ANSWERED”, I answer a series of questions from James and his sister Christine again that are excerpts from various 1:1 phone/email consulting and advocacy session with me and the topic this week as part of this series of 1:1 consulting and advocacy session with me and the topic this week is

Dad developed a Pneumonia and now needs to be ventilated again, what should we do to make sure he keeps improving?

You can also read or watch previous episodes of 1:1 consulting and advocacy with James and his sister Christine here

Hi Patrik,

please see questions below.

Patrik they put in the arterial line but they never started him on any vasopressors/inotpropes because I guess his blood pressure came back in the normal on his own but they wanted the arterial line there just in case.

Do you have any idea why they gave him an IV through his neck to deliver antibiotics?

I think this is what made him so agitated and angry today. I don’t know why maybe he was in pain but he did not want the IV going through his neck for whatever reason.

They put him back on the ventilator last night. However, they are going to leave him off the ventilator until later all night and on the tracheostomy collar which in my opinion may be a bit too soon.

They are testing his sputum for pneumonia.

Right now his temperature is 98.7F (37.05 C) which is normal.

They did do a chest x-ray which was negative but it is a good point that they should check his catheter.

They did check his feeding tube but seems to be fine.

My father is not a depressed person however if an antidepressant will help his healing and maybe something to consider. At the moment he seems more angry than anything else and I am trying to figure out where his anger is coming from!

Please advise on the above and let us know your thoughts.

James

Hi James & Christine,

the IV in his neck is a central line or central venous catheter also known as a CVC line. They can administer Antibiotics (AB’s) as well as inotropes/vasopressors via the CVC. They can administer AB’s via a peripheral IV catheter but not the inotropes/vasopressors if needed, they have to be given via the CVC.

Also, a low blood pressure and potential infection sometimes requires fluid boluses and again it’s a lot easier to give it via the CVC and just leaves more options because of more IV access lumens being readily available. On the other hand the CVC also poses a risk for infection if it stays in for >7 days.

They would have to do a chest x-ray to confirm the right position of the CVC and also look at his chest in terms of ruling out Pneumonia /chest infection and look at effectiveness of his breathing.

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Placing the CVC in his neck would have made him agitated no doubt about it. They would have had to lie your Dad flat for a while to insert the CVC, not pleasant for sure.

Testing sputum for Pneumonia is good and some of the answers will also be in his chest x-ray results.

Regarding depression/anger, again, many Patients in Intensive Care especially after now 5 weeks?, you can appreciate that as time progresses, frustration, anger and depression may come into the mix. I’m all for minimizing drugs as much as possible, if depression is real an antidepressant might help in the short term.

As long as he can tolerate staying off the ventilator and as long as his oxygen saturation is >92%, the chest x-ray is clear and he’s not struggling to breathe (for example breaths per minute should be<30), keeping him off the ventilator is fine. Moreover, now that he’s got the arterial line they will have all the test results readily available to gauge the effectiveness of the tracheostomy collar vs ventilation.

Having said all of that, if he has a Pneumonia putting him back on the ventilator might help by simply giving his lungs a bit of a rest as well as added on pressure via PEEP (Positive end-expiratory Pressure). The PEEP will help in opening up any collapsed parts of the lungs.

Hope that helps James & Christine.

Give me a call if you want to discuss in more detail.

Kind Regards

Patrik

Hi Patrik,

You mentioned in your email

“Moreover , now that he’s got the arterial line they will have all the test results readily available to gauge the effectiveness of the tracheostomy collar vs ventilation.”

Can you please explain this to me more in depth?

Many thanks

James

Hi James & Christine,

An arterial line or arterial catheter will give the option for doctors and nurses to draw bloods for testing anytime without needing to do a stab. It’s effortless because of the arterial line is stuck and secured in an artery.

Furthermore, unlike blood samples drawn from venous blood, arterial blood will give readings about oxygen levels as well as Carbon dioxide (CO2) levels in the blood. Nothing could me more accurate and also more current to assess the effectiveness of breathing in real live time, besides visibly gauging breathing efforts of your Dad such as breaths/minute and assessing his work of breathing (WOB) including oxygen saturation on the monitor.

For example PO2 (oxygen levels) in the arterial blood gas should be ~75-100 mmHg

PCO2 (Carbon Dioxide levels) in the arterial blood gas should be ~35-45 mmHg

Any measurements outside of those levels usually need treatment and therapy.

You can find out more about the arterial line and its purpose here

https://intensivecarehotline.com/arterial-line-insertion/

https://intensivecarehotline.com/arterial-catheter/

https://intensivecarehotline.com/blood-pathology-tests-in-intensive-care/

Furthermore, if your Dad needs inotropes/vasopressors such as Norepinephrine/Epinephrine, it is considered life support, therefore a real time reading of his blood pressure would be necessary and the arterial line can transduce a real time, live blood pressure on to the monitor and inotropes/vasopressors can be titrated up and down according to the target blood pressure to achieve that blood pressure. An arterial line can be very useful in sick Intensive Care Patients and in fact arterial lines for sick Patients in ICU are imperative.

I hope this helps and is not too technical, I’m very happy to explain over the phone if it helps.

Kind Regards

Patrik

Recommended:

1:1 email counselling and consulting with Patrik

1:1 phone and email counselling and consulting with Patrik

Thanks again Patrik,

No not too technical.

Is there a method to weaning off ventilator with the data used from the arterial line or is it simply used to monitor oxygen and co2?

James

Hi James,

When Patients have prolonged times off ventilation they often don’t have an arterial line anymore because it’s also an infection risk.

It’s good to have data and assess the weaning process against it and make changes, but it’s often not necessary.

If your Dad had one day off the ventilator already that’s a good sign. If he has to go back on it for prolonged periods it’s good to have the arterial line to make assessments.

In order to keep weaning I would refer you back to the attached email and follow those steps.

“Normal” weaning off the ventilator with tracheostomy goes as follows

Get off the ventilator on to the tracheostomy collar for 1-2 hours, then back on ventilator and assess effectiveness of such, including breathing pattern, oxygen saturation as well as arterial blood gas (ABG) whenever an arterial catheter is present

Increase the time off the ventilator during the day time, 1-2 hours off the ventilator, back to 1-2 hours on the ventilator until the time off the ventilator can be gradually increased so that Patients can stay off the ventilator throughout the day

Once Patients can stay off the ventilator during the day time and “only” need night time ventilation, they should be able to eventually not be needing night time ventilation as well

Time lines around the process may vary from a few days to few weeks or even months. In rare cases, Patients will need tracheostomy ventilation for the rest of their lives

As I mentioned before, ICU is often two steps forward and one step back, therefore if things progress for now, there maybe setbacks

The weaning process should be supported by ongoing mobilisation, as breathing tends to be easier in a chair and also breathing/respiratory muscles will be strengthened with mobilisation. This should also be supported by chest Physiotherapy

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THE 7 ANSWERS TO THE 7 MOST FREQUENTLY ASKED QUESTIONS IF YOUR LOVED ONE REQUIRES ONGOING MECHANICAL VENTILATION WITH TRACHEOSTOMY IN INTENSIVE CARE

For the method described in the email, an arterial line is often not necessary although preferred.

I hope that makes sense. Any questions please let me know.

Hope that helps.

Kind Regards

Patrik

Hi Patrik,

Thank you for this detailed and specific information, this is very good advice.

Just curious. Why is it specifically that you are against an LTAC (long-term acute care)?

I know why they are bad but just wanted to hear it in your words.

Also, why do you think step down is better?

Many thanks

James & Christine

Hi James & Christine,

Step down will keep him in hospital and close to ICU.

LTAC (long-term acute care) is implying long-term care.

Not many Patients and families report good things about LTAC.

Having way too many enquiries from families with a loved one in LTAC.

You don’t want long-term ventilator weaning.

Why would anybody want to have LONG-TERM CARE?

It doesn’t make sense to me.

You want to focus on neurology rehab.

Step down will bring him closer to that.

Besides, if he does need long-term ventilation, your Dad would be so much better off going home with a service like INTENSIVE CARE AT HOME.

Hope that helps. Any questions please let me know.

Kind Regards

Patrik

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