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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 our readers and the question was
What Are the Benefits of Early Mobilization of My Loved One in the ICU?
You can check out last week’s question by clicking on the link here.
In this week’s episode of “YOUR QUESTIONS ANSWERED”, I am here with a live stream today, where I want to answer your questions if you have a loved one in intensive care. And this is one of the most commonly asked questions for families in intensive care and it’s a question that we get all time. And today’s live stream is about how long can a breathing tube or endotracheal tube stay in intensive care.
How Long Can a Breathing Tube or Endotracheal Tube Stay In in Intensive Care? Live stream!
Welcome to another live stream. Today, I want to focus on how long can a breathing tube or an endotracheal tube stay in when someone is on a ventilator in intensive care. I obviously want to take your questions live here as well as you join in and ask your questions. You’re also welcome to call in on the show live. I’ll quickly give you the numbers. That is 415-915-0090 for our viewers in the U.S. and Canada. That is again 415-915-0090 for our viewers in the U.S. and in Canada. In the UK, the number is 0118-324-3018. That is again for our viewers in the UK, 0118-324-3018. For our viewers in Australia it’s 041-094-2230. That is again 041-094-2230. You can dial those numbers from any other country as well, and just use the prefix that you need to dial overseas.
So, let’s dive right into our topic today, how long can a breathing tube or an endotracheal tube stay in when someone is on a ventilator in intensive care? Most people that go into intensive care and need mechanical ventilation end up with a breathing tube or an endotracheal tube in the mouth, it’s going into the lungs and it’s being attached to a ventilator. Part of that is being induced into a coma with sedation and opiates, because the breathing tube, an endotracheal tube is very, very uncomfortable with mechanical ventilation. It’s very uncomfortable with the breathing tube in particular, and therefore, an induced coma is necessary.
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So, what gets people into an induced coma and on a breathing tube/ventilator in the first place? Well, there are many scenarios. It could be after surgery, people still need the ventilator because maybe surgery was taking very long, maybe surgery was something like open heart surgery, where there was hemodynamic and respiratory instability, and therefore people need to be ventilated for at least 24, 48 hours to come off the ventilator. So, that’s one of the reasons, but other reasons are simply critical illness. It could be a septic shock. It could be a pneumonia. It could be COVID nowadays. It could be ARDS or lung failure. It could be trauma. It could be a head injury. It could be a stroke. It could be Guillain-Barre syndrome. It could be seizures. It could be other neurological conditions. It’s an endless list of why people end up with a breathing tube/endotracheal tube and on a ventilator.
The other reason why people get induced into a coma and end up with a breathing tube or an endotracheal tube and end up on a ventilator is simply that they need a rest from their critical illness and they need to rest to recover. When people are going into almost what is a natural coma, they’re still at risk of stopping breathing or having airway issues, hence they are induced into a coma and go on a breathing tube/endotracheal tube and end up on a ventilator. So, that’s sort of to set the scene a little bit.
I know some viewers might have the question, “Okay, what’s first? Is it the breathing tube or endotracheal tube first, or is it the induced coma first and the sedation and the opiates first?” It’s almost like a chicken and egg question. One goes with the other. Let’s just say, God forbid, someone is coming into ICU after some trauma, maybe they’ve fallen off a roof or they had a motor vehicle accident or whatever the case may be. In order to deal with their injuries, they often need to be induced into a coma. Because they often need surgery. They often need pain management. On the other hand, if they’re coming in with respiratory issues as part of their trauma, they also need the mechanical ventilator and the breathing tube, hence an induced coma will follow. So it’s really a chicken or egg question. It’s slightly different, but one definitely goes with the other and you can’t do one without the other.
So then when someone is in an induced coma and on a ventilator with a breathing tube or endotracheal tube, what are the next steps? Well, a mechanical ventilation should be optimized for the situation that a critically ill patient is in. What is the right ventilation mode? Is there adequate oxygenation? Is CO2 managed well? Are tidal volumes managed well? Is there adequate ventilation, PEEP levels, pressure support levels, what ventilation mode needs to be used in the first place, making sure that a critically ill patient gets what they need in order to maximize their situation in a positive way? So when that is done, it’s often not a straight line. You start someone off often in an SIMV (Synchronized Intermittent Mandatory Ventilation) control mode with the volume control or pressure control, and then you need to assess regularly and quickly whether that is adequate for a critically ill patient. You can do that by, again, assessing the ventilation parameters. You can assess regularly the hemodynamic stability and you regularly need to assess obviously oxygenation. You can do that by checking oxygen saturation just with a finger clip consistently.
You can also check and you need to check arterial blood gases, making sure that oxygen in the arteries, as well as the CO2 level in the arteries are within physiological limits. So that’s how you can assess. Other things you need to assess is tube tolerance, of course. Is the induced coma at the right level? Because if you’re putting someone on a breathing tube, endotracheal tube, and they’re not sedated enough, there’s a very good chance they’re tube intolerant, they might be fighting the ventilator. So, there’s all these things that need to be optimized when someone is ending up on an endotracheal tube/breathing tube and a ventilator.
How long should it take to get off that ventilator? That’s a very interesting and also tricky question. Again, it very much depends on the situation. Of course, you want to minimize the number of days, hours someone is on a ventilator. You want to minimize it to the lowest possible time, simply because the risk for someone being ventilated is high to end up with a pneumonia, to end up with other complications, such as barotrauma/pneumothorax. If the pressures are too high in the lungs, there is a real risk for barotrauma/pneumothorax to occur, where the patient then needs a chest drain. So, you want to minimize the number. The risk for that or ventilator-associated pneumonia is real, and therefore you should minimize the time someone spends in an induced coma to as little as possible.
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Let’s just take an example. Let’s just say someone coming into ICU with a pneumonia, and for whatever reason, the pneumonia is so bad that they can’t breathe any more. Their oxygen have dropped to a point, where they need to be ventilated and go into an induced coma. How long should that take? Well, let’s just say it’s a bacterial pneumonia. You should start antibiotics as quickly as possible. And then after you started the antibiotics, you should assess whether the antibiotics are working and you should assess whether a critically ill patient is responding to those antibiotics, and then also can have the ventilation support reduced and eventually removed because the pneumonia is clearing up because the antibiotics are working.
Again, then it comes down if that’s the case, you then need to take off sedation, you need to take off opiates, and then you need to make assessments. Is that patient waking up appropriately? Can they follow commands? Can they breathe? Can they cough? Can they squeeze hands? Can they follow commands to the point where when you take out the breathing tube, can they assist with following the instructions how to breathe, how to cough. Because that’s really important that they can manage an airway independently or that they can manage their own airway independently once they’re off the breathing tube/endotracheal tube.
Often, when patients come out of the induced coma, one of the challenges is simply that they’re fighting against the ventilator. Okay. Depending on the nature of their critical illness, they may be too weak to breathe. But what is important here is a lot of families come to us when they have a loved one on a ventilator with a breathing tube/endotracheal tube and they say, “Oh, my loved one’s been ventilated now for eight or 10 days, and they can’t come off the ventilator. They’re not waking up even though they’ve been off sedation now for a few days. They’re not waking up. What should we be doing next? The ICU team is talking about a tracheostomy as a next step.” And then my response to that is, “Has the ICU team done everything beyond the shadow of a doubt to get your loved one off the ventilator and the breathing tube in the first place?” That is the most important question to ask in a situation like that.
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What does that mean? What does that even mean, have they done everything beyond the shadow of a doubt to get someone off the breathing tube and the endotracheal tube? So let me go one step back quickly before I look at the “Have they done everything beyond the shadow of a doubt?” The research has shown that you shouldn’t ventilate someone for much longer than 10 to 14 days on a breathing tube or endotracheal tube, because as we mentioned before, they need to be in an induced coma and you want to minimize the time spent in an induced coma as much as possible. So, that’s one of the reasons. But the other reason is, as I mentioned before, being ventilated with a breathing tube or endotracheal tube is very, very uncomfortable because the tube is very uncomfortable. Also, there is a cuff going up and the breathing tube is in the back of the throat so it can be staying in place. And also, the balloon is up to seal the lungs from the mouth and also prevent aspiration. You can see that this is very uncomfortable already.
But now, what does it mean when I say, have they done everything beyond the shadow of a doubt to get your loved one off the ventilator? So, there’s a number of things that need to happen there. A) What needs to happen is, sedation needs to be stopped. Opiates such as morphine or fentanyl need to be stopped or minimized to the absolute minimum. B) Next is ventilation settings need to be changed from a controlled mode, such as SIMV or assist control to a CPAP/pressure support mode. And then, obviously, you need to make the assessments, can your loved one trigger breaths? Are the volumes adequate? Are they breathing sufficiently while they’re getting more and more awake? C) Next is they need to have some physical therapy and some physiotherapy, some breathing exercises, and that’s where I believe in this day and age ICU seem to fall down.
I’m a bit more old-fashioned. I did my nurse training/ICU training in the late 90s, early 2000s, so I’m a bit old fashioned in terms of how do you wean someone off the ventilator, but I also believe that 20 years ago, ICU professionals weren’t as complacent as they are now. I think there’s a lot of complacency in this day and age, where you need to mobilize a patient to get off the ventilator. It’s not negotiable. We were mobilizing patients 20, 25 years ago even when they had a breathing tube into a tilt chair. You can’t wean someone off the ventilator really without strengthening their upper body muscles, especially if they’re coming to day 10, day 14, because every day in an induced coma weakens the muscles. So, you can see that you can’t run a marathon without training for it. It’s the same that when someone is critically ill and they’re on a ventilator, they need to be trained to get off the ventilator.
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It can’t just happen by switching off medications. People need to be talked through it. They need to be told what they need to do to aid that process. A lot of ICUs in this day and age, they just stopped sedation without doing the work. That needs to happen to get someone off a ventilator. So, a good ICU has a physical therapy team that can do the breathing exercises or has respiratory therapist teams that can help with the breathing exercises, that can guide the patient to go from intubation /breathing tube to extubation, which is the removal of the breathing tube. So, it doesn’t just happen by switching off medication and then someone will wake up and is ready to breathe by themselves. That can happen. Don’t get me wrong, that can happen. If someone is only ventilated for 24, 48 hours and is otherwise previously fit and healthy, they probably don’t need that, but that’s in ICU. You have an elderly population. You have a population with pre-medical histories, and therefore it’s often not a straight forward process.
Let’s look at what happens if let’s just say the breathing tube can’t come out after day 10 to 14. If it can’t come out, the next step is often a tracheotomy. If the patient is sitting on the edge or on the fence for that breathing tube to come out or not, you could also do a trial extubation, which means you can see what happens when you take the tube out and you could have BiPAP or CPAP ventilation with a mask ready. If all of that fails, you can then look at doing a tracheostomy as a next step. So leading up to having the breathing tube removed though, you need to constantly, besides the mobilization part and the physical therapy part that I talked about, you also need to look at issues such as, what else needs to be checked? And that is obviously, is your loved one breathing on CPAP/pressure support? What are their tidal volumes? Is the PEEP lower than 7.5? Is the pressure support lower than 8? Is oxygen saturation above 95%? Is FIO2 or oxygen that is delivered from the ventilator less than 35 or 30%? Is your loved one waking up and obeying commands? That is really important. Are they even strong enough to take the breathing tube out by themselves? Are they strong enough to even cough out the tube by themselves? If they’re strong enough to take out the breathing tube by themselves with their arm, with their hand, and if they’re strong enough to even cough out the breathing tube, that’s a very good sign that they are ready for extubation. In some instances, if you’re not watching the patient very closely, or if you’re not even restraining their hands, which I don’t recommend, by the way, they have that breathing tube out in no time doing it themselves, but that is dangerous in and of itself, especially if the tube is cuffed. You could injure the vocal chords or the structure of the trachea. We don’t want that. So, it’s something that needs to be done by the intensive care team.
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Other things that need to happen as part of that is assessing arterial blood gases. So, what does that mean? Again, let’s just say someone is on breathing on minimal support, which is often CPAP/pressure support ventilation. A critically patient needs to trigger every single breath from the machine. They need to overcome resistance, which is showing everyone that they’re strong enough to overcome resistance. Then, you need to assess tidal volume. How many mls are they breathing in, breathing out? As a rule of thumb, 7 to 10 mls per kilogram. So, let’s just say someone is 60 kilogram. As a rule of thumb, they should be breathing between 450 to 600 mls per breath, again, and that can vary a little bit.
You might have to play around a little bit with pressure support to get the volumes vary, to get them to the point where you want them to be, but the lower, obviously, pressure support, and if less than 8 and tidal volumes are adequate and the results of the arterial blood gases are within normal limits, you can then proceed to extubation most of the time. But sometimes you also need to assess if someone might be ready for extubation, might be ready to have the breathing tube or endotracheal tube removed. It’s almost you’re working with a limited time window. If you’re not doing it within a certain time window, the risk that someone can’t come off the ventilator is there as well, and you certainly want to proceed. On the one end, you want to proceed with caution. On the other hand, you also don’t want to leave it too long because then chances are patients would go backwards. Again, also, there is the increased infection risk. The longer breathing tube stays in, bugs can enter the lungs and the risk for a pneumonia is definitely there.
Other issues that are happening around the breathing tube or how long can a breathing tube stay in are definitely nutrition. Most patients in ICU, if they get intubated with a breathing tube or endotracheal tube and end up on a ventilator, they need to have nutritionist, while they often have a nasal gastric tube or an orogastric tube. They will be fed with enteral feeds. That is important as part of their journey in intensive care. You definitely need to give patients food. And then by the time the breathing tube can come out, you also need to stop the feeds, that you’re basically removing the breathing tube on an empty stomach, because otherwise there is aspiration risk. If someone aspirates while they’re having the breathing tube removed, it’s a huge risk for another pneumonia to happen and it’s a huge risk for the breathing tube needing to stay in or needing to be reinserted/reintubation.
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I also need to talk about the exceptions when a breathing tube can’t come out after day 10 to 14. An exception would be someone might be breathing on pressure support, CPAP with minimal support, and they yet can’t have the breathing tube to come out, or they definitely need to proceed with the tracheostomy even though they are breathing on minimal support. That is the case in head and brain injuries, neurological conditions, where patients can’t protect their own airway because they’re not awake and they can’t follow commands. That’s when a tracheostomy might also be inevitable, even though someone is breathing on minimal ventilation support.
So, what happens often with neurological conditions, such as stroke, seizures, head and brain injuries, just to name a few, is that patients are not waking up. Their Glasgow Coma Scale is diminished. They might not even be able to cough as part of their neurological condition. They might not be able to swallow as part of their neurological condition, and therefore the risks of them aspirating as soon as you take the breathing tube out and being unable to protect the airway is high and it’s real, and therefore someone needs to proceed with the tracheostomy for those patients. So, that’s what happens with neurological conditions when it comes to breathing tubes.
Maybe just quickly looking at the pediatric space because children in particular are often intubated through the nose, and that from my experience there, it’s not necessarily a two-week, 10 to 14 day timeframe.Those breathing tubes can stay in for a little bit longer. They tend to be easier to tolerate compared to intubation through the mouth. Nevertheless, it’s the same with kids. If they can’t come off the ventilator, eventually they need to have a tracheostomy.
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Also, quickly talking about other reasons why an endotracheal tube might need to stay in a little bit longer, even though it’s coming to the day 10, day 14 mark, which is more or less the cutoff. So other things that can happen sometimes is airway swelling for whatever reason. And what that means is even though the patient might be ready to take out the breathing tube or endotracheal tube, the reality is if the airway is swollen, if you take out the breathing tube, A) you could, again, injure the trachea, B) if you take it out while there’s airway swelling, the airway might close and people are at risk of literally having the airway closed, and then the only option is to do a tracheostomy anyway. Ways to manage that is A) by letting the cuff down and see whether they can breathe spontaneously while you take them off the ventilator. That’s one way to test for it. B) Another way to manage it is, for example, adrenaline nebulizers. Steroids sometimes help to get that airway swelling down. If it’s temporary and steroids and adrenaline nebulizers help, then the breathing tube can come out. But if the airway is too swollen and can’t be reduced, then obviously the challenge is that the airway blocks off and you need to do an emergency tracheostomy straight away, and you definitely want to avoid that wherever you can.
I also want to welcome our viewers, of course. Sorry if I haven’t done this before. I want to welcome our viewers. If you have any questions, please type them in the chat pad, or you can also call me on one of the numbers on the top of our website at intensivecarehotline.com. You can even dial live into the show, and you can ask me questions here over the phone. So, that’s in a nutshell how long a breathing tube and an endotracheal tube can stay in. The shorter, the better. Infection risk is high. Also, another thing that happens, obviously, if a tracheostomy happens. Whilst sedation often can be stopped straight away and while people can be weaned off the ventilator often straightaway because the tracheostomy is easier to tolerate, it’s not nowhere near as uncomfortable as the breathing tube/endotracheal tube.
The risk is that if someone ends up with a tracheostomy, especially for our viewers in the United States, patients often end up in subacute or in LTAC. If you have followed me for any length of time, we strictly advise against subacute or LTAC for various reasons, including that subacute or LTACs don’t have the staff with the right qualifications to look after ventilated patients with a tracheostomy. It requires ICU nursing skills. It requires ICU medical skills, and it requires a respiratory therapist if you are in the United States or in Canada. Other countries such as Australia or the UK don’t have respiratory therapists, but it still requires ICU nursing skills and I assume medical skills to look after someone on a ventilator with a tracheostomy, therefore we advise strictly against LTAC.
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Many patients are dying in LTAC, because unfortunately they simply don’t have the skills and the expertise to look after someone on a ventilator with a breathing tube, with a tracheostomy. That’s why it’s so important that you, as a family, seek help as quickly as possible when you have a loved one in intensive care, simply because the ICU team needs to do everything beyond the shadow of a doubt to get your loved one off the ventilator with the breathing tube. You can guide them with our help, for example, here at intensivecarehotline.com because we understand intensive care inside out, and you need that when you have a loved one in intensive care. You definitely need that. You can’t be leaving things to chance because it’s life or death.
Now, before I close this off today, and I am being mindful of the time, does anybody on the call have any questions? If you do, please type them into the chat pad or call me on one of the numbers on the top of our website at intensivecarehotline.com. I’ll just keep talking for another couple of minutes and wait for your questions to come in. If there are no questions, I want to close this off for today and also want to refer you to our next live stream next Sunday or Saturday night if you’re in the U.S. Next week’s Saturday/Sunday live stream will be about “Intensive Care versus Intensive Care at Home, what are the differences?”
So, let me thank you again for coming onto the call. Let me thank you for watching my videos. Let me thank you for all the comments on YouTube. Please subscribe to my channel. Please leave your comments below, your questions below, and like the video if you feel like it’s given you any value or any insights that are beneficial for you and for your family of course.
If you have a loved one in intensive care, go to intensivecarehotline.com. Call us on one of the numbers on the top of the website, or send me an email to [email protected].
I assume there are no questions today, and that’s great. I really wish you and your families all the very best. Stay safe, stay positive, and never give up if you have a loved one in intensive care.
We’re here to help you at intensivecarehotline.com. Take care for now.
How can you become the best advocate for your critically ill loved one, make informed decisions, get peace of mind, control, power and influence quickly, whilst your loved one is critically ill in Intensive Care?
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In Your FREE “INSTANT IMPACT” report you’ll learn quickly how to make informed decisions, get PEACE OF MIND, real power and real control and how you can influence decision making fast, whilst your loved one is critically ill in Intensive Care! Your FREE “INSTANT IMPACT” Report gives you in-depth insight that you must know whilst your loved one is critically ill or is even dying in Intensive Care!
Sign up and download your FREE “INSTANT IMPACT” REPORT now by entering your email below! In your FREE “INSTANT IMPACT” REPORT you’ll learn how to speak the “secret” Intensive Care language so that the doctors and the nurses know straight away that you are an insider and that you know and understand what’s really happening in Intensive Care! In your FREE report you’ll also discover
- How to ask the doctors and the nurses the right questions
- Discover the many competing interests in Intensive Care and how your critically ill loved one’s treatment may depend on those competing interests
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- 5 mind blowing tips & strategies helping you to get on the right path to making informed decisions, get PEACE OF MIND, control, power and influence in your situation
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- How to stop being intimidated by the Intensive Care team and how you will be seen as equals
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- How you need to manage doctors and nurses in Intensive Care (it’s not what you think)
Thank you for tuning into this week’s YOUR QUESTIONS ANSWERED episode and I’ll see you again in another update next week!
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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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