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
Why is the ICU Team Being Negative About my Loved One’s Weaning off ECMO 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 want to answer questions from one of my clients Tara, as part of my 1:1 consulting and advocacy service! Tara’s brother-in-law is with a breathing tube and ventilated in ICU due to ARDS. Tara is asking how long will it take for her loved one to recover after being on ECMO in the ICU.
How Long Will it Take For My Loved One To Recover After Being on ECMO in the ICU?
“You can also check out previous 1:1 consulting and advocacy sessions with me and Tara here.”
Patrik: Yeah, so let’s just say… so that’s 300 pounds, is it?
Tara: Yes.
Patrik: Yeah. So that’s around 136 kilos. I’m just looking at my calculator here. The research suggests 7 to 10 mils per kilo. If he’s 136 kilo, you could say per breath, he should be breathing at least 1,000 mils. Now-
Tara: So when they’re saying 300, that’s mls?
Patrik: That’s not enough. It’s not enough. It’s not enough.
Tara: But I’m saying, when they’re saying 300, that’s considered mls? Is that-
Patrik: Yeah, mls. 300 mls. Yeah. It’s not enough.
Tara: Okay. All right.
Patrik: Probably not even a third he should be breathing. Just remind me, Tara, does he have a tracheostomy?
Tara: No. That was our other question, because they had told her, originally, the doctor had said they were going to do that, and then they just decided they’re not going to do it, because they said it would not change his outcome is what they said that we said they were being negative. Now, what they’re saying is they’re saying they don’t want to do it because it’s too dangerous to do it while he’s on the ECMO.
Patrik: Agreed.
Tara: But they want to possibly do it… you’re possibly doing it as soon as they get him off the ECMO. That was the other thing we were wondering about, because I don’t know… sounds awful to do another procedure at this point, but I mean, at what point… because she said at first, it seemed like those tubes really bothered him down his throat, and now he’s actually had… he’s been on the ventilator with those tubes for six weeks now, and the weird thing is, it doesn’t seem to affect him anymore, as far as he’s not acting irritated. Is there a danger to having them long? I mean, I know they already put it on six weeks.
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Patrik: Let me start with the reverse. There would be a lot of advantages if he had a tracheostomy already. I’ll tell you the advantages. A tracheostomy literally requires no sedation, okay?
Tara: Okay.
Patrik: The breathing tube, however, does require sedation because it’s very uncomfortable in the mouth.
Tara: Right, and that’s why they were telling her originally that they couldn’t really wake him up very much, because he would get so irritated.
Patrik: Correct. If he had the tracheostomy, they would wake him up most likely. They could wake him up most likely if he had a tracheostomy, and that would probably increase his ability to breathe.
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Tara: Okay.
Patrik: Here is why they haven’t done a tracheostomy or here is one of the main reasons why they haven’t done a tracheostomy. While he’s on ECMO, he is on heparin.
Tara: Right.
Patrik: Have you heard of heparin?
Tara: Yes. Yeah, that’s the blood thinner.
Patrik: Right. Heparin is a blood thinner.
Tara: Yeah.
Patrik: He could..
Tara: So it’d be dangerous to..
Patrik: Very dangerous, and it would also be dangerous to stop the heparin even for 24 hours to do the procedure. Even that would be dangerous.
Tara: Right.
Patrik: But I would argue that if he had a tracheostomy, he would be on minimal, very minimal sedation. It would increase his ability to get off ECMO, get off sedation and do more work himself.
Tara: Right. If they would’ve done it before, which why they didn’t do it before, I don’t know.
Patrik: Yeah. I’ll tell you… how long has he been in hospital? A month in ECMO and how long prior to ECMO?
Tara: He was in for about 6 days on oxygen.
Patrik: Right.
Tara: And then they moved him to the ventilator for a week, and after one week on the ventilator, they did the ECMO.
Patrik: Yeah. There’s a number of things that… normally the cutoff is the 10 to 14-day mark when you do a trach. That’s sort of the cutoff.
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Tara: Okay.
Patrik: It might have been just a little bit too early, that’s number one. Number two, he would have been on so much support because he needed ECMO, he would have been on settings on the ventilator that would have been a contraindication.
Tara: Or high.
Patrik: Too high.
Tara: Yeah.
Patrik: Right?
Tara: Yeah.
Patrik: And the minute he was on ECMO and heparin, the risk would have been way too high.
Tara: Right. Well, they actually were going to do it when he was on that originally, or they said they were, but I’m glad they didn’t in hindsight.
Patrik: Right.
Tara: We’re very glad now that we know the risks.
Patrik: And also, when someone is COVID-positive, they’re shying away from it still because the risk for staff getting infected is very high because of aerosols.
Tara: Okay.
Patrik: So there’s a number of things coming into play.
Tara: But if they weaned him off of the ECMO, like I said, it’s been six weeks that he hasn’t been intubated. Besides the sedation, is there any other disadvantages of just leaving him on that for another week or two? I don’t know how, I guess it depends how long he’d have to be on it.
Patrik: Yep. Rather than looking at the disadvantages with the breathing tube, in a situation like that, the tracheostomy would have many, many more advantages.
Tara: Okay.
Patrik: A) he could come out of sedation. B) it’s so much more comfortable. It’s a much safer airway. I’m not the one to jump on a tracheostomy at all, but in this situation, he would benefit greatly from a tracheostomy. But the risk is too high.
Tara: But if he was off the ECMO, you think it would be beneficial at that point?
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Patrik: Oh, big time, big time, big time.
Tara: Once they get off, if they get weaned off the ECMO, is it usually still a couple weeks at least that they are on a ventilator?
Patrik: That’s very individual. I would need to know more, chest x-rays, blood gas results, would need to know more to give you an indication.
Tara: So, when we’re talking about tidal volume, you said if he’s at 400, he should be at a thousand? At what point do they not need ventilator support then, to get all the way up to the thousand or…
Patrik: Yep. I’ll tell you what the ideal scenario looks like to wean someone off the ventilator. He would need to trigger every breath from the machine. That requires a certain level of alertness, which is hard to achieve whilst he’s sedated.
Tara: I see.
Patrik: Right?
Tara: Okay.
Patrik: That’s what I’m saying.
Tara: See, that’s what I always thought, but I guess the reason they sedated him must have been I guess the lung, because that was always my thought, is couldn’t he fight, do more if he was awake, you know?
Patrik: Absolutely. He would be more awake if he could have a tracheostomy.
Tara: Okay.
Patrik: Or he could be more awake. There’s a number of things that need to happen for him to be weaned off the ventilator. As much as that’s the goal, the first is to be weaned off ECMO. Only then can you..
Tara: Exactly. That’s what I thought, but we just were wanting to make sure that’s how that worked. What is the difference between a ventilator and somebody needing oxygen support? I have a couple coworkers who just got COVID a couple weeks ago, and they were having low oxygen. Honestly, I was a little hesitant to come into the hospital because certain outcomes we’ve had here lately. I have a doctor that is… she’s kind of more of a natural doctor, but she gave both these people were lost and she gave them an oxygen tank and sent them home with it and they were on oxygen for a couple weeks until they recovered, and then they were able to hold their oxygen level. Once you’re on a ventilator is it you have to be on a ventilator? You can’t be on oxygen or how does that work?
Patrik: Yeah. I’d say 90% of people in ICU that are on a ventilator are also on oxygen.
Tara: They’re receiving oxygen through the ventilator?
Patrik: Very much so. The air that you and I breathe in consists of 21% oxygen. Room air is 21% oxygen.
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Tara: Okay.
Patrik: Most patients on a ventilator in ICU are on a minimum of 30% of oxygen.
Tara: I see. But the ventilator actually is pumping the air in and out of the lungs and the lungs themselves can’t do the work. Is that the difference between an oxygenator and a ventilator?
Patrik: Pretty much. Pretty much, but then again, there is varying levels of support on a ventilator, too. There’s varying ventilation modes that tie in with a patient’s condition. For example, a ventilator can give full support, especially when someone is in an induced coma, okay?
Tara: I see.
Patrik: And then, you can change that to a mode where the patient can breathe spontaneously, still with some support, and your brother-in-law needs to get to that level where he gets minimal support from the ventilator, where they can take him off, but there’s various steps in front of your brother-in-law at the moment. Number one, get off ECMO, then probably the ventilator will kick in with support, with a lot of support, and then it’s a case of weaning off the ventilation support.
Tara: Okay. Yeah, I guess I didn’t realize that they would have to support, he would need more support on the ventilator. I didn’t realize that was without being on the ECMO. Is that safe? Because I know that was a concern before, was that they still want to keep the ventilator running low, not to damage the lungs any further, et cetera.
Patrik: Look, yes, absolutely. At that stage, the lungs were probably so sick that they needed to give the lungs a rest, but now, a month of ECMO, the sooner they can get rid of that ECMO, the better.
Tara: I see. Okay. Okay. Well, that answers the question for me. We were trying to figure out how that works, and now that they’re talking about the tracheostomy, we were just wondering if that really was the best option.
Patrik: Right.
Tara: Because like he said, he’s been intubated for five weeks, and so we’re thinking, “Well, what’s another couple weeks?” But I see your point. If it allows him to be awake and working more, than that just makes sense.
Patrik: Right.
Tara: Is there any other disadvantages or risks I guess with having that procedure done?
Patrik: The tracheostomy?
Tara: Yeah.
Patrik: Look, there are always risks, but to put things in perspective for you, and I don’t want to be by any means negative or anything, your brother-in-law would be one of the sickest patients in this ICU. There may be a couple of others on ECMO, but your brother-in-law would be… there is no higher form of life support currently in ICU than ECMO.
Tara: Correct, yes.
Patrik: ECMO is an absolute last resort. Absolute last resort.
Tara: Right.
Patrik: Besides the challenge of being on ECMO at the moment and being on maximum life support, if he comes out of this, the next challenge is recovery. How long will that recovery take?
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Tara: Right, yeah.
Patrik: So every little step that he is making forward comes with massive risks.
Tara: Okay.
Patrik: Your brother-in-law’s life has been hanging at the thread and continues to at a thread as long as he’s on ECMO and even while he’s on the ventilator. So, every step that he’s making forward comes with many risks attached. By the same token, I’m talking to many people in similar situations than you and your family are in. Because I hadn’t heard from you, I was actually thinking to myself, “I hope he’s still alive,” and I’m very glad to hear that. I am very glad to hear that, because we are dealing with many other people in similar situations and people don’t make it.
Tara: Yeah.
Patrik: Right? So, he’s taken some steps that other patients have not taken in those situations, so that you should definitely see as a positive. The other thing that is important to understand is roughly 90% of intensive care patients survive. So 9 out of 10, roughly, leaving intensive care alive.
Tara: Wow. That’s pretty high.
Patrik: That’s pretty high. Now, that’s pretty high. That doesn’t take into consideration when you look at COVID cases in ICU, when you look at ECMO in ICU. The survival rate would be lower, right?
Tara: Right.
Patrik: But that should not stop you from doing what you’re doing and pushing forward, but, just to put it in perspective, he is one of the sickest patients in that place.
Tara: You’re right. Yes.
Patrik: And there are many risks attached to any step he’s taking forward, you know?
Tara: Well, that’s what I just told my sister originally when they were talking about doing it. I just said, “If it allows him,” basically, you can’t get any worse than what he’s on right now. So even though another procedure sounds awful, that doesn’t even compare to what he’s on now, you know what I mean? If it helps him be awake and helps him with his recovery, you got to look at the benefits, as well.
Patrik: Exactly. It’s touch and go. The ICU, I don’t know what they’ve done, whether they mentioned to you, for example… have they mentioned to you that even if he does survive, he may not have any quality of life? Are they giving you that talk?
Tara: No. I guess so..
Patrik: Good.
Tara: I mean, I don’t know what… he’s still responsive and everything to all their questions and they do tell him to… I mean, he can only do so much because he’s pretty tied down, but yes or no, shake your head, wiggle your toes.
Patrik: That’s good.
Tara: Give me a thumbs up if you’re in pain.
Patrik: That’s great.
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Tara: All those kind of questions. He can do all that.
Patrik: That’s great. That’s fantastic. If you get that from a patient in a situation like that, that is fantastic. You can’t be asking for more, really. That is fantastic.
Tara: That’s what I thought, especially after that many weeks.
Patrik: Absolutely. That is really great news.
Tara: Okay, good. Well, I appreciate the help answering all those questions, and I just, we’re believing he’s going to keep showing improvement, I mean, I do think from the 70s, being in the 70s on Friday to up to 400 yesterday is a pretty good sign of improvement.
Patrik: Very much so. I think overall, you’re giving everyone good news, here. The biggest risk is he needs to get off that ECMO.
Tara: Okay.
Patrik: That’s the biggest risk.
Tara: Yeah, so the ventilators safer, even on higher settings?
Patrik: Yep. Absolutely. ECMO is a replacement therapy for lungs and for hearts. You can replace
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Tara: Yeah.
Patrik: … the lung and the heart for a period of time on ECMO.
Tara: Right.
Patrik: But the longer, the higher the risk that things go wrong.
Tara: Okay, well that’s good to know. I’m waiting to move forward in a good direction and they can get him off of that, because it does sound like a tricky thing. They’ve said it is very tricky to wean him off of it.
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Patrik: Yeah, yeah. In a nutshell, they need to wean him off sedation. He needs to show that he can tolerate ventilation. If he can tolerate ventilation, they should be able… and his arterial blood gases are good, his chest x-rays improve, his vital organs are perfused with oxygen, there’s healthy oxygen/carbon dioxide exchange, that’s when they hopefully can remove the ECMO and let the lungs do the work with the help of the ventilator to begin with, and then start hopefully weaning off the ventilator.
Tara: Right.
Patrik: And then, once he’s off..
Tara: Okay.
Patrik: Once he’s off ECMO and hopefully on the ventilator, they might be in a position to do a tracheostomy. They might.
Tara: Okay. Well, we’ll cross that bridge when we get there, I guess.
Patrik: Yes. Yeah.
Tara: She did want to know and so they’re asking her about it, but..
Patrik: Yeah, very much so.
Tara: I guess we can’t do it right now. Until he’s off of that, it’s a no. We’ll cross that bridge when we get there. If I have any other questions when we get there, I’ll probably reach out to you.
Patrik: Please. Anytime.
Tara: Okay. Well, thank you so much. I really appreciate your help.
Patrik: Pleasure. Thank you so much, Tara. All the best to you and your family. Thank you.
Tara: Thank you. Thank you.
Patrik: Bye. Bye.
Tara: All right, have a good day.
**After a series of consulting and advocacy services with the Intensive Care Hotline, Tara’s brother-in-law continued to live. Please have a look at this link with Tara’s testimonial where her brother-in-law has successfully survived.
The 1:1 consulting session will continue in next week’s episode.
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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- 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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- 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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