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!
You can check out last week’s question by clicking on the link here.
In this episode of “YOUR QUESTIONS ANSWERED” I want to answer a question from one of my clients Tom as part of my 1:1 consulting and advocacy service! Tom’s mom is with a breathing tube in the ICU and can’t come off the ventilator. Tom is asking if tracheostomy is the next best step for his mom.
My Mom is in ICU and Can’t Come Off the Ventilator. Is Tracheostomy the Next Best Step For Her?
Patrik: Hello Tom.
Tom: Hello Patrik.
Patrik: Can you tell me about your mom’s situation now?
Tom: Just so you know, this is what prompted us to email you in the middle of the night. So my mom is 28 days now in the ICU. I’ll do my best to give you the nuts and bolts of what I think is going on, but I’m certain you’re going to have some really good questions, so please ask and if we remember the details, we’ll tell you, or if we’re not even sure, we can definitely write it down to ask later.
Tom: She went in 28 days ago. She was COVID positive several days before that, but was staying home isolating. And then started to experience the shortness of breath and ultimately asked my dad to take her to the ER. And that’s when they admitted her.
Tom: Her heart was lacking oxygen, so she did have a little heart injury, but what they told us, it’s not so significant that her heart’s failing, but there was some injury and they expect to have just lung affected that has been from her going in on the onset of all of this. But she did have to be mechanically ventilated, after she was checked into the hospital.
Patrik: Right, any pre-medical history prior to COVID?
Tom: No. But she has had pneumonia before and right now, she has a pneumonia from a secondary infection in her lung.
Patrik: Right, right. But prior to this, fit and healthy?
Tom: No health issues. No.
Patrik: Okay. How old is your mom?
Tom: She’s 65 years old.
Patrik: Right, okay.
Tom: She just turned 65. So yeah, when they intubated her, she was very awful. She’s not able to breathe on her own, full maximum ventilation support. They started to do the proning technique that you talked about. So when we saw your videos, we were like, “Okay, we know what that is. But we remember that.” They did several days of proning. She was developing a lot of greenish secretion so they did bronchoscopies on top of the regular suctioning through the breathing tube. They didn’t see major progress through those efforts because she’s producing more. Because the secretions are, from what they’ve explained to us, but we understand is it’s secondary infection has complicated that healing and all the mucus coming up and then her not being able to cough to help bring those things up, it’s only complicating gas exchange that she needs in her lungs. But she is breathing. I mean, she’s able to, from what we understand right now, not deteriorating, but not progressing either very much.
Tom: So now they’ve presented us with the option of recommendation to do a tracheostomy so that they can continue her on mechanical ventilation however long she needs. There are other benefits and again, we saw your video about the pros and cons and this, so those were the things that they explained to us. But that’s where we’re at that fork in the road right now where my dad’s just taking in information about moving forward with the tracheostomy or what other options or alternatives might be.
Patrik: When was the first time they suggested a tracheostomy?
Tom: Yeah, yesterday formally. They told us about it last week, but they said we’re not there yet. Because I asked them how long she can be … I didn’t know how long she can be on a ventilator. They said, “Well, there is an option to do a tracheostomy or there is an option to do other forms of oxygenation, but if the ventilation is providing her the pressure, the volume, everything that she’s showing she needs.” So they had told me about it, but it wasn’t until yesterday that the doctor approached my dad formally to inform him.
Dad: She said because we’re on to weeks already.
Patrik: I’ll tell you my theory without obviously knowing all the details, but if someone can’t come off of the ventilator, you should be looking at a tracheostomy sort of day 10 to day 14. However, what we are seeing in practice at the moment is that with COVID, that time span is getting longer and longer.
Patrik: I see it as a good sign that they are at least suggesting a tracheostomy. There are many COVID patients at the moment that even after three weeks in ICU, can’t have the tracheostomy because they’re on too much support. Certain boxes need to be ticked that you can do a tracheostomy. You know, if she was continuously, for example, on 100% of oxygen, they couldn’t even do a tracheostomy. So to a degree, I see it as a good sign that it’s on the table.
Patrik: Are they still proning her?
Tom: No, because they didn’t see any real improvement. They tried it several days, and of course that put her into the induced coma with sedation and paralytics. And I want to say they tried it at least three, no, at least four or five days, maybe even a little more, but they weren’t seeing significant changes in her X-rays or secretion development. So they felt that the risk was outweighing the benefit, to continue the technique.
Patrik: Yeah, okay. Do you know the official diagnosis for your mother? Like, obviously, COVID. But do you know what she was diagnosed with COVID ARDS, COVID pneumonia? Do you know? Maybe both?
Tom: Yeah, I believe it’s both, but actually we need to ask that specifically outright today, because they did tell me about the acute respiratory distress syndrome. But I kind of just took that in. That was several days ago and I just kind of took it in, but I don’t know if they were saying it may be that … Or no, actually, it’s considered ARDS where there’s respiratory failure, right?
Patrik: Correct. Correct.
Tom: Is that correct?
Patrik: Yes, correct.
Tom: So then, yes. She does have ARDS because all of her charts say respiratory failure. Like her X-rays and all of those documents do say respiratory failure. So if that’s hand-in-hand, the only criteria for ARDS, then yes. So she is diagnosed with ARDS. She does have pneumonia, as what they explained to us was hospital … What is it called?
Patrik: … ventilator-associated pneumonia, or hospital-acquired pneumonia? Might be one or the other, might be.
Tom: There you go.
Tom: Hospital-acquired or ventilation … What did you say?
Patrik: Ventilator-associated pneumonia.
Tom: Oh, associated. Well, we’ll ask for clarification on which one it is, but what we do understand is that it’s like bacteria that entered through the tube because it’s susceptible to that. So I don’t know what’s that.
Patrik: Probably ventilator-associated pneumonia. At the end of the day, it doesn’t matter where it’s coming from, the reality is it’s there, and obviously anybody on a ventilator, the risk to have a pneumonia on top of what’s already going on is real and it sounds like this is what might’ve happened for your mom in this situation.
Patrik: Is she still COVID-positive?
Tom: They just took her out of isolation on Thursday, so they believe she’s no longer contagious, and we did ask that outright today. I was like, “Can you just tell us?” She’s technically considered COVID-recovered, which they confirmed again, but these are secondary complications at this point.
Patrik: Yes, yes, yes. Absolutely. Okay. And what are they doing at the moment? They would be giving her antibiotics for the pneumonia?
Tom: Yes. They are. What’s today’s date? The 8th. So tomorrow, she’s supposed to finish the antibiotics that they started her on 10 days ago. They gave her a very aggressive dose prescription more than seven days, typical for the bacterial infection, but because there’s still greenish thick secretions and having to do bronchoscopies, the doctor sent in another culture to the lab I want to say two days ago or … maybe one or two days ago to determine if there’s another bacteria or now a fungal infection, but he’s suspecting there’s another possible infection because the secretions, they’re getting a little better, but they’re still present.
Tom: She is on antibiotic now. She is on two sedation medications and a painkiller medication. I forgot which one of them, the painkiller. One of them has some antianxiety to help kind of an element to it, but she’s also on an antianxiety medication like standalone because that’s part of the challenge in waking her up. She is waking up. I guess, you can say that in a way, they kind of ruled out the neurological concern that there may have been brain damage or somehow because they just did a CT scan and they affected as normal-
Patrik: Oh, good. Good.
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Tom: … but they were just trying to rule it out because she’s been so heavily sedated it’s taking her a while to be very present mentally.
Patrik: Of course, of course.
Tom: Positively. So at least that’s ruled out, but it’s evident. She’s just very, very heavily drugged from all of these-
Patrik: Right. And you can visit her? You are able to see her?
Patrik: Good. Good, good.
Dad: We were seeing her since last Monday.
Patrik: That’s good. That’s good. And now what has the team put in front of you? The team has put in front of you to do a tracheostomy and is that what they put in front of you?
Tom: Correct, they did. And one of the things we wanted to understand better and that was part of the family meeting this morning was what’s her, I don’t know if prognosis is the right word, but her likelihood … Where we were unclear actually is she progressing or is she digressing and then we’re going to put her on a trach and she’s just going to need full ventilator support as life support. Is that good? Is that the quality of life that my dad wants for her? We weren’t sure.
Tom: But from meeting with them this morning, they explained that they are seeing some progress, but keeping that the mouth intubation is more riskier than it’s benefit. All the benefits of moving to the tracheostomy, that they could lower sedation, help manage her anxiety, at some point down the road, help her recover her speech through the trach. Different things.
Tom: But that’s the option. So one of the things that we are concerned about and you’ve alluded to it quite a bit in your messages online is moving into an LTAC. They didn’t tell us right away that it would happen, but we asked about it and they said, “Well, yes. That’s typically the procedure.” But we don’t want that-
Patrik: Yeah, absolutely.
Tom: … for obvious reasons that you’ve outlined in your online content. But we want to avoid it at all costs before you at least knowing that we’ve exhausted or asked in the proper way how to keep her in a hospital setting.
Patrik: Yeah, yeah. So couple of things there. Generally speaking, it sounds to me like a tracheostomy is the natural next step in your mom’s situation. That’s what it sounds like to me. I would need to know a few more things, but after three weeks of not coming off the ventilator, she might be too weak to be extubated and there’s these issues around if someone in a prolonged induced coma, right, with waking up and they’ve got anxiety, there’s nothing new there, unfortunately. That is often what happens. The longer someone is in a coma, the more difficult it is to get them out of it for all the reasons that you’ve just mentioned.
Patrik: If patients have the trach, and they stay in intensive care, to be weaned off the ventilator, from my experience, that is the best course of action, right? Because ICUs, generally speaking, are just well-equipped to deal with those challenges, right?
Patrik: The problem with LTAC is well, (A) from my experience, patients are being sent out far too quickly, right? So what I’ve seen is often your mom might have a tracheostomy tomorrow, and two days later, they may want to send her to LTAC. Now, they can only do that if she’s stable. For example, you haven’t mentioned anything … Do you know if she is on inotropes or vasopressors? Do you know what I mean by that?
Tom: That’s the name of the medications?
Patrik: It’s a medication classification like if her blood pressure is low, she would be on medication such as epinephrine, norepinephrine, Vasopressin. They are intravenous medications to support low blood pressure.
Tom: Okay, thank you for explaining that. I believe she is because that is one of the risk factors when they have done breathing trials in the weaning process because they’ve been trying to last several days. Her blood pressure is dropping and so they’ve explained she is getting medication for that, so that’s even more reason why we are very careful about the weaning process with her. They’re aware of that.
Patrik: That makes sense. That makes sense. If she is on those medications, I would say that almost stops her from going to LTAC at the moment anyway because they would not be able to manage that at LTAC. However, what I’ve seen or whatever seen over the years is as soon as people are of vasopressors, they try and send them out and quickly as possible, With the risk that they’re bouncing back anyway because they might become unstable too quickly. And if patients become unstable too quickly, they bounce back into ICU anyway.
Patrik: The whole argument why I am so anti-LTAC is simply your mom/wife is in the most vulnerable situation she’s probably ever been in her life. And the last thing someone with a critical condition needs is changing hospitals or facilities. I mean, being a patient in the ICU is one of the most stressful experiences anyone can ever go through. And during that period, changing hospitals or facilities is even more stress. Often sets patients back, right?
Patrik: And the other added on complexity what we’re seeing is sometimes they want to send people two hours away. The next LTAC might be two hours away from where you are. It’s hideous. There is no rhyme or reason to it from my experience. It’s all about saving money, it’s all about freeing up ICU beds that are in high demand, but there is, from my experiences, there’s very little patient-centered care when it comes to making the transfer from ICU to LTAC.
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Tom: Okay. And we did ask some of those questions. We didn’t fully lay out all the reasons that we’re opposed to that option, but some of the content that we heard from your videos kind of helped us bring some of our questions a little more direct. And we did explain that we were concerned about the continuity of care in transferring her and her level of vulnerability. And of course they said, “Okay, that’s fine.” And they did tell us those things that we quite understand that if she was still on intravenous medications, which they didn’t say it’s a blood pressure medication, but that’s just sort of one of them, that she would still be here at the hospital while she’s still re-requiring that kind of medication.
Tom: So they kind of made it seem like don’t worry, as long as she’s on that, she’s here. But then because we understand at some point, the whole thing is she’s not going to need that, but then it’s good news, bad news. Good news, she doesn’t need it, bad news, she can’t stay in an acute facility like a hospital. But we did ask them. We said, “Is there any option? Is there anything that we could do?” And we did try to say like, “We’re concerned about her medical vulnerability to leave. We would like it to be known that we want her to stay in the hospital, even if it’s not in the ICU.”
The 1:1 consulting session will continue in next week’s episode.
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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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This is Patrik Hutzel from INTENSIVECAREHOTLINE.COM and I’ll see you again next week with another update!
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