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

Today I have a question from one of our clients, Adela, who writes:

“Hi Patrik,

Thank you so much for your updates.

Today, my family member’s breathing is raspy. She also has blood in the tracheostomy while cleaning the tube, which the nurse saw yesterday afternoon and said she relayed the message to the ICU doctor.

The other ICU nurses added more water into the ventilator circuit for moisture, did suctioning and tracheostomy cleaning, and switched the setting to AC, which stands for Assist Control, which is a Ventilation mode. The breathing sound went away and went back to normal.

Is there something else we should watch out for in regard to her breathing and ventilation? She was yesterday started off on the tracheostomy collar and lasted for about 45 minutes. Then she was on Pressure Support 5 for 17 hours until 2:00 a.m. and again this morning until 5:00 p.m. The blood when cleaning the tracheostomy, is that a concern or is that normal? Also, physical therapy in the Neuro ICU only comes 2 to 3 times a week because they are short-staffed. They said the next step after here would be the LTAC (Long-Term Acute Care), but we want to avoid LTAC.

Please help.

From Adela.”

Hi Adela, you’re asking some excellent, very important question that every family with a loved one in ICU with a tracheostomy and ventilator should understand.

Let’s start with the blood in the tracheostomy.

A small amount of blood or pink tinged secretions during suctioning can sometimes happen, especially if the tracheostomy tube has been recently inserted, or if suctioning is done too deeply or too frequently.

However, persistent or increasing bleeding, especially bright red blood, is not normal and should always be checked immediately by the ICU doctor or ENT (Ear, Nose, and Throat) specialist.

So, what can cause blood in the tracheostomy?

Irritation from suctioning or the tracheostomy tube rubbing the tracheal wall, infection or inflammation, dry air from inadequate humidification, which seems like what the ICU nurses address by adding more water, and blood thinning medications can also cause this like heparin, warfarin, Clexane, Plavix (also known as clopidogrel) can cause this as well.

It’s good that the ICU nurse has added more moisture; humidification is absolutely essential to prevent crusting, dryness, and bleeding in tracheostomy patients. This could also include do some nebulizers, saline nebulizers; you can’t go wrong with that to keep the moisture up.

Now, regarding the ventilator and breathing pattern, you mentioned that your family member tolerated 17 hours on Pressure Support. Pressure Support of 5 and 45 minutes on the tracheostomy collar, that’s actually a good sign of progress, it shows she’s doing some spontaneous breathing and building endurance. However, the transition from pressure support ventilation to tracheostomy collar must be done gradually.

If she’s getting tired or her respiratory rate, heart rate, or oxygen levels start to worsen, that’s a sign she’s not ready for longer collar trials yet. You should be watching out for increased respiratory rate, greater than 30 breaths per minute, drop in oxygen saturation, less than 92%, use of accessory muscles, working hard to breathe, change in skin color, pale or bluish, agitation, sweating, or fatigue.

If any of these signs occur, she needs to rest back on Pressure Support or Assist Control for recovery. This should also be backed up by an arterial blood gas to look for pO2 in the blood, CO2 in the blood, as well as the pH of the blood that will help in determining the next steps in terms of her ventilation.

Now, let’s look at physical therapy, physiotherapy.

This is a major issue in many ICUs. Physical therapy 2 to 3 times a week is not enough for patients on ventilators and tracheostomies who need daily mobilization to wean off the ventilator successfully. Early mobilization and daily physiotherapy are proven to improve outcomes and reduce ventilator dependency.

If the Neuro ICU is short-staffed, you have every right to question why and request daily mobilization regardless, even if nursing or some other aides assist. A good ICU will do that, so don’t settle for second best.

Finally, regarding avoiding LTAC. Obviously, this is a client in the US. LTACs are unique to the US.
You’re absolutely right to be cautious. Most LTACs have limited staffing, no ICU trained nurses 24/7, and no full-time ICU doctor on site. Once transferred, patients often deteriorate so fast that they have to go back to ICU within 24–48 hours.

I’ve seen it over and over again, and then they go back to another ICU because the ICU that your family member has been discharged from no longer has any beds. So, that means your family member, in such a vulnerable condition, would be going from ICU to LTAC to another ICU within 24 to 48 hours. That is insanity. Think about that, that is insanity.

So, if you’re watching this and your family member is still in ICU and they’re on the verge of going to LTAC, put a stop to it now and you can put a stop to it. We’ve done it many, many times, very successfully. If you need help, just reach out to us, we can guide you step by step.

So, if your family member is stable enough, a much better option to go home is obviously intensive Care at Home. Have a look at intensivecareathome.com for more information, with 24/7 ICU trained nurses providing ventilator and tracheostomy care at home . This is really the gold standard alternative to an LTAC, and it keeps patients safe, stable, and progressing in a home care and familiar and family friendly environment.

In summary, lesser amounts of blood from the tracheostomy can happen, but persistent bleeding must be investigated. Humidification and gentle suctioning are key. Monitor closely during weaning trials for fatigue and distress and arterial blood gasses. Request daily physiotherapy, physical therapy, not just 2 to 3 times a week.

Avoid LTAC at all costs and explore intensive Care at Home options instead for more information, go to intensivecareathome.com.

If you want to know how to avoid LTAC and bring your loved one home safely with 24-hour intensive care nurses, go to intensivecarehotline.com, check out intensivecareathome.com and call me directly on one of the numbers on the top of our website.

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.