My name is Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care. At intensivecarehotline.com, 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, control, power, and influence, making sure your loved one always gets best care and treatment in ICU, even if you’re not a doctor or a nurse in intensive care.

So, today’s question comes from Wynn, and Wynn is asking,

“Hi Patrik,

They want to withdraw treatment for my father after aspiration pneumonia because he’s not a candidate for a tracheostomy. Do you think my father can breathe on his own if he comes off the ventilator and reduces his ventilator settings. He’s 94 and has not been majorly sick for most of his life. All his vital signs are stable, but he’s not alert enough to protect his own airway. His weight is 96 kg. What clinical picture of normal settings is for him? Does he need to have an arterial blood gas before he comes off the ventilator.

Please help.

– Wynn”

Wynn, thank you so much for your question, and I can hear the urgency and the concern in your message, and I want you to know that you’re not alone in this situation.

Now, first let’s talk about aspiration pneumonia, and what’s actually happening here.

Aspiration pneumonia occurs when food, liquid, saliva or vomit enters the lungs instead of going down the esophagus into the stomach. This is a serious condition, especially in elderly patients, and it’s one of the leading reasons why patients end up on ventilators in ICU. The fact that your father is 94 years of age and has been relatively healthy for most of his life is actually a positive factor here. Many families don’t realize that prior health status matters enormously when it comes to recovery potential in intensive care.

Now let’s also break down the treatment options for aspiration pneumonia because this is critical for you to understand.

Antibiotics are generally speaking the first line of defense. The ICU team should be treating your father with broad spectrum antibiotics to combat the bacterial infection in his lungs. Common choices include piperacillin-tazobactam, carbapenems or a combination of antibiotics depending on the severity and the suspected organisms. Respiratory support is what your father is currently receiving with a ventilator. The ventilator is doing the work of breathing while his lungs heal from the pneumonia. The key here is that the ventilator is buying time for the antibiotics to work and for his lungs to recover.

Chest physiotherapy and suctioning are essential to clear secretions from the airways. This includes regular turning, chest percussions, and suctioning to prevent further aspiration and to help clear the infection.

Nutritional support is often overlooked but absolutely crucial. Your father needs adequate nutrition to fight the infection, but it must be delivered safely, usually through a feeding tube, a nasogastric tube, or a PEG (Percutaneous Endoscopic Gastrostomy) tube to prevent further aspiration.

Monitoring and supportive care includes managing his oxygen levels, blood pressure, kidney function, and overall organ function while his body fights the infection.

So, you’ve asked a very critical question. Can my father breathe on his own?

Now here’s what I need you to understand about ventilator weaning. The ICU team is telling you he’s not a candidate for a tracheostomy, and they want to withdraw treatment. But let me ask you this, have they actually given your father’s lungs enough time to heal from the aspiration pneumonia? Aspiration pneumonia doesn’t resolve in days. It can take 1 to 2 weeks or even longer, especially in elderly patients. The question isn’t just can he breathe on his own right now. The question should be – have we given him adequate treatment and time to recover so that he can breathe on his own?

You mentioned that his vital signs are stable and that’s huge. Stable vital signs indicate that his body is handling the stress and that his organs are functioning. The issue you’re describing that he’s not alert enough to protect his own airway is concerning, but this can also improve as the pneumonia resolves and as sedation and opiates are reduced appropriately.

You asked about what normal ventilator settings would look like for your father at 96 kg.

Here’s what you need to know. For a patient of your father’s weight, typical ventilator settings during recovery might include PEEP (positive end expiratory pressure), usually between 5 – 8 cmH20, fiO2 (fraction of inspired oxygen), ideally below 40 to 50% if lungs are recovering. Pressure support around 5 to 10 centimeters of water during weaning trials. Respiratory rate – the ventilator backup rate might be 10 to 15 breaths per minute.

What you want to see is that your father is triggering breaths on his own and that the ventilator support is being gradually reduced. If he’s still requiring high oxygen levels, fiO2 above 60%, or high PEEP above 10, that suggests his lungs need more time to heal.

Let’s look at the importance of arterial blood gases.

You asked if your father needs an ABG (arterial blood gas) before coming off the ventilator, and the answer is absolutely yes. It’s not only one ABG he needs, he needs multiple ABGs because it tells you how well his lungs are oxygenating his blood, which you can see in the blood gas with a paO2, how well he’s eliminating carbon dioxide or paCO2, and his acid-base balance, pH. These numbers are critical for determining if he can sustain breathing on his own. Without an ABG you’re flying blind. The ICU team should be doing this regular and doing regular ABGs especially before any discussions of extubation or withdrawal of treatment, but with an ABG you can also then adjust the ventilator settings to optimize ventilation.

Now I want to come to another critical point.

You need to access all of your father’s medical records as soon as possible. This includes daily progress notes from doctors and nurses, physios, ventilator settings, hourly, lab and pathology results, including ABGs, chest x-rays, culture results showing what bacteria is causing the pneumonia and whether the antibiotics are working, list of medications, vital signs. Leave no stone unturned. Without this information, you cannot make an informed decision, and quite frankly, neither can I give you the most accurate guidance. These records tell the story of whether your father is improving, plateauing, or declining.

But this is exactly why families reach out to me and our intensivecarehotline.com team for a consulting call. We can review all the medical records with you, help you understand what’s really happening, and then join you on a call with the ICU team to ask all the right questions.

We can advocate your father by questioning – has adequate time been given for the pneumonia to resolve? What are the current ventilator settings and trends? What does the chest X-ray show? Is it improving? Are the inflammatory markers like white cell count, CRP (C-reactive protein), procalcitonin trending down? Have sedation and opiates been appropriately minimized to allow for neurological assessment? Why is the tracheostomy being ruled out? Is it truly not an option, or is this age or prognosis-based bias?

Having someone who understands intensive care nursing and intensive care medicine inside out, to have them in your corner completely changes the dynamics. The ICU team knows they’re being held accountable, and they often become more thorough in their assessments when they know an expert is reviewing the case. We have advocated successfully for continuation of treatment, for a tracheostomy, for dialysis, for any treatment option really that can help your loved one.

We have a proven track record, and you can verify that on our testimonial section at intensivecarehotline.com, and you can verify it on our intensivecarehotline.com podcast section where we’ve done client interviews.

The ICU team is saying your father is not a candidate for a tracheostomy, but I want you to question this.

Age alone, condition alone, should not disqualify someone from a tracheostomy. This is actually discrimination. The decision should be based on potential for a meaningful recovery, and what’s meaningful for you might not be meaningful for the ICU team, but it’s completely irrelevant what’s meaningful for the ICU team. It’s based on your values and what your dad wants. It’s also based on quality-of-life considerations, patient and family wishes, whether prolonged ventilation is needed for the lungs to fully heal. Sometimes ICU teams are too quick to dismiss a tracheostomy in elderly patients due to age or prognosis bias, rather than actual medical contraindication.

A tracheostomy can be lifesaving and life prolonging because it allows for better airway management. Reduces sedation and opiate requirements, improves comfort, makes it easier to wean from the ventilator, reduces the risk of further aspiration.

Now, here’s something many families in intensive care don’t know exists. Go and check out intensivecareathome.com. If your father does require long-term ventilation with or without a tracheostomy, this is a game changing option. Because another option for your dad might be to have the breathing tube removed and have Home BIPAP (Bilevel Positive Airway Pressure), Home CPAP (Continuous Positive Airway Pressure) ventilation.

Again, we would need to look at the medical records, but in any case, Intensive Care at Home would allow your dad to go home on a ventilator with a tracheostomy, go home on a ventilator without a tracheostomy, or go home with a tracheostomy without a ventilator.

Intensive Care at Home allows patients who need ongoing ventilator support to be cared for at home with 24-hour intensive care nurses, rather than staying in ICU indefinitely or being transferred to a long-term acute care facility or to nursing homes, which are not appropriate anyway.

Intensivecareathome.com can keep your father out of ICU predictably and permanently if he needs continued respiratory support. This is also an excellent option if your father cannot be weaned off the ventilator in the typical timeframe or even if the family decides that palliative care at home with ventilation support is the most appropriate path forward. Being at home surrounded by family, with professional 24/7 intensive care nurses and medical support is often far better for quality of life than remaining in an ICU and in an institutional setting. Many families don’t realize this option exists and it can completely change the trajectory of care and the family’s experience.

So, my recommendation for you right now, Wynn is:

1. Request a formal family meeting with the entire ICU team, including the attending ICU doctor, respiratory physician and have me there as your advocate and consultant.
2. Get complete access to all medical records. You have a legal right to this information. It’s a right, not a privilege, and you need it to make informed decisions, have peace of mind, control, power and influence.
3. Ask specifically about the timelines. How long has your father been treated for aspiration pneumonia? Has he completed a full course of antibiotics? Do the follow-up cultures show.
4. Question the tracheostomy decision. Ask for specific medical reasons why he’s not a candidate, not just general statements based on age.
5. Insist on proper weaning trial with documentation. This means gradually reducing ventilation support while closely monitoring his breathing pattern, oxygen levels, and arterial blood gases.
6. Reach out to me and the intensivecarehotline.com team for a consulting call including getting on the call with the ICU doctors. We help you ask the right questions and join you on calls with the ICU team. Having expert advocacy completely changes the outcomes for families.
7. If long-term ventilation becomes necessary, explore intensivecareathome.com as a viable option rather than accepting that ICU is the only choice or that withdrawal of treatment is inevitable.

Keep in mind, 70 to 90% of intensive care patients survive so that means the odds are actually in your dad’s favor and you should be asking why the ICU team is so negative. Also, time is your ally, not your enemy.

The ICU team may be creating a false sense of urgency around withdrawal of treatment, but I want you to understand something crucial, your father’s body needs time to heal.

Aspiration pneumonia in a 94-year-old patient requires patience. If his vitals are stable, that means his body is coping and there’s no immediate medical emergency requiring withdrawal of treatment. You have the right to request more time, to get a second opinion, question everything, and to advocate for your dad’s continued treatment. Don’t let anyone pressure you into a decision you’re not comfortable with, especially when there are questions left unanswered.

Withdrawing treatment against your wishes could be perceived as euthanasia. Euthanasia is illegal, could also be perceived as even murder.

The bottom line, Wynn, is your father’s situation is challenging but certainly not hopeless. The fact that he’s been healthy most of his life, has stable vitals and that you’re asking these important questions, put you in a much better position than most families. The key is getting all the information, having expert guidance and handhold you to interpret that information, making sure your father receives best care and appropriate treatment options, before any discussions about withdrawal treatment should even be brought up.

And remember, if long-term ventilation becomes necessary, intensivecareathome.com provides a pathway to keep him out of ICU permanently and predictably, whilst still receiving all the intensive care nursing and treatment he needs.

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. 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 for our clients in intensive care. You can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section, where we have done client interviews. You can find our podcast again at intensivecarehotline.com.

Because our advice is absolutely life changing, it’s absolutely life changing, you can join a growing number of clients and members that we have helped over the years to improve their lives instantly and to save their loved ones’ lives, or at least to get a better outcome for their loved ones.

That’s why I do one on one consulting and advocacy over the phone, Zoom, Skype, 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. I also talk to doctors and nurses directly. I ask all the questions to the doctors and nurses that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care. I hold them accountable, and you will see how the dynamics will change in your favor very quickly.

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 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. 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. You also have access to 21 eBooks and 21 videos that I’ve personally written and recorded, making sure you make informed decisions, have peace of mind, control, power and influence, making sure your loved one gets the 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.