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Quick Tip for Families in Intensive Care: Can a Tracheostomy Be Done with High PEEP (Positive End-Expiratory Pressure) in Intensive Care?

“Can a tracheostomy be done with high PEEP (Positive End-Expiratory Pressure) in intensive care?” That is what I’m going to answer today.

My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

One of our members and clients who has their son in intensive care has the following question, “My son remains ventilated with FiO2 (Fraction of Inspired Oxygen) down to 40%, but with high PEEP. A tracheostomy is scheduled for Friday, though he may still be borderline for the procedure due to high PEEP with 14.” PEEP stands for positive-end expiratory pressure. It’s the pressure left in the lungs at the end of the breath to help keep the airways and alveoli, also known as air sacs, open, so gas exchange can continue.

Lower PEEP, ideally less than 10, is usually preferred before a tracheostomy because it means the lungs are more stable and can tolerate the procedure more safely. Ongoing and continued coordination with ENT specialists, anesthetists and respiratory therapists are essential to optimize readiness for the tracheostomy procedure. So, that’s the situation with our member’s son in ICU.

I know if you’re watching this, it’s probably because your loved one is ventilated in ICU and the ICU team is either talking about a tracheostomy, or they’re delaying it using high PEEP as the main or one of the reasons. So, let me break this down for you in simple terms as I always do here at intensivecarehotline.com.

What is PEEP and why does it matter? PEEP stands for positive-end expiratory pressure. It’s the pressure left in the lungs at the end of exhalation, designed to keep the air sacs alveoli open. This is critical when someone’s lungs are very sick, like in ARDS (Acute Respiratory Distress Syndrome), pneumonia or COVID, because it helps with oxygenation. Generally speaking, a PEEP of 5 to 10 cmH2O (centimeters above water) is considered safe and stable. But, once your loved one needs a PEEP of 12, 14, or even higher, it means their lungs are still in trouble and dependent on that pressure to stay open.

When the ICU team says, “We’re not sure if a tracheostomy can be done at PEEP 14.” They’re not wrong, but they’re not telling you the full story either. This is what I’ve been saying on this channel for over a decade now, that ICU teams are not even telling you half of the story of what you actually need to know.

So, can a tracheostomy done with high PEEP?

Yes, it absolutely can, but it’s not ideal, so let me explain. A tracheostomy is often done when your loved one has been ventilated for more than 10 to 14 days, if your loved one is not waking up or it’s not strong enough to come off the ventilator. They’re failing spontaneous breathing trials or CPAP (continuous positive airway pressure) trials. The breathing tube in the mouth, also known as endotracheal tube, becomes a long-term risk, for example, for vocal cord or mouth damage. But here’s the catch, if PEEP is too high like 14, there’s a risk of the lungs collapsing or oxygen levels dropping during the tracheostomy procedure. That’s why ICU teams and also ENT surgeons get nervous.

So, what is the actual real answer? The real answer is that this needs a skilled coordinated approach. I’ve seen tracheostomy done safely even on PEEP 14, 16, or more, if it’s done by experienced hands. It requires full coordination between ICU, ENT (ENT stands for ear, nose and throat), anesthetists and respiratory therapy, and of course, ICU nurses.

Ideally, FiO2 should be coming down below 50% and even 40% in the ideal world, and PEEP ideally less than 10 centimeters above water. But again, I’ve seen it on higher when really needed. ENT or ICU should have a plan to keep the lungs recruited during the procedure, sometimes using apneic oxygenation or jet ventilation.

It can be done at the bedside, which is a percutaneous tracheostomy, or in the operating room, also known as a surgical tracheostomy, depending on your loved one’s condition and also on your loved one’s anatomy and physiology.

What are risks versus benefits? Delaying the tracheostomy because of high PEEP also has its risks: longer sedation, more opiates, painkillers, higher infection risks from prolonged intubation, more difficult to wean later on. There’s one thing that you mustn’t forget if your loved one has a breathing tube with a ventilator, the best time to wean is now. But if it’s not possible to wean, for whatever reason, then that’s when a tracheostomy is necessary.

Also, potential tracheal damage from prolonged endotracheal tube, sometimes even with a borderline PEEP, but tracheostomy is still the lesser of two evils.

So, what’s my advice?

Don’t just accept we can do a tracheostomy because PEEP is too high is the final answer. A better question to ask is, what is the plan to lower PEEP and FiO2? Can the ENT or anesthetist evaluate if it’s still safe to proceed? Can it be done with extra precautions? What are the risks of waiting versus doing it now? Remember, you need to ask the right questions, so the ICU team knows you’re informed and not just sitting on the sidelines.

If you need help advocating for your loved one or want me to speak to the doctors with you on a call, that’s what we do here at intensivecarehotline.com every day. We fight for families in intensive care like yours, so you can make informed decisions, have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment always.

You can always click on the link below to schedule a free 15-minute consultation or you can just call 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 critical 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 for our clients in ICU. You can verify that by looking at our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews.

Because our advice is absolutely life changing, the advice and advocacy that we’re providing is so life changing that, like I said, we have saved many lives, and we’re improving the lives of our clients and our members instantly, so that they can make informed decisions, have peace of mind, control, power and influence, making sure their loved ones get 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. Once again, to improve their lives instantly, making sure they can make informed decisions, have peace of mind, control, power and influence, making sure their loved ones get the best care and treatment, always.

That’s exactly 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 can’t afford to get wrong. When I talk to doctors and nurses directly, I ask 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 talk to doctors and nurses directly either one on one or I have you on the phone with them, or I’ll set you up with the right questions to ask.

I also represent you in family meetings with intensive care teams so that you can have clinical advocacy and representation on the 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. In the membership, you also have exclusive access to 21 videos and 21 e-books that I have personally written and recorded. All of that, once again, will help you to improve your life instantly so that you 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.

If you like my videos, subscribe to YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families and comment below what you want to see next, what questions and insights you have.

I also do a weekly YouTube live where I answer your questions live on a show. You will get notification for the YouTube live if you are a subscriber to my YouTube channel, or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

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.

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