My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives of 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 the best care and treatment, even if you are not a doctor or a nurse in intensive care.

In today’s video, I will answer a question from one of our clients, Deborah, who is asking:

“Hi Patrik,

With a PEEP (Positive End-Expiratory Pressure) of 10 and FiO2 (Fraction of Inspired Oxygen) of 55%, if the doctor won’t do a tracheostomy on day eight, could we try high flow nasal cannula instead? It is sometimes used with hospice patients to keep them comfortable and off sedation and off opiates, and they can even go home on it.”

We will unpack this question in detail, talk about ventilator settings, PEEP, FiO2, sedation and opiate management, and most importantly, how you can advocate for your loved one to avoid the wrong decisions in intensive care.

Background: Ventilator Settings and Why They Matter

Your mom is on PEEP of 10 and FiO2 of 55%. That means she is still requiring a moderate to high level of ventilatory support. PEEP keeps your mom’s lungs open at the end of each breath. FiO2 tells us how much oxygen the ventilator is delivering.

A patient needing PEEP of 10 and FiO2 of 55% is not ready to come off the ventilator. She is still too dependent on mechanical ventilation support. It also means a tracheostomy is contraindicated at this stage, because PEEP needs to be below 7.5 and FiO2 needs to be below 35%. Your mom is still some way from those targets. That means no surgeon and no intensive care specialist will operate on her to perform a tracheostomy, it is simply too risky. The risk of a respiratory arrest is far too high with PEEP of 10 and FiO2 of 55%. Those parameters would need to be weaned first. On top of that, she would need to be breathing spontaneously, which she is not at the moment because she is on too much sedation and opiates.

Can High Flow Nasal Cannula Replace the Ventilator?

The short answer is no — not safely, and not at those levels.

HFNC (High Flow Nasal Cannula) delivers high-flow humidified oxygen or air through nasal prongs and provides mild positive airway pressure. It is excellent for patients after extubation or with milder respiratory failure. However, HFNC cannot replace the level of support provided by a ventilator at PEEP of 10 and FiO2 of 55%. The jump would simply be too great, and the risk of respiratory arrest and death would be too high. If a patient is switched from a ventilator to HFNC too early, they can go into respiratory distress, respiratory failure, or even cardiac arrest.

HFNC is best suited for:

• Post-extubation oxygen support, with PEEP around 5 and FiO2 less than 35 to 40%, and where spontaneous breathing trials have already been passed
• Palliative or hospice care settings for comfort, not recovery
• Step-down therapy when the lungs are still frail but improving — again, mainly post-extubation
• Patients with a tracheostomy who need a tracheostomy collar, where HFNC is often also used via a tracheostomy collar

HFNC is definitely not a substitute for full mechanical ventilation when the lungs are still severely compromised, which is the case in your mom’s situation.

The biggest challenge for families in intensive care is 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. This is a typical situation where Deborah simply doesn’t know what she doesn’t know — and that is what I am here to help with.

Why a Tracheostomy May Be Necessary

If your mom cannot be weaned off the ventilator after 7 to 10 days, a tracheostomy is often the next logical step because:

• It reduces sedation and opiates, and patients can often wake up and communicate
• It facilitates weaning more easily because breathing trials are easier to manage
• It improves comfort and mobility, and reduces ICU length of stay if your mother can be weaned off the ventilator
• It allows for long-term ventilation at home if needed, with Intensive Care at Home support — more information is available at intensivecareathome.com

Rather than keeping your mom deeply sedated and on opiates on a breathing tube for weeks, a tracheostomy is often a safer and more humane option.

The Problem with Sedation and Opiates in ICU

You mentioned your mom is still on propofol and fentanyl and possibly not receiving Precedex, also known as dexmedetomidine. This is very concerning.

Ongoing heavy sedation keeps patients unresponsive and unable to participate in weaning. It often leads to ICU delirium, ICU psychosis, deconditioning, muscle weakness, delayed recovery, and an inability to wean off the ventilator.

If the ICU keeps your loved one sedated and opiated for too long, they cannot wake up. If they cannot wake up, they cannot come off the ventilator quickly. Those delays can be quite deadly. And if they cannot come off the ventilator, the team will tell you a tracheostomy or withdrawal of treatment is the only option.

One of the most important questions you need to ask early on is: what is the intensive care team doing — beyond the shadow of a doubt — to wean your loved one off the ventilator and the breathing tube? And what are they doing — beyond the shadow of a doubt — to avoid a tracheostomy?

Precedex, for example, allows patients to be awake, calm, and cooperative, making weaning safer and more achievable. Ask the ICU team: what is the sedation plan? Why not use Precedex instead of heavy propofol and fentanyl? When will sedation and opiate breaks and SBTs (Spontaneous Breathing Trials) begin? Those cannot begin until your mom has been weaned off opiates and sedation.

Fluid Overload and Kidney Failure in ICU

Deborah, you also mentioned your mom is bloated, has minimal urine output, and is not receiving water flushes. This sounds like likely AKI (Acute Kidney Injury) or fluid overload — both of which can severely affect lung function. If the body is fluid overloaded, the lungs become congested and gas exchange becomes more difficult, making it much harder to come off the ventilator.

You need to ask:

• What is the fluid balance?
• What are her kidney numbers — creatinine, urea, BUN (Blood Urea Nitrogen) levels?
• What is the GFR (Glomerular Filtration Rate)?
• Has the ICU considered frusemide (Lasix) or dialysis?

These issues must be addressed before any ventilator weaning can succeed. The old saying in ICU is: you have to keep the lungs dry in order to succeed with ventilation weaning.

What You Can Do Right Now

Number one: Get access to all medical records. Getting access to medical records is not a privilege — it is a right. Do not let anyone tell you otherwise. If the ICU team is making it difficult, they may have things to hide, and that should concern you. We can help you gain access to medical records if the ICU team is being difficult — we have always managed to do so for our clients.

Number two: Ask for clear answers about:

• Sedation and opiate management
• Tracheostomy timing
• Kidney and fluid management plan
• Ventilation weaning goals and timelines

Document everything. Take notes, obtain reports, access medical records, and stay involved in ward rounds. Do not let the ICU rush or delay decisions without your input.

Number three: Get independent clinical advocacy. That is what we provide at intensivecarehotline.com.

If you are watching this right now and you have a loved one in intensive care — stuck on a ventilator, heavily sedated, heavily opiated, and the doctors are pushing towards withdrawal of treatment or hospice — do not make that decision without talking to us first. Come to us at intensivecarehotline.com. We help families just like yours to:

• Speak directly with ICU doctors and ICU nurses
• Interpret medical information in real time
• Advocate for best care and outcomes
• Make informed decisions confidently

Contact us at intensivecarehotline.com. Call directly on one of the numbers at the top of our website, or email us at [email protected].

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over five years in intensive care. And I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. And I can very confidently say that we have saved many lives with our consulting and advocacy, because of our insights, 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 have done client interviews.

And because our advice is absolutely life-changing, right? 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. And 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 the best care and treatment always. And 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.

And that’s why I do one on one consulting and advocacy over the phone, Zoom, WhatsApp, whichever medium works best for you. And 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. And 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, so, 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 e-books and 21 videos that I’ve personally written and recorded. And 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 the best care and treatment always.

And all of that you get at intensivecarehotline.com. Call us on one of the numbers at the top of our website or simply send us an email to support at intensivecarehotline.com with your questions.

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Thank you so much for watching.

This is Patrik Hutzel from intensivcarehotline.com and I will talk to you in a few days.

Take care.