My name is 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, control, power and influence making sure your loved one always gets best care and treatment even if you’re not a doctor or a nurse in intensive care.

So, today’s question comes from one of our clients, Angela, who says,

“Hi Patrik,

The ICU doctor has given me three options for my mom. Number 1, extubate and if fail, use BiPAP, CPAP, and reintubate if needed, but would need to consider tracheostomy in 2 to 3 days.

Just for explanation, extubation means the removal of a breathing tube.

The next option they’ve given me is a tracheostomy, and the 3rd option they’ve given me is extubate and not reintubate.

I am leaning towards number 1. She told me I can think about it and talk tomorrow. I want to buy my mom some more time, but should we do it tomorrow?”.

Angela, this is such an important and common situation in ICU, but I will break this down for you today in your three options and talk about what they really mean, because this is where families in intensive care can easily be pushed into irreversible decisions without understanding all the implications. Always keep in mind these are life or death situations that you simply can’t afford to get wrong.

So, let’s look at option 1 – Extubation with BIPAP (Bilevel Positive Airway Pressure), CPAP (Continuous Positive Airway Pressure) or high flow nasal cannula support. If your mom is being weaned from the ventilator, extubating onto noninvasive ventilation like BIPAP, CPAP, or even high flow nasal cannula can absolutely help her transition more gently. This option gives your mom a real chance to breathe on her own, but with support to begin with. It also buys you some time to see how she responds without closing the door to reintubation. It’ll also give you time to talk to your mom and see what she wants.

However, make sure the ICU team understands this is not a, “one-way extubation.” A one-way extubation in ICU terms means extubation will take place, the removal of breathing tube will take place, not for real intubation in most cases, that means a patient is often going to die. And that’s not what you want. That’s not what your mom wants. So don’t even engage in any of those conversations. It’s as simple as that.

So, let’s just say she fails the extubation and can’t maintain oxygen or CO2 (carbon dioxide) levels. She should be reintubated quickly or BIPAP or CPAP can be commenced. Too often ICU says, let’s extubate and see how it goes, but what they don’t say is that sometimes they mean a one-way extubation, which is basically an end-of-life pathway, but they’re not saying it as such. They’re not telling you as such. But that’s what I’m here to do, to tell you how things are in the real world.

So one-way extubation means no reintubation that could lead to death within hours or days. So, clarify with them, is the extubation reversible if she struggles? Don’t accept a no reintubation.

Option 2 – Tracheostomy. If your mom has been ventilated for more than 10 to 14 days or if repeated extubation attempts fail, a tracheostomy is the next logical and safest step. Tracheostomy is much more comfortable than a breathing tube through the mouth, allows for less or no sedation, allows for less or no opiates, helps with weaning, and even allows some patients to talk and eat and drink again. It’s also the right option if your goal is to give your mom more time to recover.

Option 3 – Extubate and no reintubation. This option, extubate and no reintubation, means end of life care. If your mom can’t breathe on her own after extubation, she will pass away shortly thereafter. And if she’s not passing away, they might send her to a hospital floor or hospital ward for end-of-life care. That’s why you need to be 100% clear that is what you want, and that this decision is not being made under pressure from the ICU. This is only really an option if there is an advanced care plan from your mom, where it’s clearly documented from your mom that is what she would want in a situation like this. Don’t be coerced into that. It requires consent from you and from your mom.

So, let’s look at timing. Should you do it tomorrow?

Angela, before making this decision, make sure you have all the facts. What are your mom’s ventilator settings? What is your mom’s latest arterial blood gas results – pO2 (oxygen levels), pCO2 (carbon dioxide levels), and pH levels in particular? And we can help you here to interpret those numbers for you, give you that second opinion. Can she manage her secretions, i.e. is she coughing? Can she clear her airway? How strong is her cough reflex? Can she wake up, obey commands, poke out her tongue, wiggle her toes, squeeze your hands, all of that?

If your goal is to buy time and keep all options open, then Option 1, extubation with BIPAP, CPAP, or high flow nasal cannula, including physical therapy and breathing exercises and the possibility of reintubation if needed, makes most sense for now. That way you’re not making an irreversible decision and you’re giving your mom the chance to prove whether she can breathe on her own or not.

Also, I encourage you to check out an article and the video that I’ve done about how to wean a critically ill patient off the breathing tube and the ventilator so that you can actually check that ICU is managing those milestones and is moving her towards those milestones that she needs to be extubated. Make sure they’re doing everything beyond the shadow of a doubt to get her off the ventilator and the breathing tube safely and avoid the tracheostomy. If you can’t answer confidently that they’re doing everything beyond the shadow of a doubt, you need to have second thoughts and you need to get a second opinion, which again is what we do here at intensivecarehotline.com.

So, let’s look at what if she needs a tracheostomy and long-term ventilation. If your mom needs a tracheostomy, it might be ventilator dependent for longer, or even tracheostomy dependent without a ventilator for longer, there’s a much better alternative than staying stuck in ICU or being sent to acute rehab, LTAC, or any other long-term facilities, and that is Intensive Care at Home.

At intensivecarehotline.com., we provide a real, genuine, and legitimate alternative to a long-term ICU stay for patients on ventilation plus-minus tracheostomy. We send critical care nurses into the home 24/7 to look after ventilated or tracheostomy patients safely and professionally. This allows your loved one to leave ICU, go home, and have a much better quality of life while freeing up ICU beds and cutting the cost of the ICU bed by around 50%.

So, if your mom needs long-term ventilation or a tracheostomy, definitely check out intensivecarehotline.com

So, let’s summarize.

Option 1. Extubation with BIPAP, CPAP, and possible reintubation, the safest to buy more time and keep your mom’s options open.

Number 2. Avoid a one-way extubation unless it’s a clear end-of-life decision.

Number 3. If prolonged ventilation is needed, tracheostomy and Intensive Care at Home are the best path forward.

Again, my name is Patrik Hutzel from intensivecarehotline.com. We help families of critically ill patients in intensive care to instantly improve their lives.

Go to intensivecarehotline.com for one-on-one consulting and advocacy where we can help you very, very fast to turn situations around that appear to be impossible.

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.