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, so that your loved one gets best care and treatment always, even if you’re not a doctor or a nurse in intensive care.

So, in today’s video, I’ll answer a question from one of our clients, Adela, who says:

“Hi Patrik,

Thank you so much for the update today. Eva was breathing rapidly and had some blood in the tracheostomy while cleaning. The respiratory therapist adjusted the settings, added more moisture, and switched to assist-control ventilation. The breathing sound went away and went back to normal. Is there something else we should watch out for in regards to Eva’s breathing or ventilation settings? She was eventually started on the tracheostomy collar for 45 minutes and then pressure support of 5 for 17 hours. The ICU nurse said the next step would be to send Eva to LTAC, but we want to avoid that at all costs. Please help.”

Thank you, Adela, for your question, and it’s an excellent question, and it’s something I see all the time when families in intensive care are trying to prevent their loved one going from prematurely being discharged to LTAC.

Now, for anyone who’s wondering what’s an LTAC, LTAC stands for Long-Term Acute Care Hospital. Now, the LTACs are unique to the United States, so really the issue addressed today is mainly for our U.S. audience, but even if you’re in another country, you will learn about intensive care anyway by just watching this video. But it is absolutely critical to avoid a transfer to LTAC because LTACs are simply dangerous and are not suitable for anybody on a ventilator with a tracheostomy. I encourage you to look up your online reviews in the area that you’re living in for your LTAC and see what families in LTAC say. You won’t see anything good, and I’ve been warning about LTACs here on this channel for over a decade now.

So, let’s now look at the blood in the tracheostomy. If you see small amounts of blood or pink-tinged secretions, it can be normal, especially when the tracheostomy is new or when the tracheostomy tube or suction catheter irritates the tissue.

However, if the bleeding is bright red, fresh, or increasing, that is definitely not normal and must be escalated immediately to the ICU doctors or respiratory therapy. So, some common causes include:

The suction catheter going in too deep, the airway being too dry, meaning there’s not enough humidity or not enough nebulization. Sometimes it can be a local infection or irritation around the stoma site, and sometimes it could simply be that your loved one is getting too many anticoagulation medications such as heparin. Could be warfarin, could be aspirin, could be Clexane or enoxaparin. Check for an anticoagulation medicine. Most patients in ICU are on anticoagulants, so please check that out. But that’s also why it is so important that you can get access to the medical records on day one. I can’t stress this enough.

Most families that we work with, when they first come to us, I ask them, “Do you have access to the medical records?” and it’s a clear no, and that’s a big mistake. You need to get access to the medical records day one of your loved one being in ICU so that you can get a second opinion from day one.

So, coming back to Adela, the respiratory therapist did the right thing by adding more humidification and switching Eva to assist control mode initially and temporarily to stabilize her breathing. Safety above all, after all. So, what should you watch for in Eva’s breathing?

Here’s what you and the team should keep monitoring very closely:

Her respiratory rate, of course. If it’s high, Eva might be fatigued or fighting an infection, especially now that she’s breathing on pressure support with the pressure support of 5.
If she’s getting too tired, her respiratory rate will most likely go up, and her tidal volume,
how deep she’s breathing, will be going down most likely.

So therefore, you also need to watch oxygen levels. It must be above 92%.
Also have a look whether she’s consuming any oxygen or whether she can just stay on room air.

If oxygen levels drop below 92%, you probably need to add on some oxygen or the RT needs to add in some oxygen to maintain the level above 92%.
Look out for the work of breathing. If she’s using neck or chest muscles or abdominal muscles, she’s overworking again, especially if that happens on the pressure support of 5.
You either have to increase the pressure support, or she might need to go back in an AC mode.

Next, secretions, thicker or discolored secretions may indicate an infection. Or may also indicate that she’s too dry again, comes back to humidity, also comes back to fluid intake.

Number 5.
Heart rate and blood pressure. These can change when a patient is in respiratory distress.

Number 6.

Check arterial blood gases, again, blood gases will indicate low oxygen levels, high oxygen levels will indicate high or low carbon dioxide levels. It will indicate pH levels. And from there you can make decisions about what ventilator settings to use as well.

The goal now is to extend her time on the trach collar gradually from 45 minutes to several hours, then to most of the day until she’s fully breathing on her own. That needs to go hand in hand with mobilization, with physical therapy. So that she can build up her strength. It’s like, think about when someone wants to run a marathon, you can only build up to running a marathon if you train and it’s the same here, the training is by getting mobilized, by getting out of bed, by doing deep breathing exercises, by moving arms, moving legs. All of that.

So, why should Eva avoid LTAC? Now let’s talk about LTAC, which again stands for long-term acute care. Again, it’s unique to the United States only. ICUs often push for LTAC because they want to free up ICU beds, not because it’s in your loved one’s best interest. So, when your loved one is being pushed towards early tracheostomy and early PEG (Percutaneous Endoscopic Gastrostomy), especially in the United States. The red flag is always that they want to discharge to LTAC as quickly as possible.

It’s a bit like out of sight, out of mind, without taking any accountability. To help your loved one avoid the tracheostomy, get them off the ventilator without needing a tracheostomy, because that can be a lot of hard work. You need skilled staff to do that. Whereas once your loved one has a tracheostomy, has a PEG tube, it’s easy for the ICU to discharge them to LTAC.

The problem is that LTACs are not ICUs, and I can’t tell you how many patients I’ve seen over the years that have been discharged to LTAC. But we said, no, no, you can’t send your loved one to LTAC, and they’re bouncing back to ICU within less than 24 hours, clearly indicating that our clinical judgment is accurate here, and then they’re bouncing back to another ICU because the ICU that discharged the patient no longer has a bed available. It is madness, it is crazy.

So, you really need to put a stop to having a loved one go to LTAC because LTACs usually don’t have an intensive care specialist, respiratory therapists, let alone ICU nurses available 24/7. The nurse-to-patient ratios are much lower. One nurse may care for 4 to 6 patients compared to 1 in 1 or 1 to 2 in ICU. Often this ratio drops down to 1 to 10 overnight. It is madness, I can tell you.

Do whatever it takes to stop your loved one from going to LTAC. And if your loved one deteriorates, it’s very hard to get them back to ICU in time. Because the skill level in an LTAC is so low they’re not even detecting the deterioration that is going on.
I’ve seen so many families in LTAC lose their loved ones after a premature and unnecessary LTAC transfer because the level of care is simply not the same. The problem here is you need to stop your loved one having a tracheostomy.

Now, I’m not opposing a tracheostomy here in general. A tracheostomy has its time and its place, but one of the first questions you need to ask when your loved one is going into ICU is, are they doing everything beyond the shadow of a doubt to get your loved one off the ventilator and a breathing tube? Are they doing everything beyond the shadow of a doubt to avoid the tracheostomy? If all of those questions can be answered with a yes, and they’re still not progressing, then a tracheostomy is probably the right thing to do. But you must ask those questions right from the start.

You must get access to the medical records and you must get a second opinion right from the start. The stakes are simply too high. So, another alternative is it’s a safe and proven alternative to an LTAC which is Intensive Care at Home, and I encourage you to go to www.intensivecarehome.com.

With Intensive Care at Home, you can have 24/7 ICU level nursing care provided by critically care trained nurses at home. Continue ventilator weaning safely at home under the supervision of ICU doctors, ICU nurses, respiratory therapists, have a much lower infection risk, more privacy, and a far better quality of life, and most importantly, keep your loved one clear of LTAC and hospital settings altogether.

It’s a model that’s been running successfully for over 25 years in countries like Australia, Germany, and now also slowly but surely branching into the U.S. It is clinically appropriate, evidence-based, cost-effective, and funded by insurance in most cases once your loved one is medically stable for discharge from ICU. Think about it, it’s only a win-win situation for everyone. Because with Intensive Care at Home, you’re cutting the cost of an ICU bed by 50%, it’s 50. And the ICU wants the bed anyway, otherwise they wouldn’t be so pushy to send your loved one to LTAC in the first place.

So, what do you need to do next? Keep Eva in ICU until she’s off the ventilator or stable on minimal support. Push the ICU to wean her off the ventilator. They must be doing something, she’s progressing.

Also, do not give consent to a PEG tube. Never ever give consent to a PEG tube unless you have a second opinion. So, the problem with the PEG tube in the U.S. in particular is that the minute your loved one has a trach and a PEG, they are easy bait for an LTAC because that’s when LTAC will open the doors for these patients.

Now, if your loved one only has a tracheostomy but no PEG tube, chances that they will be discharged to an LTAC are much lower because LTACs, generally speaking, cannot look after a nasogastric tube, which is the alternative to a PEG tube. So, you actually have a lot more control than you think you have, unless you’re giving into everything that they’re telling you. Don’t do that.

So, what’s next? Request a family meeting with the intensive care team and clearly say we do not consent to an LTAC transfer. We want Eva to stay in ICU until she’s ready for Intensive Care at Home or until she’s been weaned off the ventilator in ICU.

Also, get the hospital discharge policy. Can’t stress this enough. Ask the ICU for the hospital discharge policy. Now, if they’re not giving it to you, they’ve got something to hide. If they are giving it to you, you will most likely find that the hospital discharge policy will say something along the lines of. That your loved one cannot be discharged without your consent.

So, in summary, a little blood in the trachea can be normal but check for anticoagulation. But watch it closely. Get access to the medical records. Continue gradual weaning on the trach collar, mobilize physical therapy. Don’t let the ICU push you into an LTAC that can’t provide the same level of care, get access to the medical records and do not give consent to a PEG tube and go and check out intensivecareathome.com for more information about home care.

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 for our clients in intensive care. You can verify that on our intensivecarehotline.com testimonial section and also on our intensivecarehotline.com podcast section where we have done client interviews.

Because our advice is absolutely life-changing, it is absolutely life-changing. That’s why you can join a growing number of members and clients that we’re helping in intensive care. We’re improving their lives instantly, making sure families in intensive care can make informed decisions, have peace of mind, control, power and influence, making sure their loved ones get best care and treatment always.

Because 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 is exactly what you’re up against.

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. When I talk to doctors and nurses directly, which I do as well, you would see the dynamics change in your favor very quickly because you have someone on your team that understands intensive care inside out.

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. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded that only our members have access to.

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 from this video.

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.