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Quick Tip for Families in Intensive Care: How to Wean Off 100% FiO2 (Fraction of Inspired Oxygen) & Safely Prepare for Tracheostomy in ICU When Ventilated with Breathing Tube?

“How to wean off 100% FiO2 (Fraction of Inspired Oxygen) and safely prepare for a tracheostomy in intensive care when your loved one is on a ventilator with a breathing tube?”

My name is Patrik Hutzel from intensivecarehotline.com with another real world insight into life and decision making in ICU.

Today’s topic is how to be a 100% FiO2 and safely prepare for a tracheostomy in intensive care when your loved one is on a ventilator with the breathing tube and on a 100% of FiO2. If your loved one is in ICU on 100% oxygen FiO2, and the team is talking about doing a tracheostomy, but they’re saying “not safe yet,” you’re in the right place! Let’s break down what you need to know, what steps should be taken, and how to move towards a safe and successful tracheostomy.

So, let’s look at the situation why weaning from 100% of FiO2 is so critical to move towards the tracheostomy. This question today is actually from a member. We have a membership for families of critically ill patients in intensive care, and he’s in that situation with his son in ICU. This is a question that’s been coming from a real life case study that we’re currently working with.

100% FiO2 (fraction of inspired oxygen) is not sustainable long term. It increases the risk for oxygen toxicity and lung damage. Before a tracheostomy can be done safely, the FiO2 typically needs to be weaned to below 50%, ideally closer to 40% with stable oxygen saturation levels above 92%, and PEEP (Positive End-Expiratory Pressure) not excessively high, ideally 8 or below.

Just for context, if FiO2 is 100%, it can’t get any higher than that. Room air, the air that you and I are breathing is a 21% oxygen, so we’re talking basically 80% above room air. So, in your case, your son had episodes of desaturation, oxygen levels dropping below 90% during circuit changes, which is a common problem called de-recruitment, temporary collapse of alveoli, when ventilator support changes even briefly. He was placed back on FiO2 100% with improvements, and now FiO2 is being slowly weaned.

What happens in ICU, again, just for context here as well, you need to change ventilator circuits once a week roughly to avoid infections, ventilator associated pneumonia. So at some point, you have to disconnect the patient from the ventilator and attach a new ventilator with a new circuit. Now, that might only take 10 seconds, but that could be enough for an unstable patient to desaturate.

Let’s look at key steps to safely wean from 100% FIO2. Number one, gentle ventilator adjustments. It sounds like the ICU team is doing the right things here, gradually reducing the FiO2 from 100 to 90%, 80%, 70%, 60%, now at 50% to 55%, while maintaining stable oxygen levels. This is key. Rushing weaning can lead to desaturation and instability. It can also traumatize a patient.

Number 2, manage PEEP levels. High PEEP like 10 helps keep alveoli open, which are the lung sacs in the lungs, especially with lung consolidation. But to make a tracheostomy safe, the goal is to reduce PEEP to 8 or below, without compromising oxygenation. This balance must be monitored closely.

Number 3, address the underlying lung problem. The chest X-ray shows worsening consolidation in the right lung and a small pleural effusion. Your son is getting diuretics like Bumex, Lasix or furosemide to reduce lung congestion. This is a common and effective step to improve lung compliance and oxygen exchange.

Next, manage suctioning and bleeding risk. The blood-tinged secretions are likely from suctioning trauma, especially with Eliquis on board. It’s crucial to suction gently and only when needed, if surgery is imminent like a tracheostomy. Eliquis should be held and heparin should be used temporarily due to its shorter half-life and reversibility.

Number 5, monitor arterial blood gases and labs. ABG results look good, normal pH, PCO2, and PO2, which means gas exchange is improving despite FiO2 still being at 50% to 55%. This is very encouraging. White blood count is trending down. Fever is centrally driven, not likely in infection. That means the cause of instability is more neurological than infectious, which can happen with an anoxic brain injury, which is what your son’s situation is.

So, when is it actually safe to do the tracheostomy? A tracheostomy becomes safer when FiO2 is less than 50%, ideally 40%, PEEP is less than 8, oxygen saturation greater than 92% on those settings, hemodynamics are stable, no active bleeding risk, no high ventilator demands, and neurologically stable enough to tolerate the procedure. In your son’s case, he’s almost there.

The ICU team is working towards a safe window, and ENT, which is ear, nose and throat, has been consulted for custom tracheostomy sizing, which is excellent. Once the custom tracheostomy arrives, they’ll coordinate with the anesthetic team for a safe placement. Another ingredient here is obviously that PCO2 or carbon dioxide levels need to be within normal limits as well.

So, what you can do as a family? Ask daily for FiO2 and PEEP levels, and also for arterial blood gas results. You want to know exactly how close your son is to the tracheostomy threshold. Ask for weaning protocols in writing. What’s the plan to reduce FiO2 and PEEP? Make sure they continue chest physiotherapy to mobilize secretions. Ensure gentle suctioning, especially with anticoagulants. Anticoagulation means using a blood thinner. Confirm with pharmacy and hematology how anticoagulation would be managed around the tracheostomy.

Another option is, if none of it works, which at the moment it looks like it does. Another procedure that could help you to get your son ready for a tracheostomy is to do prone positioning, head down so that the lungs can drain excess fluids. But that would certainly delay a tracheostomy, but it might actually also help.

Final thoughts. Your son is progressing. It may feel slow, but every step, the weaning is going in the right direction. The tracheostomy can and should only be done when oxygen and PEEP requirements are reduced, stable, and PCO2 or carbon dioxide levels are stable as well. Stay on top of the daily progress and keep asking questions.

We have helped thousands of families, just like yours, navigate this very situation, and we’re here for you. If you need help now, go to intensivecarehotline.com, go call with me or send an email to [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 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.

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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.

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