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Quick Tip for Families in Intensive Care: ICU Doctors are Anxious Extubating My Dad! Pressure Support Isn’t 12 on the Ventilator & He’s Conscious

“The ICU doctors are anxious, and the pressure support number isn’t down to 12 on the ventilator. He’s conscious, all blood work is good. Why can’t they take out the breathing tube?” That’s a question that Darren has, and I’m going to answer it today.

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

Darren, you must have your dad probably in ICU. We get questions like this all the time, but let’s look at this in much detail.

So, if the pressure support number isn’t down to 12 or lower, that very likely means your loved one still needs much help from the ventilator to breathe on his own consistently, even though he’s conscious and his labs look good.

Here’s why they may be hesitant to remove the breathing tube. Number one, pressure support indicates work of breathing. Pressure support is the amount of extra air pressure the ventilator gives during each spontaneous breath to reduce the effort it takes to inhale. If it’s still high, i.e. 12 or above, it suggests his respiratory muscles still may be too weak. He may not be able to sustain adequate breathing once the tube is out. A good number for extubation with pressure support is usually 10 or less, that is if your loved one breathes on pressure support or CPAP (Continuous Positive Airway Pressure) already and has been breathing on pressure support or CPAP for prolonged periods of time, i.e., more than 24 hours.

Next, maybe he had a failed weaning attempt in the past. You mentioned earlier that an attempt to wean him failed, which can make ICU teams more cautious. They might want to avoid the risk of reintubation, which is associated such as complications like trauma, infection, or prolonged ICU stay or respiratory failure, which can be life threatening.

Next, consciousness alone isn’t enough, even though he’s awake. They’re looking at respiratory rate breaths per minute. If it’s more than 25 to 30 breaths per minute, it’s too fast and the tidal volumes are probably low. That leads me to tidal volume, how much air he inhales per breath, which should be, by the way, 7 to 10 mL per kilo. For simplicity, if you loved one is 70 kg, that should be around 490 mL minimum, and 700 mL maximum somewhere in between.

But that would also then needs to go hand in hand with good arterial blood gases, with good oxygen saturations, and a regular breathing rate, that’s not too fast or not too slow. Also, oxygen requirements, is a loved one breathing on room air, or does he require oxygen, for example? Room air, the air that you and I are inhaling is 21%. Your loved one might be on 30, 40%, 50%. If it’s 40% or more, that’s also concerning and would also be a reason not to extubate.

Next, CO2 (carbon dioxide) clearance. If any of these aren’t stable off support, extubation can fail, i.e., what is his carbon dioxide in the blood? Is he exhaling enough carbon dioxide? Is he awake enough? So, what should you be looking for? You might want to ask, what’s his current pressure support FiO2 (fraction of inspired oxygen), i.e. oxygen, that he’s getting from the ventilator? PEEP (positive end-expiratory pressure)? What’s his breathing rate, also known as respiratory rate? What are his arterial blood gases like? PO2 (partial pressure of oxygen) and PCO2 (partial pressure of carbon dioxide) in particular, also pH? Have they tried spontaneous breathing trial today, yesterday and the day before? Are they planning to do more spontaneous breathing trials? If yes, do they think they can reduce the pressure support? What’s stopping them from trialing extubation if all his other vitals and labs are good? Can the ICU doctor, ICU nurses, respiratory physician reevaluate his readiness for extubation?

It would also be very good to have the ventilator settings of your loved one, because then I can guide you even further. Ventilator settings, also the variables, what he’s doing, tidal volume is a variable, breathing rate is a variable, and so forth.

Also, his pathology. It will also be good to know why your loved one is in ICU. I have written a blog post and an email and also made a video about it, “How to wean a critically ill patient off the breathing tube and the ventilator?”  And I link to that video and blog post in the written version of this blog, so you can check them out because that is your best bet to take the next step here.

Also, what you also need to ask is, is your loved one off all sedation and opiates? Check that one out as well, that’s very important. Also, ask them if there’s no neurological impairment that he definitely didn’t have a stroke, God forbid, or a seizure or anything like it. Ask for that as well.

So I hope that helps you clarify, Darren.

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 intensive care.

You can verify that if you go to our intensivecarehotline.com testimonial section at intensivecarehotline.com or if you go to intensivecarehotline.com podcast section where we have done client interviews. Those clients will verify and will tell you all about how we help them to save their loved ones’ lives because our advice is absolutely life changing, our consulting and advocacy 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. And that’s exactly what you and your family are up against.

You can join a growing number of members and clients that we have helped over the years to improve their lives instantly, making sure they 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 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 can’t afford to get wrong. I make sure you ask the right questions. I make sure you understand everything that’s happening with your critically ill loved one so that you can ask the right questions and get the right outcomes. I also talk to doctors and nurses directly on your behalf or with you or I set you up with the right questions. I’ll make sure 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 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 videos and 21 e-books that only are exclusively accessible to our members. All of that will help you to 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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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.

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