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If you want to know what to do if your loved one is on 100% of oxygen in intensive care and it’s not enough, stay tuned! I’ve got news for you.

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

So, one of our readers reached out this week and asked, “What if 100% of FiO2 (which is fraction of inspired oxygen) is not enough for my critically ill loved one in intensive care? What are the next steps?” That’s a great question.

So, what that basically means is that a ventilated patient with a breathing tube in the mouth or a tracheostomy is ventilated on 100% of FiO2, which is fraction of inspired oxygen. It is basically oxygen they’re getting through the ventilator and it’s still not enough. Their oxygen saturation is low, their arterial blood gases are poor, probably their chest X-rays are poor, and there’s limited organ perfusion.

So, what are the next steps? Obviously, maintaining or requiring 100% of FiO2 is a critical situation, requiring immediate intervention. Here is what can be done.

Number one, optimize ventilator settings. Increased PEEP (positive end-expiratory pressure) helps to keep alveoli open and improves oxygenation. But there’s only so much so far you can go with the PEEP; the highest PEEP that I’ve probably seen is around 20, but even a PEEP of 15 is extremely high.

Next, prone positioning. Prone positioning basically means you turn a patient on their tummy, head down to drain any secretions of the lungs, but also to make sure that the lungs can expand because they can open up easier if a patient lies on their tummy because that improves lung perfusion and oxygenation in severe ARDS (Acute Respiratory Distress Syndrome) in particular.

The ICU team can also adjust tidal volume and respiratory rate. Low tidal volume ventilation (4 to 6 mL per kg) can reduce ventilator-induced lung injury while maintaining adequate ventilation. The challenge there, however, is to play devil’s advocate as well, is that volume control breeds a higher risk for a lung injury such as barotrauma, because you can’t control the pressure in the lungs, but you can only control the volume. Also, recruitment maneuvers, which means briefly increasing airway pressure to reopen collapsed alveoli. Yep, you can do that as well, of course, and there’s also a risk of barotrauma or a pneumothorax.

Next, alternative oxygenation strategies, which is inhaled nitric oxide or epoprostenol, because that can improve ventilation perfusion, also known as V/Q mismatch, by dilating blood vessels in better ventilated lung regions. Bear in mind, with nitric oxide in particular, you can only give minimal amounts because nitric oxide in high doses is toxic.

Next, High Frequency Oscillatory Ventilation, also known as HFOV, may be considered in refractory hypoxemia.

Last but not least, ECMO, of course, which stands for extracorporeal membrane oxygenation. If all ventilation strategies fail, ECMO provides oxygenation outside the lungs. Basically, what ECMO is doing is, it takes venous blood from the body, runs it through a bypass machine, puts oxygen into the blood like the lungs would do, and then puts it back into the arteries of the body, once again, like the lungs would do. So, that’s a last resort strategy.

Other things you need to do, you need to, of course, check for other causes of refractory hypoxemia. Hypoxemia means obviously low oxygen in the blood, which means is there a pneumothorax, which is air trapping in the chest may prevent adequate oxygenation. Right to left shunt which means severe ARDS, which stands for acute respiratory distress syndrome or lung failure can cause non-aerated lung regions where blood bypasses oxygenation.

Also, you need to check for a pulmonary embolism because a pulmonary embolism can severely impair oxygenation despite mechanical ventilation. You can do that usually with the CT (computed tomography) scan if the patient is stable enough to have a CT scan, or an MRI (magnetic resonance imaging) scan. You can do a chest X-ray, but not necessarily do you see pulmonary emboli there.

Next, other causes could be ventilator-associated pneumonia or VAP because the infection can worsen oxygenation. If there is a ventilator-associated pneumonia or any other chest infection/pneumonia, it needs to be treated with the right antibiotics, antivirals, or antifungals, which whatever, or wherever the infection is coming from.

So, I hope that helps.

Also, if your loved one is on 100% of FiO2 and they’re having a breathing tube and they might need a tracheostomy, it’s a contraindication. 100% of FIO2 is actually a contraindication for a tracheostomy. Just as a side note, because the patient, your loved one would be too unstable to have a tracheostomy.

So, that is my quick tip for today. I hope that answers your questions.

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. 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. So, go to intensivecarehotline.com and click on our testimonial section, and you can verify it on our intensivecarehotline.com podcast section where we have done client interviews. You will see what our clients say in an interview, how we help them to save their loved one’s lives because our advice is absolutely life-changing here at intensivecarehotline.com.

You can join a growing number of clients and members, hundreds of them over the years, and we have helped 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 or Teams. 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. I also talk to doctors and nurses directly. When I talk to doctors and nurses directly, 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. That’s how I will hold them accountable, and you will see the dynamics change in your favor very quickly.

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.

All of that you get at intensivecarehotline.com where 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 have personally written and recorded. All of that will help you, once again, 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.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Like, comment, subscribe, click the notification bell, and share the video with your friends and families.

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 email newsletter at intensivecarehotline.com, or if you’re a subscriber to my YouTube channel here.

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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