My name is Patrik Hutzel from intensivecarehotline.com, where we instantly improve the lives of families of critically ill patients in intensive care, so that you can make informed decisions, have peace of mind, control, power and influence, even if you’re not a doctor or a nurse in intensive care, making sure your loved one always gets the best care and treatment.

Today I have a question from one of our clients, Janine, who says:

“Hi Patrik,

My mom keeps failing the pressure support, so I suggested speaking with the pulmonologist and ICU doctors to give her something else. I reiterate that her heartbeat is different, plus she has lung cancer — maybe that’s how it is, as long as it’s not dangerous. They placed her on Buspar to see how she reacts to it. They will also try pressure support when I’m there. She was tolerating it before, so I don’t understand why not now. Can you please let me know why my mom can’t be weaned off the ventilator? I really don’t want my mom to spend the rest of her life on a machine. That’s not fair to someone who loves to laugh, talk, eat, etc., nor do I want her to spend the rest of her days in ICU. Our goal is to at least be on something if she has to, like a CPAP or a tracheostomy.

Thank you for your help.”

From Janine.

Janine, thank you so much for your question. You’re asking why your mom can’t be weaned off the ventilator, especially since she was tolerating pressure support before but keeps failing it now. You’ve mentioned her heart rhythm is different, she has lung cancer, and understandably, you don’t want her spending the rest of her life on a machine or in the ICU. Let me walk you through what might be happening here and offer some solutions.

Why Ventilation Weaning Might Fail

When someone keeps failing pressure support trials, there are usually multiple factors at play. Pressure support is a weaning mode where the ventilator provides assistance when your mom takes a breath, but she has to initiate each breath herself. If she’s failing these trials repeatedly, the ICU team needs to dig deeper into why.

Common reasons for failed weaning attempts include:

Underlying lung disease progression. In your mom’s case, the lung cancer may be affecting her respiratory mechanics and gas exchange.

Cardiac issues. You mentioned her heart rhythm is different, and cardiac function is absolutely critical for successful ventilation weaning. Heart failure, arrhythmias, or coronary issues can prevent weaning even when the lungs are ready.

Respiratory muscle weakness. Prolonged ventilation causes diaphragm atrophy, sometimes called ventilator-induced diaphragmatic dysfunction.

Anxiety and agitation. This is interesting because they’re trying Buspar — also known as buspirone — for your mom. Anxiety dramatically increases oxygen consumption and can sabotage weaning attempts.

Fluid overload. Too much fluid in the lungs makes breathing harder and weaning nearly impossible.

Nutritional status. Malnutrition or electrolyte imbalances affect respiratory muscle strength.

Infection or inflammation. Pneumonia, sepsis, or other infections prevent successful liberation from the ventilator.

The fact that your mom was tolerating pressure support before but isn’t now suggests something has changed. This could be disease progression, a new complication, further cancer growth, inadequate treatment of underlying issues, or even the weaning approach itself. She’s also possibly still on too much sedation or opiates.

That is why you need to get access to the medical records right now, and that’s why you need a consulting session — because the biggest challenge for families in intensive care is 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.

Why the Heart Rhythm Matters

You mentioned your mom’s heart rhythm is different — this is actually really important and often overlooked. The cardiovascular system and respiratory system work together intimately. When someone is on a ventilator, positive pressure breathing actually helps the heart pump blood. When you try to wean them off, the heart has to work much harder.

If your mom has underlying cardiac dysfunction — whether it’s heart failure, coronary artery disease, arrhythmia such as atrial fibrillation, or heart valve problems — her heart might not be able to handle the increased workload during weaning trials. This is called weaning-induced cardiac failure, and it’s a common but frequently missed reason for failed extubation.

The ICU team should be evaluating your mom’s cardiac function thoroughly. This might include echocardiograms or ultrasound, checking cardiac biomarkers like BNP (B-type Natriuretic Peptide) and troponin, optimizing fluid status, and potentially adjusting cardiac medications. She needs input from a cardiologist.

 

The Lung Cancer Factor

Having lung cancer adds another layer of complexity to ventilation weaning. Depending on the type, location, and extent of the cancer, it can cause airway obstruction, reduce functional lung tissue, cause pleural effusions — fluid around the lungs— or lead to post-obstructive pneumonia.

The ICU team and pulmonologists need to assess whether the lung cancer is stable, progressing, or potentially treatable in a way that could improve respiratory function. Sometimes palliative radiation or other interventions can help improve breathing, even in advanced cancer.

Why Buspar Makes Sense and What Else Might Help

It’s good they’re trying Buspar for your mom. Anxiety is a massive barrier to ventilator weaning. When patients are anxious, they breathe rapidly and shallowly, consume more oxygen, and work their respiratory muscles inefficiently. This creates a vicious cycle that makes weaning almost impossible.

Buspar is a non-sedating anti-anxiety medication, which is smart, because traditional sedatives like benzodiazepines, propofol, ketamine, or Precedex actually worsen delirium and prolong ventilation. However, Buspar takes time to work — usually several days to weeks — so this isn’t a quick fix.

Other strategies that help with ventilation weaning include aggressive mobilization and physical therapy, optimizing pain control without over-sedation, treating any underlying delirium, ensuring adequate sleep, and having family present during weaning trials for reassurance.

The Importance of Timing and Trying Pressure Support When You’re There

It’s insightful that they’re planning to try pressure support when you’re there. Family presence can make a huge difference. Your mom will likely be calmer, more cooperative, and better able to handle the stress of a weaning trial when you’re at the bedside providing reassurance.

This also gives you the opportunity to observe exactly what’s happening during the trial. Does she become anxious? Does her heart rate or blood pressure change dramatically? Does she look uncomfortable or distressed? Can she still tolerate the breathing tube in her mouth? These observations are incredibly valuable.

What Questions Should You Be Asking?

This is where having access to all medical records becomes absolutely critical. You need to see the complete picture — all the test results, imaging, consultation notes, and daily progress notes from doctors, nurses, physios, and so forth. Without this information, you’re making decisions in the dark.

Questions you need answers to:

• What specific parameters is she failing during pressure support trials? Is it respiratory rate, oxygen saturation, heart rate, blood pressure, comfort, tidal volumes, or minute volumes?
• What does her chest X-ray show?
• What do her arterial blood gases show?
• Is there fluid overload, pneumonia, or worsening lung cancer?
• What do her cardiac studies show? Has she had a recent echocardiogram or ultrasound?
• What does her blood work show? Are there electrolyte imbalances, signs of infection, or nutritional deficiencies?
• Is she opening her bowels? Is she absorbing her feeds?
• What is her sedation and pain medication regimen? Could medications be contributing to respiratory depression?
• Has she had a swallow evaluation? Aspiration can cause recurrent pneumonia and prevent weaning.
• What is the pulmonologist’s specific weaning plan? Is there a structured protocol, or are they just trying things?
• Have they considered a tracheostomy as part of a longer-term weaning strategy?

This is exactly where a consulting call with me or one of my team members will make all the difference. We review all the medical records, identify what’s being missed, help you formulate the right questions, and even participate in a call with the ICU team to advocate for your mom, clarify treatment plans, and change the dynamics in your favor.

Too often families are given vague answers like “she’s not ready” or “we’re doing our best” — but that’s not good enough. You deserve specific, detailed explanations about what’s preventing weaning and what the concrete plan is to address each barrier. We can question and advocate on your behalf, pushing the ICU team to optimize every modifiable factor: cardiac function, fluid status, nutrition, anxiety management, sedation, mobilization, and more.

Sometimes having an independent critical care expert review the case reveals missed opportunities or alternative approaches the ICU team hasn’t considered.

The Tracheostomy Question

I know the word tracheostomy sounds scary, but here’s the reality. If your mom continues to fail weaning attempts and requires prolonged ventilation, a tracheostomy might actually be the best path toward getting her off the ventilator eventually.

A tracheostomy offers several advantages:

• It’s more comfortable than an endotracheal tube
• It allows for better oral care and potentially eating and drinking
• It reduces sedation requirements
• It makes weaning trials easier
• It reduces dead space — the air in the breathing tube
• It facilitates transfer to a step-down ICU eventually for controlled weaning, or to go home with Intensive Care at Home

Many patients who get tracheostomies are successfully weaned and decannulated — meaning the tracheostomy tube is removed over time. It’s not necessarily a permanent situation.

Intensive Care at Home

Now here’s something really important that most ICU teams don’t discuss. Go and check out Intensive Care at Home because we offer a long-term option that keeps your mom out of ICU predictably and permanently if she needs long-term ventilation and/or a tracheostomy.

You mentioned you don’t want your mom in the ICU long-term, and I completely understand that. The thought of someone who loves to laugh, talk, and eat being warehoused in a facility for the rest of her life is absolutely heartbreaking.

Intensive Care at Home provides:

• Private duty nursing with ventilator expertise right in your home, with intensive care nurses 24 hours a day
• All the equipment and supplies needed for home mechanical ventilation
• Ongoing medical management by doctors and 24-hour intensive care nursing experience in home ventilation
• A care plan focused on quality of life, not just survival
• The dignity and comfort of being at home with family

Many patients on long-term ventilation — whether through tracheostomy or non-invasive ventilation like BiPAP or CPAP — can live at home with proper support and 24-hour intensive care nurses. This allows your mom to be in familiar surroundings, maintain her personality and interests as much as possible, and have meaningful time with family.

Some patients even continue weaning efforts at home with a structured weaning program. Sometimes the ICU environment itself — the noise, constant interruptions, lack of sleep, and anxiety — prevents weaning, and patients do better in a calm, familiar environment.

Alternative Ventilation Options: CPAP, BiPAP, and High Flow

You mentioned your goal is to at least get her on something like CPAP or a cannula if she has to be on support long-term. This is absolutely reasonable, and there are several intermediate options between full mechanical ventilation and room air.

Non-invasive ventilation like BiPAP or CPAP can be used for many hours a day or just at night, supports the work of breathing without a tube in the throat, and can be used at home indefinitely.

High flow nasal cannula delivers heated, humidified oxygen at high flow rates, is comfortable and well tolerated, and provides some positive airway pressure support.

Nighttime-only ventilation — some patients only need support while sleeping and can breathe independently during the day.

The key question is whether your mom’s respiratory failure is reversible or if she has chronic respiratory insufficiency that will require ongoing support. Her lung cancer and cardiac issues suggest she might need some level of support long-term, but that doesn’t mean full-time invasive ventilation.

What Needs to Happen Next

• Comprehensive cardiac evaluation
• Pulmonary and respiratory assessment
• Optimized fluid management
• Aggressive delirium and anxiety management
• A good day and night rhythm
• Structured weaning protocol
• Physical therapy and mobilization
• Nutritional optimization
• Family involvement
• Consideration of Intensive Care at Home if needed

Get on a consulting call with me as soon as possible. Go to intensivecarehotline.com, call us on one of the numbers on the top of our website, or send an email to [email protected]. Also go and check out Intensive Care at Home for long-term ventilation options at home.

I have worked in critical care nursing for 25 years in three different countries where I worked as a nurse manager for over five years in intensive care. And I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. And I can very confidently say that we have saved many lives with our consulting and advocacy, because of our insights, and you can verify that on our testimonial section at intensivecarehotline.com and you can verify it on our intensivecarehotline.com podcast section, where we have done client interviews.  And because our advice is absolutely life-changing, right?

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 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 the best care and treatment always. And 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. And 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. And 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, so, 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 e-books and 21 videos that I’ve personally written and recorded. And 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 the best care and treatment always.

And all of that you get at intensivecarehotline.com. Call us on one of the numbers at the top of our website or simply send us an email to support at intensivecarehotline.com 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.