Hi it’s Patrik Hutzel from INTENSIVE CARE AT HOME where we provide tailor made solutions for long-term ventilated Adults & Children with Tracheostomies and where we also provide tailor made solutions for hospitals and Intensive Care Units whilst providing quality services for long-term ventilated patients and medically complex patients at home, including home TPN.
In last week’s blog, I talked about,
You can check out last week’s blog by clicking on the link below this video:
In today’s blog post, I want to answer a question from one of our clients and the question today is
How Can Dad Be Weaned Off the Ventilator and the Breathing Tube and Avoid A Tracheostomy? Livestream!
Wherever you are, welcome to another Intensive Care at Home and Intensive Care Hotline livestream.
I want to welcome you to today’s livestream and today’s livestream is, “How can dad be weaned off the ventilator and the breathing tube and avoid the tracheostomy?”.
That’s today’s topic and this is a question we get so often. And I could replace, “How can dad be weaned off the ventilator and the breathing tube and avoid the tracheostomy while he’s in ICU?” with, “How can mom be weaned off the ventilator and the breathing tube and avoid the tracheostomy while in ICU?” I could replace it with how can my wife, how can my husband be weaned off the ventilator, avoid the breathing tube and the tracheostomy? So, I could replace my dad with many other terms there.
Before we dive into today’s topic, what makes me qualified to talk about this topic? I am a critical care nurse by background. I have worked in intensive care for over 20 years in three different countries. I have worked for over 5 years as a Nurse Unit Manager in intensive care. I have been consulting and advocating for families in intensive care all over the world since 2013. I’m talking to families in intensive care, all over the world every day of the week. I’m also running an organization called Intensive Care At Home, where we provide intensive care services at home for long-term intensive care patients. Where we provide a genuine alternative for long-term intensive care patients. Genuine alternative to an intensive care bed.
Little bit of housekeeping here, type your questions into the chat pad if you can. Keep them on topic. So, today’s topic really is about, how to avoid a tracheostomy and wean someone off the ventilator with a breathing tube? If they’re off topic, but are still related to intensive care, I will get to them at the end of this video. But let’s dive right into it.
So, how can dad be weaned off the ventilator and the breathing tube while he’s in intensive care and avoid the tracheostomy? What a great question to ask. And it’s such an important question because a lot of families in intensive care come to us when they’re at the crossroads of their loved one, needing a tracheostomy. So, one of the first questions families in intensive care need to ask is, “How can we wean my mom, my dad, my wife, my husband, my brother, my sister, my spouse, my child, whoever, off the ventilator and the breathing tube so that they don’t even go towards a tracheostomy.” And unfortunately, families in intensive care are so overwhelmed when they have a loved one in intensive care, and they can’t see the wood for the trees. And that’s understandable. That is perfectly understandable.
It’s such a highly specialized area. And it is like, I always say. It’s like learning a new language, learning a secret language, when you have a loved one in intensive care. And unless you speak that language, you’re fighting a losing battle and the intensive care team will be 100% in control of what’s happening, what’s not happening. They are to a degree in control of the outcome, and you need to change that very quickly when you have a loved one in intensive care, especially if they are on a ventilator.
So, when you have a loved one in intensive care on a ventilator and the breathing tube, this should be a short-term issue. It should be short-term. It should be to help your loved one recover, take the breathing tube out, and switch sedation off. And then move them onto a hospital ward or to a hospital floor. Leave intensive care, get on with recovery rehabilitation, and go home. That should be the ideal scenario.
Now, intensive care is very complex and it can be very complex at the best of times. However, the goal should not be to move towards a tracheostomy. The goal should be to avoid the tracheostomy and have the breathing tube removed. Now, when families come to us and say, “Hey, the intensive care team has said, we need to do a tracheostomy next. And they’ve tried to schedule it for tomorrow.” My next question here is this, “Has the intensive care team done everything beyond the shadow of a doubt to get your loved one off the ventilator and the breathing tube?” That should be your next question. But today I want to focus on, what does need to happen? So, they have tried beyond the shadow of a doubt to get your loved one off the ventilator and the breathing tube to avoid the tracheostomy.
If someone has a tracheostomy, it could prolong their stay in intensive care for long times to come. It could mean that they’re going to an LTAC facility, Long-term Acute Care, or a skilled nursing facility. This is predominantly for our U.S. audience because skilled nursing facilities and LTACs don’t exist in other countries. But leading up to a tracheostomy, everything is the same in other countries. So, it’s a global thing that I’m talking about here, how to get someone off a breathing tube and the ventilator.
So, the first thing that needs to happen when someone is on a ventilator with a breathing tube, there needs to be a plan how to try and wean them off. And what often puts a spanner in the works is simply the attitude of intensive care teams. When you have a loved one in intensive care, you will hear them to be overtly negative. You will hear them to be pessimistic. You get what I refer to as the “doom and gloom” speech. And you will hear them say things like, “Well, they’re not going to survive the next 24 hours. They’re not going to survive the next 48 hours. If they do survive, there’s no way they will get off the ventilator. There’s no way they can avoid a tracheostomy if they do survive.” So that’s often what you hear. And today, in this video, I really try to give you some perspective around that. Because it is so important that you understand what can lead to avoid the tracheostomy and have the breathing tube removed.
The medical term for having the breathing tube removed, by the way, is also called extubation. Important term in this context. Extubation means the removal of a breathing tube. So as soon as someone is on a ventilator with a breathing tube, they’re often induced into a coma. Strong sedation is used such as Propofol, Versed also known as Midazolam. Sometimes Ketamine is used. In this day and age, more and more Precedex is used. When Propofol, and Versed, or Midazolam are used, there’s often a combination. Also, with fentanyl or morphine, which are strong painkillers. Those strong sedatives and strong pains really make mechanical ventilation possible with a breathing tube. Because someone is in induced coma, they can’t tolerate mechanical ventilation. It’s incredibly uncomfortable. Patients wake up with a tube in their mouth. They’ve got air and oxygen going in. They’ve got a high PEEP which puts pressure on the lungs. It’s a very uncomfortable situation. And therefore, they need to be weaned off sedation and need to be weaned off opiates, the pain medication.
So, after a few days of ventilation, hopefully the treatment goals have been achieved. Maybe your loved has been intubated for a pneumonia, hopefully the pneumonia is clearing up and now is the time to wake them up. And then when they wake up, you will often find it’s not straightforward. You will often find that your loved one is fighting against the ventilator. Your loved one is not comprehending what’s happening. Your loved one is aggressive, thrashing around, trying to take the breathing tube out, trying to pull at lines. They’re not cooperative. And unfortunately, when they come out of an induced coma, they’re often disoriented because they’ve been put to sleep for a few days. They have no recollection of what’s happened. When they do wake up, they can’t talk because they’ve got the breathing tube in their mouth. And then families get extremely frustrated because they see that intensive care teams do re-sedate their loved ones rather than helping them getting out of the induced coma and then have the breathing tube removed. And I can tell you from experience, it’s easier said than done. What do you do if you know a patient is not quite ready to have the breathing tube removed? They’re halfway there. They’re not comprehending, they’re confused, they can’t talk. It’s incredibly difficult and it’s very uncomfortable. It’s incredibly difficult talking a patient through this experience, especially if they can’t respond. You can try by giving them a pen and a piece of paper to see whether they can write things down, that might help. It will also give you an indication of can they express themselves? Are they strong enough? There’s all these questions.
Now you might think, why can’t a patient just wake up and have the breathing tube removed straight away? Where’s the problem? The problem is that when patients come out of the induced coma, they’ve been on such strong sedatives and opiates that it’s not as simple as switching off those sedatives and opiates and then everything would be back to normal. Those sedatives and opiates have long-term effects. For example, Midazolam or Versed, and also morphine, or fentanyl are addictive in nature. They’re addictive substances which means your loved one might go through withdrawal. Which can make them confused. Which can make them agitated. It can make them aggressive. It can make them uncomfortable. And then you might have to re-sedate to protect the airway. Because if they’re taking the breathing tube out too early, it might lead to re-intubation. You will see in a minute that this can be a vicious cycle as I go along in explaining how that might pan out on a day-by-day basis in intensive care.
So, you can really only extubate someone once they are coherent, once they can obey commands. Once they’ve passed some breathing trials. What do I mean by breathing trials? And that’s the next step obviously. Sedation is off now, let’s just say. Your loved one is semi awake. They’re semi cooperative. So, what are breathing trials? Because the next step really is, breathing trials need to happen. What do I mean by that? So, when someone is being intubated and in an induced coma and on sedatives and opiates, they are on what’s called a “Controlled Ventilation Mode”. What that means is, they’re getting a set breathing rate per minute from the ventilator. Let’s just say for argument’s sake, they’re getting 16 breaths per minute, guaranteed from the ventilator. They get a set volume or a set pressure that meets the minimum respiratory or breathing requirements.
So once that’s been achieved, the patient is more stable. Arterial blood gases are adequate. Chest x-rays look good. Once you can again switch off sedation, get people out of the induced coma. The next step is to then switch the ventilation mode ideally. So, for example, drop the rate of a breathing rate of 16 breaths per minute, down to 10 breathing rates per minute. See whether your loved one can take some extra breaths themselves. See whether the volumes are adequate. Let’s just say they’re getting 500 mls per breath from the machine per breath. Can your loved one breathe those 500 mls? It’s often dependent on weight or are they only breathing 200 mls. If they’re only breathing 200 mls, but they need 500 mls, it’s a sign that if you drop the rate down to 10 breaths per minute. You got to put it back up to 16 breaths per minute.
So, what do you do then? Well, maybe they’re not awake enough. Maybe they’re in the wrong position. Maybe they need to sit up more. Maybe they need to be spoken to how to breathe. Maybe there is a pain issue. Maybe there is other discomfort such as they haven’t opened their bowels for many days. Maybe they’re not digesting their nutrition. Maybe they’ve got a bloated tummy because of not opening bowels. Maybe they’ve got a bloated tummy because they’re not digesting their feed. So, there could be all sorts of issue. Maybe they had surgery, maybe they’re in pain. Pain is not controlled and therefore they can’t take deep breaths. So, there’s a whole spectrum of things that could happen if they’re not breathing as you would expect them to breathe so that they can move towards extubation. One day you try that, it fails. Try again the next day or try again few hours later in the day. Maybe you try again after you’ve optimized pain medication.
So, the next thing is that, if your loved one can breathe up and you’ve dropped the rate from 16 guaranteed breaths from the ventilator down to 10, and your loved one is breathing up on top of that. Their blood gases are good. They look comfortable. Then the next step is to drop the rate completely and put them in a CPAP or pressure support breathing trial, that is the next step.
Hi, Helene. I’ve seen that you’ve come on, how are you?
And then if they’re breathing in a CPAP or pressure support trial, what that means is the rate has gone from 10 or 16 down to zero, and now they need to trigger every single breath from the machine. What that means is, they need to overcome resistance in the ventilator circuit, and that will give them flow and volume and it’ll help them breathe. If they can’t do that, they’re not ready. And then they need to be put back in a controlled ventilation mode.
Now, maybe they are breathing when they’re on CPAP or on pressure support. But if they are breathing, maybe they’re not breathing with the volume that’s needed. As I explained before, they need 500 mls per breath, and they’re only breathing 200 mls. That’s not enough, it’s not sustainable. So then again, you need to go back to putting them back into a controlled ventilation mode. Maybe in the beginning, they only breathe for two hours on CPAP or pressure support. And then after two hours, they get exhausted. So, you got to put them back in a controlled ventilation mode. And then you got to try again, maybe the next day, maybe a few hours later. But that’s pretty much how you wean someone off a ventilator. There are some patients you put them in CPAP or pressure support, and they never need a controlled rate. Again, that’s great, they’re the ideal patients, they can be moved towards extubation reasonably quickly. But it could also take many days. It could sometimes take many weeks and that’s when patients need a tracheostomy.
Now on top of what I explained at the moment, what else needs to happen is physical therapy. So, a good physical therapist and a good respiratory therapist can help a patient breathe. They can help explain them how to manage the ventilator. They can help them, give them steps, what to do, how to breathe in, how to breathe out, how to relax. It’s very important that you have that psychological support and psychological component when someone weans off a ventilator, because it’s very scary for them. They can’t talk. They’ve got this awful tube stuck down their throat. They might be in pain. All sorts of things happen when someone is in intensive care. And let’s just say that with physical therapy, leg movement, arm movement, breathing exercises, also mobilization.
So, for example, there’s no reason why a loved one can’t get out of bed with a breathing tube. I’ve done it, we’ve done it in some ICUs that I worked in. You can get a patient out of their bed, into a recliner chair, special chair. It’s all doable. And if an ICU is telling you, they can’t do it, they’re either lazy or they don’t have the know-how. They don’t know how to do it, but it’s definitely doable. Because imagine this, you’re lying in bed, you’re on a ventilator, you need to start breathing by yourself. Your breathing muscles need to strengthen because your body deconditions very quickly in intensive care. You need to start get going. You need to sit in a chair, strengthen your upper body so you can start breathing.
So, Helene, what’s the difference between BIPAP and CPAP? It’s almost the same. The difference is that on CPAP, a patient is breathing spontaneously with a PEEP, with a set PEEP. The PEEP might be 5, might be 10, and then they can trigger their own volume. Now, what’s BIPAP? It’s very similar. A PEEP is set, but there are two levels of PEEP. What that means is on CPAP there’s only one level of PEEP. As I said, most of the time it’s between 5 and maybe 8, some very rarely is it 10. On BIPAP, you have a PEEP on inspiration, and you have a PEEP on expiration. So, it’s more support. BIPAP is very effective. So, let’s just say you have a PEEP of 5 on expiration. You might have a PEEP of 10 on inspiration. Often, it’s higher. It’s often PEEP of 5 and the PEEP of 15.
So that is the main difference. BIPAP is very effective. CPAP can be effective for the right client or for the right patient, but BIPAP is one step removed from extubation. If someone is in CPAP, they should be heading towards extubation. On BIPAP, they’re one step removed because they need more support. Also, what I’ve seen on BIPAP is you can also have a set rate on BIPAP. So, you can have BIPAP settings with the PEEP 5 on expiration, with the PEEP of 15 on inspiration. And you also have a rate of 12, let’s just say. You don’t usually have that with CPAP. So those are the differences. I hope that explains. But basically, the difference between CPAP and BIPAP is, for someone on BIPAP they still need more support. That’s why they need two different levels of PEEP.
Okay. So, coming back to the mobilization part. I see so many ICUs, not mobilizing early, not doing the physical therapy. That’s one of the reasons why your loved one can’t come off the ventilator. Most ICUs that I worked at, we were mobilizing early, which is why I believe we avoided many tracheostomies. If patients are not getting mobilized early, the risk of them ending up with the tracheostomy is very high.
Now I have done a podcast a few months ago with a lady, I have to put the link. Mrs. Kali Dayton. She’s a nurse practitioner in the U.S. in ICU. And in their ICU where she’s working, they don’t sedate at all, and they avoid a lot more tracheostomies. Now, quite frankly, that sounds almost like a miracle that they don’t sedate when someone is on a ventilator with a breathing tube. But she says they have good results in extubating people early. And I’m not surprised by that. How can you wean off a ventilator if you’re asleep for many days, induced by very heavy drugs? So, there’s definitely an argument for not sedating, if you can do that, because it’s very uncomfortable.
But anyway, so let’s just say in the ideal world, your loved one is mobilized, getting physical therapy, breathes on CPAP. Chest X-rays look good, the pneumonia has cleared up. I’ve just taken pneumonia as an example, if that’s one of the conditions. Blood gases are good. Now, you can look at the neurological condition or the GCS (Glasgow Coma Scale). What that means is, your loved one needs to open eyes spontaneously. They need to have a good cough. They need to have minimal secretions, meaning they need to be able to clear their own airway. They need to have minimal need for suctioning through the breathing tube. They need to be able to obey commands, which means poke out their tongue, squeeze hands, wiggle toes, things like that. If all those boxes are ticked, then your loved one can be extubated. But it doesn’t happen with switching off sedation early. It doesn’t happen without physical therapy. It won’t happen without mobilization. And what do we see? We see across the board that patients are lying in their beds overly and heavily sedated, which pushes them right towards a tracheostomy, because that’s the easy way out. It’s much easier doing a tracheostomy and sending patients to another facility than it is to mobilize them. Doing the breathing exercises, doing the physical therapy. It’s a lot of work. But it works and it’s very effective. Now one could argue, ICUs are very short staffed at the moment. I probably agree with that, but they’ve always been short staffed. It’s not a novelty. Yes, they’re probably more short-staffed at the moment than they were ever before. But if they get their patients out early, I argue they have less demand. And ICUs would benefit from that as well.
It is really a quick overview today on what needs to happen to avoid the tracheostomy. So, a lot of families come to us, again, they come to us after two weeks, three weeks. And they say, ‘Hey, our loved one’s not waking up, they’re now talking about a tracheostomy.” And then when we look at the individual situations, we’re often finding that, well, they’ve been overly sedated. They have not had physical therapy. They have not been mobilized. This is why it’s so important that you do your research from day one. Because I’m giving you a different perspective here. But I know that perspective, if that is implemented, I know it works.
Unfortunately, there’s a lot of complacency in this day and age in ICU. Why, do I say that? There’s a lot of complacency because they know if we are just heartbreaking. Absolutely heartbreaking. People go from one facility to another. They go to LTAC, they have setbacks, then patients bounce back into ICU. And they don’t necessarily bounce back do a trach, we can send the patient out to LTAC, and ICUs can wash their hands clean. It’s terrible. The stories we hear from families in the ICU where they’ve come from. So, they’ve been to three different places within a few days. It’s just madness. It’s just madness, and that’s why it’s not patient-centric, it’s not holistic. And that’s why it’s so important that you understand the concept of what I’m talking about today how you can move towards extubation as quickly as possible.
Helene you are asking, “I had to advocate for physical therapy. They only showed me how to do for mom, because I was told Medicare won’t pay handicapped.” I wouldn’t know, Helene, what Medicare pays. What I will say is this, there is a higher incidence of physical therapy not happening in intensive care in the U.S. compared to other English-speaking countries. I can definitely see that. Again, I’m talking to people in the U.K. I’m talking to people in Australia, in New Zealand, in Canada. It seems to be a higher incidence in the U.S. of less physical therapy available compared to other countries. I do believe, I could be wrong there. This is my own conclusion that I’m telling you here. My own conclusion is that, because there’s LTAC on the other end, that there is a lot of complacency and if we don’t physical therapy, so be it. We’ll just do a trach and then send the patients out to LTAC or a skilled nursing facility. It’s different in other English-speaking countries. LTACs don’t exist in other English-speaking countries, which means the ICU have to take ownership of taking someone off the ventilator. They have to take ownership. Because if they can’t, they’ll be left with those patients.
In terms of who’s funding what, I wouldn’t know what Medicare’s funding in ICU in this particular situation. It can be a funding issue, but I don’t think it is because the people that we are talking to, it’s rarely a funding issue. It’s staff availability issue. It’s complacency. It’s the thinking that, “Oh, well, if we do a tracheostomy, we’ll go to LTAC and then they’ll finally get physical therapy.” But I can tell you that’s the sales pitch for an LTAC, but the reality is it’s actually not happening in reality, unfortunately. Therefore, it comes back to what I said earlier. You need to do your research from day one. You need to make sure the right things are happening from day one. Minimize sedation, minimize opiates, starting physical therapy early. If there are no contraindications, of course. And by contraindications, I mean things like, are there fractures? That might be a contraindication just as an example.
So, I hope that helps today. Because before you’re asking me, we have so many families asking us, how to avoid LTAC ? And I hope by today’s video, that’s part of avoiding LTAC. Ask the right questions early 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.
So, I want to wrap this up in a minute. If you have any other questions, please type them in the chat pad before I wrap this up. I am conscious of the time. And I want to thank you for coming onto the call. I want to thank you for all your support. And if you know of someone who has a loved one in intensive care and who needs help, send them to our website, intensivecarehotline.com.
Helene, you’re asking, “I experienced by asking questions and advocated for Mom, I was threatened to be put out.” It’s nothing that we don’t see, Helene. I would be lying to you if that’s not what we are seeing that families get threatened. But that’s I believe where also my knowledge is coming in. What are your rights? How can you exercise those rights? And it’s also a case of being persistent. And I’m not saying that you weren’t persistent. I don’t know the ins and outs. It’s a case of being persistent. Eventually they will listen. They have to listen. They just choose the path of least resistance. And by that, I mean, they walk all over 99% of families, why would they not try and walk all over you? They will only understand that you’re not in the 99% of families by consistently standing up. So, I’m not surprised, unfortunately. But it’s a case of almost working your way through the system and working your way through the bulldozers, unfortunately.
Helene, you can send questions to [email protected]. But please bear in mind that outside of the free content that I’m providing here on YouTube, for any other services, I do charge a fee. But I can get back to you if you wanted to engage on that level. You know, the free content that I’m providing is for free here. But obviously if you wanted to engage with me and my team outside of the YouTubes and what’s on the website, I do charge a fee for that. But if you send me what questions you have. If you wanted us to review medical records, I’ll be very happy to give you a quote, so we can help you.
So going to wrap this up, if you have a loved one in intensive care, you should check out intensivecarehotline.com. Call us on one of the numbers on the top of our website or send us an email to [email protected].
If you liked the video, give it a thumbs up. Subscribe to my YouTube channel for updates for families in intensive care and the livestreams. Comment below what you think, comment below your experience, comment what questions that you have, and click the notification bell.
“Subject to cover to recommend.” I’m not sure what do you mean by that, Helene. Subject to cover to recommend. I don’t know what you mean by that. No idea what you mean. Maybe you can elaborate on that.
I’m hopefully back in the habit now of doing those YouTube Lives every Saturday evening, Eastern Standard Time. 6:30, 7:00 PM, Eastern Standard Time. Which is 3:30, 4:00 PM, Pacific Time. 10:30, 11:00 AM Sydney/Melbourne Time. Unfortunately, it’s in the middle of the night in the U.K. but you can definitely watch the recordings. They go up on YouTube fairly quickly within a few hours. I will do another one next Saturday evening, Eastern Standard Time in the U.S. around 7:00 PM. 10:30, 11:00 AM, Sydney/Melbourne Time. And 4:00 PM, California Time or Pacific Standard Time. So, I’m going to wrap this up.
“Future subjects to recommend on live chat”. Helene, you are very welcome to recommend any future live chats. You could just post them below the video once they’re uploaded or you can post them below any video. I usually get them. Or you can email them to the email address that I’ve given you. I’ve got a whole list of subjects that I want to talk about. I’ve got no shortage of things to talk about, but I’m very happy to look into what you want to hear about and what you’re suggesting.
Okay, I’m going to wrap this up. I wish you and your families all the best. Look out for the next YouTube Live and look out for the quick tips that are coming next week. I hope you have a wonderful weekend and then wonderful week. All the best to everyone.
Now, if you have a loved one in intensive care and you want to go home with our service intensive care at home and if you want to find out how to get funding for our service and how it all works, please contact us on one of the numbers on the top of our website, or send me an email to [email protected] That’s Patrik, just with a K at the end.
Please also have a look at our case studies because there we highlight more about what we can do for clients, how clients can live at home with ventilation and tracheostomies and you can look at our case studies as well at our service section.
And if you are at home already and you need support for your critically ill loved one at home, and you have insufficient support or insufficient funding, please contact us as well. We can help you with all of that.
And if you are an intensive care nurse or a pediatric intensive care nurse with a minimum of two years, ICU or pediatric ICU experience, and you ideally have a critical care certificate, please contact us as well. Check out our career section on our website. We are currently hiring ICU and pediatric ICU nurses for clients in the Melbourne metropolitan area, Northern suburbs, Sunbury, Bendigo, Mornington Peninsula, Bittern, Patterson Lakes, Frankston area, South Gippsland, Drouin, Warragul, Trida, Trafalgar and Moe as well as Wollongong in New South Wales.
So we are also an NDIS, TAC (Victoria) and DVA (Department of Veteran affairs) approved community service provider in Australia. Also have a look at our range of full service provisions.
Thank you for watching this video and thank you for tuning into this week’s blog.
This is Patrik from Intensive Care at Home, and I’ll see you again next week in another update.