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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,
CAN YOU LIVE A LONG LIFE WITH A TRACHEOSTOMY?
You can check out last week’s blog by clicking on the link below this video:
https://intensivecareathome.com/can-you-live-a-long-life-with-a-tracheostomy/
In today’s blog post, I want to answer a question from one of our clients.
My Mother is In and Out of ICU Needing BIPAP, High CO2 (Carbon Dioxide) for COPD (Chronic Obstructive Pulmonary Disease), What Should I Do?
Hello, and welcome to another Intensive Care at Home livestream.
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Today’s show will be about, “My mother is in and out of ICU needing BIPAP (bilevel positive airway pressure). She has high CO2 (carbon dioxide) for COPD (chronic obstructive pulmonary disease). What should I do? Is home care an option?” We will talk about this question from a reader today in much detail, and I will also answer your questions.
If you have any questions, type them into the chat pad and I will get to them as quickly as possible. Also, for anyone watching this on replay, I know most people don’t have the time to get on a livestream, but they watch this on replay. Again, I want to encourage you to post your questions on the chat pad. I will get back to them or make another video about it. One way or another, your question will be answered, but often not in real time, especially if you’re watching it on replay.
In case you’re wondering what makes me qualified to talk about today’s topic, again, my name is Patrik Hutzel, I am a critical care nurse by background. I have worked in critical care for over 20 years in three different countries. I have also worked as a nurse unit manager for over five years whilst working in critical care. I’m also the founder and managing director of Intensive Care at Home. In Intensive Care at Home nursing service, where we are predominantly looking after long-term ventilated adults and children with tracheostomy at home instead of ICU. We’re providing a genuine alternative to a long-term stay in intensive care. We’re also looking after patients that are on BIPAP, which is our topic today, BIPAP, CPAP. We are also providing home TPN (Total Parenteral Nutrition), IV infusion, such as saline, electrolytes such as potassium, magnesium, IV antibiotics. Pretty much anyone that needs a critical care nurse in the community, we can provide that with Intensive Care at Home.
We have been in business for the last 10 years. I’ve also been part of pioneering Intensive Care at Home in Germany over 20 years ago. I have a lot of experience in that space, and I argue we are the market leader for Intensive Care at Home in Australia currently. We employ hundreds of years of intensive care nursing experience and critical care nursing experience in the community, which I believe is unmatched by any other provider. We also are the only provider in Australia that actually has third-party accreditation for Intensive Care at Home. We have all the policies, procedures, we have the know-how. We have thing intellectual property to make that happen. We also employ hundreds of years of critical care nursing experience in the community, which is once again, unmatched by any other providers.
Now, I’m also the founder of intensivecarehotline.com where we provide consulting and advocacy for families in intensive care, and we do that all around the world. We’ve helped hundreds of, potentially thousands of families all around the world with consulting and advocacy in intensive care. Go and check out intensivecarehotline.com as well.
Let’s dive into today’s topic, “My mother is in and out of ICU needing BIPAP. She has high CO2, which is high carbon dioxide, for COPD. What should I do? Is home care an option? There’s no quality of life in intensive care.” Well, of course, there’s no quality of life in intensive care. It sounds to me like your mom is really struggling with bouncing in and out of ICU here. If she remains with a high CO2, the only way usually to get that down is with BIPAP.
I would imagine you haven’t sent a very detailed email, but what I’m reading from your email is that as soon as she leaves ICU, she takes off the BIPAP, her CO2 rises, and then she gets drowsy again. Then she ends up in ICU again on BIPAP, CO2 goes down, and she’s in a vicious cycle if the CO2 doesn’t stay down continuously or on an ongoing basis. What that means is she can’t really leave ICU, she needs the BIPAP because she’s bouncing in and out of ICU as soon as she goes to a hospital ward or a hospital floor. Her CO2 rises again, she becomes drowsy, and then goes back into ICU again.
The same will happen if your mom goes home without BIPAP, her CO2 will rise because of the COPD. Then, she will become drowsy again and needs to be readmitted back to ICU. What’s the long-term solution here? The long-term solution really is that with Intensive Care at Home, she can have BIPAP at home, whether it’s continuously, whether it’s intermittently.
How can you establish whether she needs it intermittently or on an ongoing basis? Well, what needs to happen before your mom goes home is ideally, she needs to have a sleep study. She needs to have some arterial blood gases to see how much BIPAP she needs to keep CO2 down. Your mom’s baseline CO2 level is probably very high. For most COPD asthma patients, the baseline CO2 is high that means they have a higher threshold to tolerate a higher CO2 without getting too drowsy. High levels of CO2 mean patients can become drowsy. The normal level for CO2 in a blood gas is 33 to 45 millimeter per mercury. You should establish a baseline. I would imagine that your mom’s CO2 might be slightly higher than 45, but that’s okay, as long as she’s not drowsy. As soon as it goes above 55, 60, whatever the number might be, then she becomes drowsy and then she’s becoming BIPAP dependent as well.
Then, other questions that come out of this is, let’s just say your mom only needs intermittent BIPAP. Can she eat and drink? What’s her nutritional status? Because what often happens is when patients go into ICU on BIPAP, they don’t necessarily eat and drink because the BiPAP needs to be on all the time.
How can they get nutrition in? Well, one way is with a nasogastric tube. Then the challenge often with ongoing BIPAP is, does it cause too much bloating in the stomach? Does it cause vomiting? Then there’s a risk of aspiration. Those are all issues that need to be sorted out before your mom can look at home care.
As a rule of thumb, with what you’ve shared with me, home care is the best option. Then at home, we should be looking at getting her into a good regime, into a good pattern. That means she probably needs the BIPAP overnight so she can rest well, and she’s well rested in the morning because what I know from experience and what we see from other clients is if they’re not having the BIPAP overnight and CO2 is rising, then patients are not well rested in the morning. They’re drowsy and then they’re sleepy during the day. You want to use the BIPAP overnight so that you are well rested in the morning and that you can live a productive life.
There’s plenty of our patients as well with Intensive Care at Home that need the BIPAP during the day as well, at least intermittently. Again, that’s why you have the critical care nurse at home that’s managing all of this with our clients, with your mother, so that it’s all around your mother’s needs, around your mother’s routine, of course. In the hospital, it’s often the hospital’s routine, whereas at home, it’s your routine and your routine only.
Just because you feel like at the moment your mom is bound to a bed in intensive care with a BIPAP, that is a, as you well know, it’s not a long-term solution. It’s not a conducive long-term solution. It’s certainly not a solution that helps your mom’s quality of life because there is no quality of life as you are well aware in intensive care. The option really is to go home as quickly as possible.
How to make that happen? Once again, talk to the team there, but also, get us involved by talking to the team because we really make the discharge process possible. Get a sleep study done, get some blood gases done, and see what the outlook, how the intensive care team suggests the BIPAP needs to be applied going forward, or how the respiratory physician suggests the BIPAP should be applied going forward.
The reality is that when you look at the Mechanical Home Ventilation Guidelines on our website at intensivecareathome.com, you will see that the only way to make a safe transfer home possible is with critical care nurses, 24 hours a day, when someone is on BIPAP. That is the Mechanical Home Ventilation Guidelines are evidence-based. They are a result of research from the last 25 years of Intensive Care at Home in Germany and the last 10 years of Intensive Care at Home here in Australia. If you don’t have critical care nurses at home with BIPAP, CPAP, tracheostomy, TPN, people have died, and we have evidence for that. We can back that up. Clearly, the guidelines have worked and continue to work.
It’s clear that intensive care beds are in high demand. (A), the intensive care unit will have an interest in getting your mom home. (B), you want your mom home because she’s having no quality of life, and the only way to improve her quality of life is at home. Also, if she keeps bouncing back between ICU and the ward, it’s clear that something’s not working. The only way to make it work in the long run is to go home, have the BIPAP, and then stay out of hospital, stay out of ICU.
Helene, you’re asking, “Is it necessary to have hospital handcuffs on a patient while being on BIPAP?” Look, I have seen this that some patients have handcuffs or mittens or whatever, or restraints, whatever you want to call it, while being on BIPAP. Look, in certain situations, I argue it might be beneficial for a patient to have that. I would not advocate for it, but I have seen it. Especially, picture this, you have a patient that needs BIPAP, whether it’s for COPD, whether it’s for a pneumonia, whatever the case may be, and they’re not having the BIPAP, they’ll probably end up being intubated.
I know, Helene, you’ve been on many of my live streams, and I know what you’ve been through with your mom. Well, you know the detriments of being intubated and then potentially ending up with a tracheostomy. One could argue that the benefit of the BIPAP outweighs the negatives of being restrained or handcuffs. Again, I’m not advocating for it, but I guess in a situation where the question comes up, whether handcuffs, restraints, mittens, whatever you want to name it, if the benefit outweighs the risks or the negatives, then yes. I hope that answers your questions.
Then again, in a home care environment, we have never had patients restrained with Intensive Care at Home for the BIPAP, never. It’s more of a hospital, it’s more of an acute thing. You would think that from our experience, once a patient’s at home, they’re in their own environment, they’re so much more settled. Also, in a hospital, for example, in an ICU, you have different nurses, different doctors all the time. Whereas in a home care environment, we’re trying to have the same people over and over again for a particular client so that there’s not a high staff turnover. That in and of itself will eliminate the friction. By having a stable team, the client knows who’s coming, who’s going. The client feels comfortable with the people that are coming and going.
It’s a very different dynamic compared to an ICU in a hospital where you’ve got travel nurses, you’ve got just strangers coming and going to keep an ICU going, if that makes sense. Intensive Care at Home has so many benefits besides the improvement in quality of life, of course, or in some instances quality of end of life. If I may just say in this note, last year we’ve had a client here in Melbourne that we looked after in a palliative care situation for about three months. He was on BIPAP for about three months for end stage lung cancer. He was on BIPAP all the time. He could not take off the BIPAP because of the progressive nature of his lung cancer.
Now Helene, you’re asking, “Should a nurse monitor the patient during the night?” Absolutely. That’s why I said when you look on our website at intensivecareathome.com, and you read the section Mechanical Home Ventilation Guidelines, once again, and those guidelines are evidence-based. You need a critical care nurse whilst the patient is on BIPAP. In a situation where someone needs intermittent BIPAP, you need a critical care nurse, 24 hours a day, very similar to an ICU hospital because you need to know when to initiate the BIPAP. You need to know when to take it off. You need to know when the patient needs a break potentially. You need to know what to do if the patient can’t have a break, which was the case with the client that I just mentioned, who was in palliative care last year because he had end stage lung cancer. He could not take the BIPAP off for a minute. He would’ve probably died there then.
It is slightly different for a patient who has sleep apnea and is on BIPAP or on CPAP. A patient who’s got sleep apnea for BIPAP or CPAP, they can self-manage.
The patient that I’m talking about that need BIPAP at home with Intensive Care at Home are patients who have a real clinical condition, such as COPD, asthma, lung cancer. Maybe they’ve gone home with a pneumonia. We have clients at home on BIPAP with cerebral palsy, for example. Also, with dementia. If someone has dementia or has cerebral palsy, they absolutely need the critical care nurse there, 24 hours a day. I hope, Helene, that answers your question around what level of care is needed.
Again, from a cost perspective, it’s half of the cost of an ICU bed if someone can leave intensive care with BIPAP and go home. It’s half of the cost.
Now, I also want to address here, especially for our audience in Australia, also want to address our NDIS support coordinators here. Most of our clients now are funded through the NDIS, the National Disability Insurance Scheme. You might be watching this, and you are an NDIS support coordinator, or you might be a participant watching this and might be wondering, “Well, how come the NDIS is funding nursing care for patients on BIPAP?” Well, assuming there’s an underlying disability, they will. It all comes down to the advocacy, it comes down to the doctor’s letter, to the nursing assessment and so forth. Don’t be discouraged. Please contact us if you’re an NDIS support coordinator or any other client support coordinator, whether it’s through an insurance scheme, private health insurance, whatever it is, please contact us one way or another. We know what’s needed for the advocacy, for the funding for our service to make it happen in the community. I really encourage you to contact us if you need more help there.
Helene, you’re asking, “Can excessive fluid overload cause aspiration pneumonia for a patient with BIPAP?” Absolutely. Look, if someone is fluid overloaded and has pneumonia or can fluid overload cause aspiration pneumonia? Yeah, absolutely. For example, if someone is fluid overloaded, there’s a higher chance of them vomiting. If they’re fluid overloaded, there’s a higher chance of them having fluid sitting on the lung, which can automatically cause pneumonia. The answer is, yes.
Then we’ve got TIS asking a question. Hi, TIS. “Hi Patrik.” Oh, it’s Leroy. Hi, Leroy. Good to see you. Your mom, Yasmin, I do remember your mom. I was actually talking to her two weeks ago, three weeks ago. I don’t know whether she told you about it. I had a long conversation with your mom a couple of weeks ago. “She went into hospital with a cough and her SPO2 was not hitting her goal to 92.” I’m very sad to hear that your mom went back into hospital. As said, I was just talking to her two or three weeks ago. To do with the cough, and her SPO2 was not hitting her goal of 88 or 92. I do remember your mom in particular, she’s got asthma or COPD as an underlying issue. That is another thing that is important to mention here. When someone has COPD or asthma, you can’t give patients too much oxygen. If you give them too much oxygen, their respiratory drive might diminish and then they might need to be intubated.
To answer your question, Leroy, she might be okay with having lower sats of 88, as long as she is coherent, as long as she’s orientated, as long as she’s cooperative, and so forth. Now, if her sats is lower than 88 and she’s drowsy, she’s not waking up, yes, she probably will need slightly higher oxygen. Then again, it comes down to an arterial blood gas.
I know Leroy, I’m pretty sure you know about blood gases. I’m sure we’ve had these conversations either on these calls here or in the past when I was working with you, your mom, and your auntie one-on-one. I would argue, what does her blood gas show? It could just be an artefact if she’s reading below 88. It could just be for short periods of time, and it could just be as simple that she doesn’t have the clip on her finger properly, whatever the case may be. The best way to verify this is with an arterial blood gas.
I also know, knowing your mom’s history and knowing your mom’s story, Leroy, I know your mom is at home by herself with a BIPAP, from memory. She shouldn’t be at home by herself. She should have a critical care nurse, 24 hours a day. I know you’re not in Australia, so just be mindful of that.
Now Leroy, you’re saying, “Respiratory sent her to ICU, and it was a case of getting her infection markers down and her blood gas is correct, which we did. Then they sent her back to respiratory.” They probably corrected or changed some of her BIPAP settings by the sounds of things, which I’m not surprised by, if she had an infection.
Anyway, be very mindful here that for anyone who is a CO2 (carbon dioxide) retainer, which I know your mom is, for anyone who’s a CO2 retainer, it’s very important not to overdo the oxygen. Getting CO2 down is more important. Also, what is important in your mom’s situation in particular is you don’t want her to be intubated. It’s very important that they get the BIPAP right with your mom and potentially change some of those settings with blood gases, and maybe she does need another sleep study.
You can now hopefully see why they may not have given her oxygen straight away because that could diminish her respiratory drive, and that would be the last thing your mom needs. If I was you Leroy, I would get back to them and I would ask them, how did they manage the sats if it was lower than 88? What’s their plan going forward?
There could also be a case of changing some of the medications. Your mom might be on steroids. She might need more steroids. These are questions I would be probing for if I was you and see what that plan is going forward.
Also, if she goes home again by herself, is it likely she will get readmitted back to ICU? You see, one thing with Intensive Care at Home is, one of our internal goals is, or one of our internal KPIs (Key Performance Indicators) is, they have non-elective readmissions back to hospitals. What that means is one of our key performance indicators is to have no unplanned admissions back to ICU. We achieved that across the board with very, very few exceptions. I argue with your mom being at home by herself, I’m not surprised she went back to ICU, unfortunately, I’m not. Going forward, going home, I argue she needs the critical care nurse at home to keep her home predictably. I hope that gives you some food for thought here, Leroy, what to do going forward.
Then obviously, I was stuck with NDIS support coordinators a bit earlier, or any support coordinators through other insurance schemes such as the TAC (Transport Accident Commission) in Victoria, iCare in New South Wales, NIISQ (National Injury Insurance Scheme in Queensland), or the DVA (Department of Veteran Affairs), or any hospital discharge facilitator. Please contact us so we can work out the funding side of things.
If you’re a patient watching this or if you’re a family member watching this, please contact us so we can take the next steps with you and walk you through the funding side of things. Once the funding side of things has been established, then we can set up a team at home.
Again, it’s very important for us to have a regular team. It’s very important for you, of course, to have a regular team so you’ve got the same people coming over and over again. You don’t have strangers coming all the time. Yes, there will be some teething issues in the beginning until you find the right people that you are comfortable with. Nothing we haven’t done before, something we’re doing all the time when we’re starting with new clients. Getting the right team together, getting the right critical care nurses together for our clients is critically important, of course.
Setting up the equipment, which we’ve done numerous times. Getting the right machine, suction machine, monitoring, having a backup BIPAP machine. Potentially a cough assist machine. Some patients on BIPAP need cough assist machine.
Another client, I forgot to mention, that another one of our clients is actually an eight or nine-year-old girl on BiPAP at home and cough assist with spinal muscular atrophy. There’s another condition that can be treated at home with BIPAP as well.
Leroy, you’re saying your mom is on FiO2 44%, which is converted to six liters of oxygen, which is normally at home. She’s currently outputting her goal of 88 to 92% SPO2 now. She’s on the high flow oxygen to eat and then NIV (Non-Invasive Ventilation) for the rest of the day. She’s on six liters at home, so they would be extremely cautious to increase that because of the history of COPD and asthma. They would be extremely cautious to increase that.
Do you have a blood gas result? Do you have one? I know you’re on the board when we were working together. I think it must be two years, nearly two years ago now. I know you were on the board then with everything, you and your auntie and your sister. You were very much on the board then with everything that was happening, which is what I believe saved your mom’s life. Including the input that we gave, of course. You have one. Look, if you’re happy to share, Leroy, her blood gas, that would be helpful and then we can talk more about that once you’ve shared it here.
In the meantime, while you’re looking for her blood gas, I’ll just keep talking. The other thing that would be helpful in a situation like that, Leroy, is to have a chest x-ray result. Because God forbid, if she has an infection, did she develop a pneumonia? I hope not. Then again, let’s go back to home care quickly. Some of our clients on BIPAP at home, they might develop a test infection. Well, they’re not going back to hospital because of that. We are treating that at home. We can now do chest x-rays at home. We can do IV antibiotics at home. There’s no need to go back to hospital. If your mom had Intensive Care at Home, had a team around her at home that would take care of her, I argue she wouldn’t be stuck in ICU now. Part of the promise of Intensive Care at Home is to do Intensive Care at Home, meaning you don’t need a hospital intensive care. That’s part of the promise.
Now, let’s move along. Leroy, I would have a look whether you can share her blood gas. In the meantime, let’s get back to some questions that came in during the week. I just need to quickly look at my emails and then I will go through some questions from the week.
Before I go to that, Helene, you’re asking, “When a patient suffered allergic reaction because she was intentionally given incorrect antibiotic penicillium for pneumonia versus a Z-Pack, can that cause high level of carbon dioxide?” I wouldn’t know, Helene. I would not know whether an allergic reaction can cause high levels of carbon dioxide. What I think can happen, Helene, is if the allergic reaction potentially ended up with the patient being drowsy or coming to the point where they might become unconscious, that might increase CO2. I guess that it comes down to whether someone is becoming drowsy or not. They’re becoming drowsy, then CO2 might rise.
Is the medication as such the trigger point? Maybe, if they become drowsy. That would be my answer to that. I don’t know enough. I would have to read up on the medication itself to do some research there.
Leroy, you’re saying “We have done an x-ray and it’s all come back clear. She’s been treated for the right heart fluid in her foot with Furosemide. Yes, seen her today and got a blood gas, but it’s a venous one. Respiratory told me they do venous blood gases more so that they can pay attention to the pH to see if she’s acidotic.” If she’s acidotic, it means that her CO2 is high. I guess yes, a venous gas, it gives you an indication. It’s not as good as an arterial blood gas, but the pH will definitely give you an indication whether someone is acidotic or not. If someone is acidotic, the chances are that it’s caused by high CO2.
Helene, you’re saying, “Yes, that did happen.” Meaning, she probably was drowsy.
Yes, Leroy, you made them do an ABG as well. Yes. Let them do an ABG. If she’s in ICU, she might have an arterial line anyway, and then it should be easy to do an ABG. Leroy, now you’re saying, “She’s no longer acidotic now.” Good. Did they change the BIPAP settings? Do you know? Why is she no longer acidotic now? Did they change the BIPAP settings?
Now, let’s get to some questions that came in during the week. One question came in from Carly who says, “My daughter was in a coma for two months in a Kaiser hospital and they never did any physio or range of movements or even told me she needed it. I found out a month later when she came out of the coma into a vegetative state from a whole different hospital in another state.” Well, Carly, here’s the thing. Just because someone is in an induced coma, that doesn’t mean they don’t need range of motion exercises. Well, I think particularly if they are in an induced coma, they need range of motion exercises.
Look, here’s the thing, every day in an induced coma means a patient is getting deconditioned. They’re losing their muscle tone, they’re losing flexibility of their joints. It’s anything but an ideal situation. A good ICU, most ICUs that I worked at, the physios or even the nursing staff would do range of motion, so that as little as muscle as possible is getting wasted. Also, if you’re not moving the joints, patients get contractions. Imagine you’re coming out of an induced coma from a few weeks and your muscles are wasted, you haven’t moved them for the last three, four weeks, whatever the case may be, your joints are stiff, you need to learn to walk again. That’s a process. A good ICU will do range of motions day one, and it won’t stop.
Now, there are some exceptions to the rule, of course. There are some contraindications, if God forbid, someone went into ICU with multiple trauma after a car accident or whatever. Yes, there’s exceptions to the rules. Let’s just take someone who is in ICU with pneumonia and may need an induced coma for a few weeks or whatever the case may be. Absolutely, range of motion. Again, you’re saying you didn’t find out.
Once again, the biggest challenge for families in intensive care is 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. They don’t know how to manage doctors and nurses in intensive care.
It comes back to that, that unless you’re asking all the right questions, you don’t need to really know what to look for. Please, also keep in mind that intensive care teams only tell half of the story unless you’re asking and unless you know what you’re looking for. Don’t take what they’re telling you for face value.
I want to really take Leroy’s situation here without giving too much away. Obviously, Leroy and his family, we’ve known each other for a long time now. Leroy’s mom was in ICU a couple of years ago. I’m not giving too much away here. The intensive care team was basically ready to stop life support and with our advocacy, I argue we saved her life. If it hadn’t been for us looking at the clinical details and saying, “Well, why are you not doing this and why are you not doing that?” I argue she would’ve passed on by now, but here we go. Leroy’s mom is a very young lady.
Anyway, Leroy, you’re saying, “They did change the BIPAP setting. It was usually IPAP 18/6 EPAP and ICU managed to get it to 16 IPAP and 6 EPAP. When she got back to respiratory, they said she started to deteriorate.” Well, I’m surprised Leroy that they decreased the IPAP and not kept it where it was. That’s a bit strange because I do believe she was an 18/6 at home when I last spoke to her. Anyway, so now they changed it to 24 IPAP over, that’s a fair increase. That’s a fair increase. The question now Leroy is can she tolerate that? Because it might be very uncomfortable for her. Is there too much air, probably blown into the stomach as well? Is there then a risk of vomiting and aspiration? I think you’ve got to watch out for that, got to pay attention to that.
Helene, “What’s the difference between BIPAP and CPAP? I was told mom should go home with a CPAP because BIPAP was not an option. However, she was discharged from LTAC without either, even though I advocated for it.” Simple difference, but big difference between BIPAP and CPAP. When you look at what Leroy wrote there, he’s written there IPAP 18/6, EPAP 16/6, 24/6. When someone is on CPAP, they have one level of PEEP. Usually, PEEP of 5, sometimes it’s PEEP of 7.5, sometimes it’s PEEP of 10. Most of the time the PEEP is sitting, especially for sleep apnea patients at home, sitting around 5.
Now, a BIPAP is two levels of pressure. PEEP is pressure and BIPAP gives you two levels of pressure. Let’s go back to Leroy’s message here where he says IPAP is 18, EPAP is 6. Someone on CPAP would only have the 6 and someone on BIPAP has the 18 and 6. What that means is on inspiration, they’re getting the higher pressure, and on expiration they’re getting the lower pressure so that the lungs never collapse. I would not know why for your mom, Helene, BIPAP was not an option. I wouldn’t know. Whether you have CPAP or BIPAP is a medical decision based on someone’s condition. The machines are often the same, just the settings are different. I could not give you any indication why they would tell you that BIPAP is not an option. Most of the time if patients can’t tolerate CPAP, they can’t tolerate BIPAP and vice versa. It doesn’t make sense to me that they’re telling you things like that.
Then again, I do believe Helene, it comes back to maybe at that stage, I don’t know how far you had progressed with your research at that stage. I’m sure if you would be in a situation like that today with all the research that you’ve done, maybe you took it for face value at the time and you didn’t know where to go for help. That’s why I’m saying ICU teams only tell you half of the story unless you know what questions to ask, and you know what to look for.
From a home care perspective or from an LTAC (long-term acute care) perspective, as you know, I’m not advocating for LTAC, not for a minute. From a home care perspective, it doesn’t make a difference to us whether we take someone home on BIPAP or on CPAP. The only other difference is, Helene, with BIPAP and CPAP, if someone has a tracheostomy. There’s only one small difference when someone is having a tracheostomy and is on BIPAP, they may also have a set rate. Meaning, whilst BIPAP is predominantly a spontaneous ventilation mode, someone can have 12 breaths per minute guaranteed by the machine. You might see that on BIPAP here and there. With a tracheostomy, you might also see it here and there on BIPAP, non-invasively, but they’re not very often.
Leroy, you’re saying, “Okay, I will pay attention to the bloating. Thanks Patrik. I did question them on why they put it so high, but their reason was because she was requiring more IPAP to blow off the CO2.” It makes sense. I guess the other question is Leroy, is she with it? Is she oriented? Is she talking? Is she mobile? What’s her mental status like? Because if she can’t blow off the CO2, does that make her drowsy? That would then make the argument for IPAP of 24. Hopefully, they can lower it down.
You’re saying Leroy, “Guess what happened next? I found out that their ECG monitor on the wall was faulty. We tried three machines because the SPO2 two kept disappearing off the screen and coming back. I made them change it too.” That’s what I’m saying. When someone has a low SPO2, the first thing that I would be looking for is, is it the monitor? Is it artifact? Is it your mom’s fingers being cool? Because cold fingers can also give a low reading. Now, I’m not suggesting that’s the case, but I argue you should be looking at that and find out whether that might be the case.
“You’ve had a new monitor then.” Sure. Has it changed, Leroy? Has it changed with the new monitor? Have the numbers come up? Because if the numbers have come up with a new monitor, it’s probably not that her SPO2 was low, it’s probably that simply there was a false reading. Leroy, you’re saying, “Now her sats stayed 88 and above. I don’t believe that your mother has an oxygenation problem on 6 liters of oxygen or 44% FiO2. I do believe your mom predominantly has a CO2 problem, especially now that you’re telling me she hasn’t got a pneumonia. The x-ray was clear because if she has a pneumonia, then oxygenation might become an issue as well. I don’t think that’s your mom’s overall problem.
Let’s move along to Veronica’s question who sent an email. It’s a lengthy email. I’ll read it out.
“Hi, Patrik. My dad has been at the LTAC.” This is Veronica from the U.S.,
“Has been at the LTAC since the end of April. He has been off the ventilator for about a month now but has primarily been on the tracheostomy collar since then. He continues to have fevers, mostly low grade, and high white cell counts. They continue to say it’s an aspiration, although he has had no need for an increase in oxygen. He’s been on 28% FiO2 consistently.
His chest x-rays do not show anything significant depending on who you ask. He has had no respiratory distress. ABGs, also known as arterial blood gases, have been done a couple of times with no findings.
The issue is his secretions. He gets a different respiratory therapist every day or two, and it really frustrates me how they have such direct influence on his trajectory. Depending on who we get, he has no secretions, minimal secretions, copious secretions. It’s all over the map with no rhyme or reason.
He has been capped several times and then uncapped and put back on the tracheostomy collar due to an increase in secretions. Still, sputum results are negative. Chest x-ray findings are minimal and no increase need for oxygen.”
Just for anyone watching this who doesn’t know what cap means, it means that when a patient comes close to having the tracheostomy removed, what’s on the tracheostomy collar, most of the time you can actually cap the tracheostomy. Basically, forcing a patient to breathe naturally. If they can tolerate that, then they can be decannulated, have the tracheostomy removed.
Let’s carry on with Veronica’s email.
“Basically, they’re saying he can’t manage his own secretions. Speech therapy says his swallow is very weak and won’t let him eat. He doesn’t receive much therapy besides with me.
I was hoping to have a call with you to help me understand why they’re saying he has copious secretions one day and no secretions the next day. What can I ask them to do? I have already asked them for a Mucomyst nebulizer, and he has received those for weeks now. Still, moderate, or thick secretions. I have asked for chest physiotherapy, increased mobilization and they do it when they feel like it.
I have asked for a smaller in a cannula so that he can cough the secretions out through the mouth. They say “no, in case he needs to go back on the ventilator.” I don’t know what else to ask. They have said two weeks ago that decannulating is off the table. We continue to try to push ahead and wean towards decannulation, i.e., having the tracheostomy removed, but are fighting the system and doctors and nurses and RTs who want to be extremely conservative and safe, rather than a little aggressive and safe.
If you can provide any advice on what to do here, how to get the secretions to think out or go away, how to convince them to go forward with decannulation and weaning, and how to get them to look elsewhere for the cause of these fevers. I would love to have a call with you.
Dad is going to be discharged home at some point and I’m sure it will be on the how to get him weaned off the tracheostomy collar at home. I’ve asked several people several times.”
I actually have spoken to Veronica this week. Let’s just get quickly into some answers here. What I suggested to Veronica is (A), watch what the RTs are doing. If you can be there, that would help. They might have different techniques. They might have different experience levels. Some of them might actually use a cough assist machine. Some of them might be very good at giving some physical therapy as well, even though they’re not physical therapies, but just doing precautions on the back of the lungs and mobilizing secretions that way. I would also say that maybe stopping the Mucomyst might be a good idea or at least reducing the dose and see whether he can tolerate that and see whether his secretions will reduce that way without his breathing being impaired, of course. You don’t want his breathing to be impaired.
I agree that a smaller size tracheostomy might help. I agree with that. If he does need to go back on the ventilator, they can put in a bigger tracheostomy. It’s not ideal, but it can be done. Because I’ve spoken to you, I also know your dad has been off the ventilator for many weeks now. The risk of him going back on the ventilator is actually really low.
Now, what I will say is this, again, mobilization needs to happen big time. Every day, the more, the better. Walking, breathing exercises, coughing exercises, the more physical therapy, the better. You can’t wean off of a ventilator and a tracheostomy without mobilization. I just haven’t seen it.
Also, with the smaller tracheostomy, yes, speech therapy needs to do some swallowing assessments. Absolutely, that needs to happen. Because how is he going to swallow again without getting those critical speech assessments done and so forth.
I would not be discouraged of having him decannulated. I think what you might need to do is you might need to leave that LTAC, we talked about that too, potentially getting him back to ICU because LTACs are so slow, and they just don’t know what they’re doing. In the ICU, they might have a real incentive to decannulate him. That could be an option.
If, for whatever reason they stop or reduce the Mucomyst and there’s still lots of secretions, another option might be to start some glycopyrrolate. Got to be careful there because it could also dry up the secretions and then your dad might end up with pneumonia. Certainly, something you should be discussing with the team there, whether that might be an option.
My advice is speech therapy, swallowing tests, smaller cannula, stop or half the Mucomyst or reduce the Mucomyst. Maybe some glycopyrrolate and mobilization, and plenty of it. I hope that helps, Veronica.
Leroy, you had some more comments to make. “Your mom was a bit drowsy at first, but the past two days her ABGs have been good and she’s awake in the morning eating breakfast and lunch. She ate dinner today and spoke with me while she was on the high flow. They’re not taking anymore, just venous once a day.” That’s good. That sounds like progress. I guess the only thing that I’m worried about, 24 of IPAP is a lot, given that she was on 18. Ideally, they should reduce that before she’s going back home. Once again, Leroy, if you were here in Australia, we could look after your mom with Intensive Care at Home. I do believe her going home with the little support she had is an ongoing risk. You’ve got to push them to get some nurses for her at home.
Now you’re saying, “I was a little bit worried today because she was trying to sleep, but I was thinking if it was because she was full. Her venous blood gas today was pH 7.415/ PCO2:8.78/ PO2:4.86.” That’s not too bad. Just give me one second. I just quickly need to look up the pH range. Seven. That’s not too bad. The CO2 two is a little bit on the high side, but again, this is a venous blood gas. It doesn’t really mean much, the CO2 in a venous blood gas, but the pH is an indicator that she should be okay.
Then Helene, you’re saying, “Can lethal amounts of medications induce high levels of CO2 and hypoxic encephalopathy brain damages?” Yes, absolutely. Absolutely. I mentioned this many times on this podcast or on many of my other videos. A lot of patients in ICU get opiates, morphine, fentanyl, oxycodone, hydromorph, Targin, oxycodone, the list goes on. The main side effect, Helene, of opiates is respiratory depression. If you are giving a patient too many opiates, their breathing drive is diminished, reduced, or will stop altogether. Therefore, one of the first things before you actually see oxygen going down, you will see CO2 going up. If that’s left unnoticed and untreated, well patients could die.
Well, if they’re not dying, then they might stop breathing and that’s when a hypoxic brain injury might come in next. I hope Helene, that answers your question. I think that’s a very straightforward answer here.
We’ve come to the hour-mark, I do want to wrap this up in a minute. I can take another quick question if you have one, but other than that, I will wrap it up. Leroy and Helene, thanks for your contributions and for your questions here.
Now, I do these YouTube lives every week, usually on a Sunday morning at 10:30 AM, Sydney, Melbourne time, which currently is 8:30 PM, Saturday night, Eastern Standard Time in the U.S. or in North America. 7:30, Central Time. 6:30, Mountain Time. 5:30, Pacific Time. U.K., it’s in the middle of the night. I know Leroy, it must be 2:30 for you or something like that.
Now you’re saying, “I’ve asked them next week, can we start looking at weaning her down on the IPAP, and they said because she has been stable the past two days, we will see how Sunday goes. If it goes well, then I think they will.” It would be ideal if they can wean it down. While she’s in hospital, you may also ask whether she needs another sleep study. You might want to ask that too. It’s 2:30 for you, Leroy. All right. Well, thanks Leroy and Helene for your contributions and for other viewers that are here as well.
“Can overuse of BIPAP cause overactive salivary glands?” I don’t think so. I think if anything, it can dry out the glands. I think a lot of things that we see with BIPAP patients or that I’ve seen in ICUs, they’re drying out. I have seen the opposite. Can it cause overactive saliva glands when someone comes off the BIPAP and stays off the BIPAP for good? I don’t know. I don’t know, Helene. My experience is if anything, patients feel dry.
It’s a great pleasure, Leroy. I really hope things will be going well for your mom. Say hi to your mom and say hi to the rest of your family. I really hope it’s going well, that you can get through this.
I got to wrap this up now.
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This is Patrik Hutzel from intensivecareathome.com, and I will talk to you in a few days.
Take care for now.
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