AboutHillarie Speziale Expertise I can answer general questions about ICU care, the frequently used medications, procedures, and life supports. I can also explain many of the diagnoses and supportive measures used for patients with that particular illness. I am familiar with the infectious, cardiac, pulmonary, renal, and gastric problems that can land you in the ICU. I can not tell you exactly how long the patient stay will be, diagnosis your symptoms, or tell you with any certainty that the care you (or your loved one) received was wrong. I can also answer career questions regarding RRT and RN fields. Please note: neurology is not a field I have a great deal of familiarity with..
Experience I have 17 yrs experience as a Respiratory Therapist, and 9 yrs as a critical care nurse. I am familiar with infectious, cardiac, respiratory, renal and gastric diagnoses that can land you in the ICU.
Education/Credentials Assoc. Degree in Respiratory Therapy, Bachelor of Science in Nursing, Master of science in psychiatric nurse practitioning.
Expert: Hillarie Speziale Date: 2/11/2008 Subject: COPD and Ventilator Use
Question My 71 year-old father has now been in ICU for 10 days with a COPD exacerbation caused, I believe, by a pneumonia infection. A long-time smoker who quit about 10 years ago, his weakened lungs are now requiring use of a ventilator since he has been in ICU. He has shown no progress in these 10 days in terms of recovering lung function (oxygen levels at 65% without mechanical assistance). He has remained entirely sedated all 10 days with arms restrained since he begins to thrash wildly every time his care givers rouse him to a conscious state (tore his respiratory tube out early on). I keep hearing reference to 2 weeks being the typical limit on a respirator to allow for patient recovery. As this time frame is rapidly approaching, I am wondering what the usual options are at this juncture. I've heard about tracheostomies and portable ventilators which suggest a possibility of extended life under very closely guarded circumstances at home. Prior to this, I had thought our only likely option was the very difficult decision of when to turn off the ventilator and end my father's life, something our family has been preparing itself to do given the current prognosis. We don't have a living will or any previous guidance from our father on his wishes under such circumstances. I realize you don't have any of the crucial facts needed to provide definitive advice, but I am really just asking for your observations of typical outcomes for patients in these circumstances of advanced COPD based on your experience. I really appreciate any insight. Craig
Answer Hi Craig,
I apologize for how long this has taken me to answer. I thought I had, but evidently the computer ate the answer. So I'll try again.
I am not sure what has transpired since you wrote. Generally, two weeks is the time frame for being maintained on the ventilator without the tracheostomy. If your father were maintained on the ventilator via the endotracheal tube too much after that, the trauma done to the trachea and vocal cords could become permanent damage. The tracheostomy, as you may have already learned, is a good bridge in weaning people from the ventilator. People finding breathing through the tracheostomy much easier than breathing through the endotracheal tube. It also makes taking the patient off and returning them to the ventilator much easier. Finally, your father would be awake, to eat, and even to speak with the tracheostomy. A real possibility would be that your father would need some level of ventilatory support, even if just during the night. There would probably be times during the day, however, when he would be able to come off.
The downside to the tracheostomy is that there is no guarantee that he will be able to come off the ventilator even with the tracheostomy. Also, if he remains on the ventilator, it would be more difficulty to manage his care at home. I think one of the hardest things is ensuring that his wishes are honored. Families often struggle with the idea that they are choosing whether or not their loved one will die. I understand how it would feel that way. The disease is the thing taking your father's life, not you or your family. Your decision is "what would my father say if he were sitting here beside me?" Would he say he wants to live at any cost, even if it means a nursing home and never coming off the ventilator? Or is he the sort of person who would more likely say, "I've had a good run. I love my independence, my home, and the chance to be outside. Don't let me finish my life tied to machines." Most people, when they are quiet and listen to their heart, know what their loved one would say in this instance. When you know what his decision would be, then you are not causing his death or tying him to a machine, but simply honoring his wishes. What could be more honorable and loving than that?
Generally, once he has the tracheostomy and can eat on his own, he would be ready for transfer to a rehabilitation facility. They are much better equipped to provide the pulmonary and general physical rehab he will need to gain back his strength. The rule of thumb is the patient will need 3 to 5 days of rehab for every one day spent in the ICU.
I apologize again for not getting this letter to you sooner. If you have further questions, please write. I assure you I will not leaving you hanging as I did this time. Sincerely, Hillarie
