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 dealt 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: 5/13/2008 Subject: weaning from vent
Question Hi, my mother has been on a ventilator for 4 weeks now. It is connected via a tracheostomy and is having severe difficulty weaning. She is also a dialysis patient, paraplegic, shows some CHF and suffers from anxiety. During the weaning process her heart rates drops dramatically to the 40's, 30's and even 20's. Thus far the Doctors are confounded as to why this happens. Also she is not absorbing any nutrition via her feeding tube. Her residual levels remains significant. Can you offer any suggestions or help? (They have ruled out the Vegas nerve and the drug Dijoxin) sp DShe is currently at a Long Term Acute Care facility.
Answer Hi Kim,
I'm sorry to hear you and your mom are going through such a difficult time. I wish I had some simple or quick answer to all this for you. Unfortunately, I think her case is rather complicated because a number of the diagnoses you have mentioned will influence her ability to wean.
Dialysis patients have a fluctuating fluid & electrolyte status which confounds their ability to wean from the ventilator. Also, on the days of dialysis, they are frequently too fatigued from the dialysis to be able to wean well.
Her slight problems with congestive heart failure will also interfere with weaning. Normally, when you or I take a breath, the air moves into our lungs because the expansion of our chest and diaphragm decreases the air pressure in our chest cavity. The air simply heads into a lower pressure zone. That same lower pressure in our chest allows the blood in our vascular bed( the large veins returning to the heart in particular) and the fluid in our lymph system to return to the heart. On the ventilator, the pressure in the chest goes from slightly positive to more positive as the breath is delivered. This decreases the return of those fluids as long as the patient is on the ventilator. During weaning, the ventilator is turned down or off, depending on where the patient is in the weaning process. The decrease in positive pressure allows the fluid that has been held back previously to return to the heart, flooding the system. Once again, if it were you or I, our hearts would simply pump a little harder and stronger to handle the sudden influx of fluid. For your mom, the increase in fluid return to her heart can lead to an overload, as her heart is not able to increase it's output to deal with the extra fluid. Additionally, while you or I would simply increase our urine output in response to the increase in fluid, your mom is not able to because of her kidney failure. The extra fluid remains there, continuing to stress the system while she is weaning.
Anxiety is often a problem for people with respiratory problems. Can you imagine anything scarier than not being able to get enough air to breathe? Once again, however, anxiety increases her difficulty in weaning. Anxiety increases our heart rate and the tension in our muscles. It makes it difficult to focus on anything other than the difficulty breathing. The increased muscle tension and cardiac response increases the body's use of oxygen. Focusing on the breathing only magnifies the issue.
You can see your mom is in a difficult spot. One thing you can do here would be to give her something else to focus on during weaning. Bring in a radio, or books on tape, pictures of loved ones she can look at, anything that would help her get her mind off the weaning process.
The decrease in heart rate is frequently seen in people who have a relatively new trach. The cannula of the trach can increase vagal stimulation, leading to a decrease in heart rate. You say they have ruled this possibility out. It would be an unusual presentation for fluid overload, but I suppose it could be a possibility.
In terms of her difficulty with tube feed, you don't mention diabetes, but is she diabetic? Patients with diabetes often develop gastroparesis. It means the stomach has sort of stopped doing its usual job of pushing the food along into the intestines. There are 2 commonly used medications to improve peristalsis, cisapride and metoclopramide.
I realize this doesn't offer much in answers, but I doubt there is much I can offer that the physicians around her haven't considered. I thought perhaps helping you understand what is occurring inside her during these processes might help, and so I offer this instead.
I hope things start going better for you and your mom. My thoughts will be with you both. If there are further questions please don't hesitate to write back. Sincerely, Hillarie
