My girlfriend is in ICU on life support at a local hospital. Respiratory failure. She has been on a breathing machine for 6 days with no improvement. Original diagnosis was pneumonia.
They are having problems weening her off of machine and I think I see a clear pattern developing. In case my pattern makes sense I would like to know how to approach them with this.
They will have oxy set at 75% for several hours, it will start to bump the 98 to 100 mark and they lower it to maybe 60 or so, if it holds well there in the mid 90's they lower it to maybe 50 percent where it is hovering in the low 90's. They say they need to force her lungs to work. After a while here it will start dipping into the high 80's and within a few hours drop down below 87 where they have to raise it back up to 75% and start over. I feel by doing this they are inviting fluids to build back up in the lungs once they hit 92% or lower saturation levels. I think if they kept the levels no lower than 94% and turned it down only a few points at a time whenever it started approaching 100% it might be more effective. This has been a daily thing.
First, I’m sorry you (and she) are having to go through this - post-pneumonia respiratory failure is a shitty hand to get dealt.
Your weaning protocol makes intuitive sense, but it’s not really how lung physiology works or, for that matter, what the clincial staff is really looking for. Respiratory function recovery occurs in somewhat broad stages rather than many small increments. Most weaning protocols I’m familiar with (and, to be fair, I’ve been away from most Pulm/Critical Care stuff for 3-4 years now…though I doubt they’ve changed much) first drop the O2 percentage, with titrations of the PEEP (the pressure level required to keep the alveolar sacs open) if the decrease isn’t tolerated well. (There are many more steps in a complete protocol, but these are the most relevant here).
In short, your logic is good/reasonable, but studies have shown that, if patients don’t tolerate the step-down protocols, they won’t do well with gradual decreases…and they would be more likely to have other side effects that are more detrimental. Fluid build up may very well be the root problem, but, if it is, her lungs aren’t ready.
Waiting sucks - it does - but sometimes it’s all we can do.
My 17 yo son was in an ICU for a couple months with pneunomia a few years ago. He was on an ECMO machine for 18 days to keep him alive while ine underlying condition improved. Is this a viable option in her case?
Yes, it is a viable option. I get the feeling from some of the doctors that they like to bring things to a conclusion quickly. They seem to be a bit better now that she has an advocate me.
I have my personal doubts about some aspects of medical care, but they are the greatest source of knowledge and care we have.
When my Mom was in the hospital for with pneumonia, it took a couple of weeks before they completely weaned her off the oxygen and when we got her home, we had an oxygen machine, a large tank and a portable tank for her. A big factor was her age (she was 88 at the time), but it was better to be safe than sorry.
Oof - that gets more complicated. About a decade ago the “high-PEEP” advocates (>15-ish) were convinced they were in the right: more lung tissue pressure equals more oxygen delivery to the body, right?
That’s become less clear in the past few years as the “low-PEEP” advocates have shown that the dynamic relationship between lung and cardiac function makes PEEPs above about 10cm…problematic. Or at least not a slam dunk.
Keep on advocating - it makes a difference.
P.S. I know 6 days without visible improvement seems like forever, but it’s not unusual for severe ARDS cases to need rather more than that to stabilize. Hang in there.
My sincere apologies to everyone if my final words above seem too light or possibly disrespectful. I realized it may be taken that was after the edit window closed. It’s my habit to always try to put a light/positive spin on even the most dire circumstances. Once again, I sincerely apologize if I offended anyone.
Heart function was fine, strictly an oxygen issue. He was on Veno-Venous ECMO which, as it was explained to me, is less likely to allow blood clots to the brain which made the 18 days less of a risk. He’s doing amazingly well now, 5 years later.
Another thoughts are with you and hoping for her to have the speediest of complete recoveries to you HoneyBadgerDC. Are you taking care of yourself through this?
I am also happy to read that these protocols are becoming more solidly evidence based. Back in the day “truth” when on call was dependent on which attending was making rounds in the morning, for one it was PIP before PEEP and the other PEEP before PIP …
Again best wishes and thanks to SuperAbe for the informed posting.
I have been asking about diuretics and have gotten no answer until today. She was blowing up like a balloon and her 02 numbers were getting weaker even on higher settings. They finally put her on diuretics and water is poring out of her in gallons of pee. They said low blood pressure had prevented them from starting this earlier. I will post back tomorrow if the diuretics are helping.
I hope she’s at the stage where fluid removal helps - sounds promising. Like most of ARDS, it’s…complicated (here’s a decent summary of the issues). In short, when all other things are equal, zero-balance fluid volumes seem to be slightly better overall. This presumes that cardiovascular function is adequate to support a zero-sum fluid resuscitation model - if not… everything goes out the window and the clinician’s hands are tied.
The need to continuously keep up with her care is not limited to her. This is not intended to trash medical professionals but the normal rotation of doctors and nurses seems to lead to inconsistencies. You may also notice the different approaches from different teams, perhaps some are better than others in communicating.
Hang in there, you’re a great friend for doing this!
A huge difference in employees attitudes and skill levels. One major factor they were ignoring that a guy tonight took very seriously is that 02 levels were not an issue until about an hour after she arrived. They were fine when she left the house for the hospital. he seems to think she may have been flooded with fluids because she was already bloated somewhat from drinking too much beer. She does have an alcohol problem.