Quick tip for families in Intensive care: What are alternatives to a tracheostomy?

https://intensivecarehotline.com/blog/quick-tip-for-families-in-intensive-care-what-are-alternatives-to-a-tracheostomy/

Quick tip for families in Intensive care: What are alternatives to a tracheostomy?

https://intensivecarehotline.com/questions/wean-critically-ill-patient-intensive-care-off-ventilator-breathing-tube/

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Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So, today’s tip is about, “Alternatives for a tracheostomy.” So, we have a reader that asks us, “What are alternatives before a tracheostomy is being done in intensive care?” What a great question. Let’s dive right into it.

So, when someone is in intensive care and is on a breathing tube or an endotracheal tube in their mouth, going down into the throat, going into the lungs for mechanical ventilation, they’re also induced into a coma with sedation and opiates. Now, if the induced coma goes longer than 10 to 14 days and a patient can’t be weaned off the ventilator, then often the discussions around the tracheostomy will inevitably come up to smoothen the process of weaning someone off a ventilator and take them off sedation and opiates because while someone is ventilated with a breathing tube and endotracheal tube, it’s so uncomfortable that they need to be sedated and on opiates.

So, therefore, there’s often a delay in weaning someone off a ventilator because there’s deconditioning and there’s muscle wastage. And whilst someone is sedated and on opiates, it’s also difficult to switch them from a controlled ventilation mode to a spontaneous ventilation mode. And there can be delays, again, because of deconditioning and muscle wastage. So, there are numerous issues when you can’t wean someone off the ventilator very quickly. And then again, that is when inevitably the discussions around a tracheostomy will come up.

So, are there alternatives? The first alternative really is to wean someone off the ventilator and the breathing tube and I’ve made a video about that, “How to wean someone off a breathing tube and endotracheal tube?” And in that video, I detailed the steps that someone on a ventilator with a breathing tube needs to go through in order to be weaned successfully and a tracheostomy can be avoided. That is the first and the very best alternative to a tracheostomy.

But next, there could be other alternatives as well. Someone might go through a trial extubation which is a trial removal of the breathing tube, and then they might be able to be started on BIPAP (Bilevel Positive Airway Pressure) or CPAP (Continuous Positive Airway Pressure) with a ventilation mask. And that should only be like a support ventilation mode until someone can hopefully breathe independently. That is another alternative.

Other than that, most importantly, in those situations, to avoid a tracheostomy is weaning off sedation, physical therapy, physiotherapy, mobilization, mobilization, mobilization, and in case you have forgotten about it, mobilization. I can’t stress it enough that the quicker you can mobilize someone, the higher chances you can get off the ventilator without a tracheostomy.

Another alternative might be high-flow nasal prongs, but it’s sort of very unlikely that it’s a real alternative to a tracheostomy. And again, as I mentioned, the BIPAP or the CPAP should be a short-term alternative. Having said that, especially with our service at Intensive Care at Home, we are also providing home care services for patients on BIPAP and on CPAP, sort of where the BIPAP or CPAP avoids the breathing tube and the tracheostomy where it can be a long-term measure. But again, it’s the exception rather than the rule from an intensive care perspective.

In ICU, the alternative really is extubation, removal of the breathing tube, mobilization, and then maybe short-term BIPAP or CPAP with a view of sending someone out of ICU and breathing spontaneously without any other support.

Continue reading at: https://intensivecarehotline.com/blog/quick-tip-for-families-in-intensive-care-what-are-alternatives-to-a-tracheostomy/