Q. 28 year old unable to sustain respiration off the ventilator, why?
Hi doctor,
My query is regarding a female patient aged 28 years. She has been on a ventilator through a tracheostomy for 50 days. She has been on continuous positive airway pressure (CPAP) mode for two weeks but is unable to sustain respiration off the ventilator. Please help.
Hello,
Welcome to icliniq.com. A young female on a prolonged ventilator through tracheostomy and having difficulty in weaning is considered to be a very bad prognosis. You have not mentioned proper medical history, indications for ventilation, and under which medications she is. There are many things that we need to consider before removing the support of the ventilator. Weaning from the ventilator depends on the control of underlying causes. With proper treatment of the underlying cause, weaning can be planned successfully. Sometimes, the complications such as aspiration of fluids into the trachea and lung, collapse of the lung, tracheal stenosis, and resistant microorganisms are the main problems that will prevent successful weaning. So, treatment of the primary cause is very important. With the use of proper antibiotics, good chest physiotherapy, proper ventilator settings, and frequent suctioning we can plan to remove the ventilator. Thank you.
Hi doctor,
Thank you for your response.
The patient, who is my wife, was admitted to intensive care unit (ICU) five months back after she became unresponsive in the general ward of the hospital, where she had been admitted the previous day for gastroesophageal reflux disease (GERD) and elevated blood pressure (BP). Computed tomography (CT) scan showed generalized cerebral edema and some infarction. The edema has been treated with diuretics. When initial weaning failed about eight days post ICU admission, a chest X-ray was done, which showed left lung collapse with pleural effusion in both lungs. Bilateral chest tubes were inserted in addition to antibiotic treatment. A tracheostomy was also done while she commenced daily physiotherapy. X-ray taken two weeks ago showed resolution of the lung, which has fully expanded. Chest tubes have been removed and there is good air movement on auscultation. But, the patient is having challenges going off the ventilator. She has been on CPAP mode for nearly two weeks with intermittent attempts of weaning. Daily chest physiotherapy has been continued and she is on antibiotics. Tracheostomy is also frequently suctioned. She however cannot stay off for more than 30 minutes. There is agitation, sweating, the elevation of BP to over 200/120 mmHg, and partial loss of consciousness. It seems there is a buildup of carbon dioxide (CO2) causing necrosis. Diaphragm and intercostal muscles seem to have suffered disuse atrophy. I am seeking help and alternate opinions on a guided approach to successfully weaning her off the ventilator. The intensivist here has put in quite some effort, but I feel we can do with some external help and guidance, hence I have come here. We are young couples. I am 30 years old and she is 28 now. We have two daughters, the last delivered just a week before she was admitted to hospital.
Please help.
Hi,
Welcome back to icliniq.com. Thanks for providing a detailed history which makes further planning easier. As you said, there is no effusion and the lungs are fully functional, we can try successful weaning as cerebral edema has also reduced. What I can suggest now is, to give intermittent T-piece trials (tracheal intubation) and keep watching her oxygen saturation. If she can sustain it, slowly continuous positive airway pressure (CPAP) support can be reduced. Along with this, good physiotherapy and constant boosting of her morale are very important. If there is no active underlying pathology, you can hope for successful weaning. But, every time it does not happen as what exactly we think. So, do not get upset if this does not work. We are now in such a situation, where we have to accept the facts and hope for the best. I hope the intensive care unit (ICU) doctor is pretty experienced in handling such cases of difficult weaning. Because there is much difference between just advising things from a distance and treating the patient. So, I hope everything will be fine soon and your wife will come out of this situation very soon. Thank you.
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