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In this episode, Kali discusses ventilators, including the risks, how they work and how they can be vital in saving lives in the ICU.
Episode Transcription
Ok, let’s talk ventilators. Your loved one may need to be on a ventilator. Don’t panic. Despite the misinformation and fear out there… ventilators do not kill people. Ventilators can be vital in saving lives.
Let me first address these rumors that have spread during COVID with the claim that “ventilators kill people”. My strong suspicion is that this misunderstanding developed when the first wave of COVID engulfed New York City and they suddenly had thousands of people on ventilators. In truth, many to most of them died. One early study of a group did show that death rates for COVID patients on ventilators were into the high 80’s. In the height of denial of the lethality of COVID, when the public recognized the main common denominator among the dead was that they were on ventilators- the assumption became that it must have been the ventilators that killed them. The reality is not nearly that simple. Let’s look a bit bigger and deeper into what happened there.
In the big picture, saving lives in the ICU is a mix of science, medicine, procedures, equipment… and all run by humans. Ultimately, PEOPLE save lives. Remember, staffing ratios- meaning, how many patients for each staff member significantly impacts the kind of care a patient receives. In the states, patients who are ventilators should only be cared for by clinicians that are specifically trained for the ICU. ICU nurses should only have 1 or 2 patients to 1 nurse. Respiratory therapists should only have 4 patients on ventilators, physicians shouldn’t have more than 13-20 or so patients.
When New York ERs suddenly had hundreds and thousands of extra patients showing up fighting to breath and their own staff was becoming sick and incapacitated…. Their ICUs no longer had adequate staff to care for these extra thousands of patients on ventilators. Out of desperation, they were sending in any nurse with a license no matter their training, medical students, psychiatric residents…. ANY willing person- to go in and try to help. This meant that patients on ventilators were no longer receiving true critical care. I had colleagues that went to help at the end of that wave and arrived to their assigned units to find they were 1 lone doctor with one other nurse for 13 patients on ventilators. There was no way they could provide the care those patients needed to survive.
So please, understand- ventilators did not kill those masses of people. COVID and the crisis led to their demise.
Ventilators come with some risks which we will discuss, so no one is placed needlessly on a ventilator. I have never received any financial benefit or been at all influenced to put someone on a ventilator by anything beyond the need for ventilator support in order to survive. That is all any clinician cares about. It is expensive to provide mechanical ventilation, so hospitals are reimbursed accordingly… but that does not determine or influence the choice to put someone on a ventilator. It is not until we determine, “They are at high risk of dying if we do not intubate this patient” that we place the breathing tube. We do not put patients on ventilators unless their lives depend on it. Please believe that.
So- don’t be afraid of ventilators. This is not the first wave in NY- your loved one now has trained physicians, nurses, respiratory therapists- the whole team- to give your loved one their best chance at survival. Quality of care on the ventilator is important because there are risks of
- ventilator-associated pneumonia
- bed sores
- trauma to the lungs
Yet the rates of those complications can be very low when adequate precautions such as cleaning the mouth every 2-4 hours, turning, mobility, trained monitoring are involved in their care while they are on the ventilator.
There are lots of different reasons patients may need a ventilator- they may not be awake enough to breath on their own, they may have dangerous swelling in their throat, they may have metabolic or infectious process that puts them at risk of having problems with breathing, their lungs may be failing…. There are dozens of different reasons to need a ventilator. Ultimately, ventilators provide the oxygen and support needed to stay alive while we treat the life-threatening problems.
Ventilators are very sophisticated machines and can be adjusted to meet the needs of your loved one. That means that the rate, volume, timing, and type of breaths given to your loved one can be customized. You don’t need to know all about this or all the settings, but I will give you some highlights so you can understand how your loved one is doing.
Ventilators can have many different settings that determine if it mandates breaths, follows the patients breaths, or completely allows the patient to breath on its own. Different ICUs have different ventilators and protocols, so I will try to explain this in the most common of terms. You will likely hear settings such as “Assist Control” and “CPAP”. Put simply, “Assist Control” is mandating breaths to your loved one but may still allow them to take their own breaths on top of the programmed breaths. CPAP allows your loved one to take their own breaths- however frequent, fast, or deep they can and want to.
When lungs are sick- with fluid, infection, inflammation… whatever it may be- assist control is the most common setting in most ICUs. Often, when lungs have improved and it’s time to see if it’s safe to take out the breathing tube, we will put them on the CPAP setting to see how well and how long they can do their own breathing.
So, now you know about assist control and CPAP.
There are two main numbers that you can be aware of that tell us how much support they are needing from the ventilator- the Fi02 and PEEP. Fi02 is oxygen- it is the level of oxygen being given to the patient. The lowest level of oxygen that a ventilator can give is 30 or 40%. Such a low oxygen level would mean that the patient’s lungs are not so infected, full, or inflamed and can easily absorb the oxygen and do not need very much oxygen support. That’s a good thing. The highest oxygen that can be given is 100%. This would indicate that the lungs are much sicker and needing full oxygen support to be able to absorb and provide enough oxygen to the body.
PEEP is positive-end expiratory pressure. Check out the video link for this episode in the blog. Ultimately- this is how much pressure the ventilator is giving. It is pressure given at the end of each breath to keep the alveoli open. This can reflect how stiff or inflamed the lung is. The lowest PEEP ventilators can give is 5. A PEEP of 5 would tell us that the lungs are pretty normal- that they’re moving normally, popping open normally- that they’re not stiff, full of fluid, or significantly damaged. The highest PEEP depends on the ventilator and team- it can go up to I think 26- though I’ve never seen it that high. The highest is usually 18 or 20. When PEEP is that high, the risks of so much pressure causing a lung to pop and have a pneumothorax can increase. The need for more pressure and a higher PEEP happens when lungs become more inflamed, full of fluid, or stiff with conditions like ARDS – acute respiratory distress syndrome. So when the need for more PEEP is increasing, we start to be concerned about the status of the lungs.
So, as a family member, you can ask, “What are their oxygen and PEEP levels at?”. Watching the trend of those numbers can give insight into how their lungs are doing and how close they are to getting off of the ventilator. These numbers can go up and down, so please don’t obsess too much. Just stay informed and watch the general trends.
So, there you have it. Ventilators help save lives. They require specialized care and are used as briefly and well as possible to allow your loved one the opportunity to survive their critical illness. Don’t be afraid of them. Be grateful that the equipment and staff are available for your loved one.
Make sure frequent oral care is being done, that they’re turned every 2 hours if they’re not mobile, and especially, push for the ABCDEF bundle so they can have the best outcomes during and after their time on the ventilator. As we buy time to treat the critical illness with the ventilator, the ABCDEF bundle will help prevent the occurrence of more problems and complications that can occur during this time. Keep listening to the next episodes to learn more about it.
Links:
https://www.youtube.com/watch?v=4IA_EEIk8Xs
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