[Old_School]

When old people go bad and the dominos start to fall, their chance of recovery is nil to long and painful. If they are intubated, weaning off the ventilator is problematic. What do you think is an appropriate length of time for a person to be orally intubated before they are trached? Personally, I think 10 days max. Too much water under the bridge to effect a successful extubation. They will always be on the razor edge for reintubation and being bounced back to you. If they have a trach, they can be weaned off sedation while still on vent support. They can be started on a soft po diet. They can even have a "talking trach" and converse with their family. Most important, they can be downgraded and sent out of ICU.

[NEPhillyRN]

O_S, you've got many years on me... but when I worked in an ICU and a patient is as you described, not likely to recover, talking about withdrawl of treatment usually happened before the trach. Oral intubation like you said is a week, 10 days max but I've seen it much, much longer than that! Trachs are fine for people with a fighting chance. But in the elderly and in hopless cases, it's sad when a family isnt able to accept the inevitable and prolongs death by invasive means. Yes, you can downgrade them and clear an ICU bed, but where are you going to send them? In this area we have ventilator dependent hospitals, I've never worked in one, but have been told by respiratory therapists that they are the saddist places to be. Patients are trached by the good intentions of staff and family then left in the hospital, by themselves with few visitors for years. Sorry, this turned into a rant....

[Old_School]

Hi NEPhilly glad you found us. I don't think it's a rant, I agree with everything you say. Obviously, we too have discussions with the families prior to recommending trach and peg. But what else is there for us to do when the families are unreasonable? We cannot tie up ICU beds and long term vent facilities won't take them w/o a trach and peg. I've reconciled this point of view with myself a long time ago. How many salvageable patients are compromised because they have no bed in ICU?

O_S

[Dorimar]

Usually around 2 wks is what i'm used to. Hopefully if the prognosis truly is hopeless, the docs are all on the same page and not giving the family mixed messages. Alas, this rarely happens and see many a trached, peged 85 y/o destined to be on teh vent in LTC facility to live out the rest of there days.

[RockinRobynRN]

I work in an 18-bed Surg/Trauma unit and it seems like we are traching pts all the time. Usually around day 7 our docs are conversing with families regarding a trach. I have found that they tend to do it earlier rather than later. I can't remember anyone recently going beyond the 2 week mark unless the family was adament that "Momma just wouldn't want to be cut." Nevermind that momma is going to develop VAP & possibly extend her already expensive/extensive ICU stay. AHHH! Where did that come from? Anyway, I think that sooner is a better option, but I understand that placement becomes an issue later. No offense, but that is an issue that we will probably never solve.

[Ricu]

Hi guys,

A little late but let me add my two cents. I come from both respiratory therapy and ICU RN backgrounds and agree on several points. I have worked in units where vent patients were trached in as little as seven days. Tracheal stenosis, tracheomalacia, vocal cord paralysis and webbing are real issues and can cause a lifetime of problems for the patient who survives. Tracheostomy is a relatively straightforeward procedure that I've even seen electively done in the ICU. It's tolerated well and when terminated, seals in a few days and is closed in less than a week. The surgical scar is inconsequential when compared to the complications of prolonged intubation. As a side bar, what are the prevailing thoughts on noninvasive ventilation- AKA BiPAP? We use a lot of this as an alternative to intubating those endstage patients. Generally a decision is made in twenty four hours about whether to advance or terminate aggressive efforts. Regarding poor long term prognosis especially as it pertains to extended vent time, we in our unit seek comfort measure/ palliative care orders from family or DPOA. Once secured, we extubate. If the patient happens to be trached, we disconnect the vent. In either case, appropriate care is delivered.

R

[gracie1]

We use bipap frequently in our facility as an alternative to intubation. We also use it as a last ditch for DNI patients. The downside is that many people can't tolerate the mask. You need to monitor the skin to avoid breakdown.