Case Study: From vent to decannulation

Meet Octavia. 61 year old female with a history of anemia, GERD, diverticulitis, osteopenia, and rheumatoid arthritis with multiple hospitalizations status post COVID-19 pneumonia. Patient later developed pneumonothorax, ESBL, E. coli, ventilator-associated pneumonia, candida parapsilosis, candida pneumonia, enterococcus bacteremia, sepsis, and required tracheostomy, mechanical ventilation, and ECMO. Patient could not be discharged to a subacute rehab due to her medical complexity and so was sent to the critical illness recovery hospital where I work.

Octavia’s Current Status

Octavia arrived NPO with a PEG tube on high levels of support from the mechanical ventilator. No prior use of speaking valve or PO trials during her recent hospital stay. It has been 5 months since she began eating. With high medical complexity, assist control mode on the vent (the vent doing all the breathing), and a high risk of repeat infection, I make sure my intervention is as conservative as possible. To understand the risk completely though I’ll need to do a full review.

What can I do with all of this information?

Now that we can see the overall risk from a mile-high view, we can get a better sense of the likelihood of the patient developing an infection from PO trials at this point (which appears incredibly high). Many patients that present with this level of complexity are often not conscious enough to consider any kind of intervention. However, this wasn’t the case with Octavia. She was awake. Maybe too awake as her anxiety was getting the best of her when I came in for my initial assessment. While she presented with a high risk and high anxiety, she expressed a strong desire to have ice water (remember, it’s been five months…). This desire was so strong that any kind of explanation of the level of risk seemed to go right over her head.

I wouldn’t typically do an instrumental study this early on in the patient’s recovery, but there’s no strict rule book to work off of here. An alert patient aching for a sip of iced water trumps any kind of written guidelines. But the only way to effectively assess her tolerance and her risk of aspiration is an instrumental study. Time for a FEES.

The results were… surprising. Even though this patient had not had anything to eat or drink for five months and was incredibly medically compromised, her dysphagia was not nearly as severe as I was anticipating. She presented with a mild to moderate dysphagia characterized most significantly by respiratory status, decreased secretion management, delayed airway closure, and decreased propulsion resulting in mild residue and shallow laryngeal penetration of secretions and puree/nectar which cleared with subsequent swallows. Surprisingly, no penetration or aspiration with thin liquids (Bonus- the thin liquid actually cleared the secretions). Huge win.

Of course, I couldn’t leave a bucket of ice water at the bedside and call it a day. Octavia has a lot going on and the risks remain incredibly high, no matter what her swallow looks like. Yes, her swallow appeared functional with thin liquids, but the decreased secretion management as well as her compromised respiratory status with ventilator dependence throws a wrench into the swallow cog. I talk to her about the possibility of starting small amounts of ice chips as tolerated and holding off on water for now to mitigate the risk. I explain to Octavia that starting slowly is a great way to make sure we don’t get ahead of ourselves and maintain her forward progress. We will let respiratory continue to work on weaning her off of the vent before assessing further. When medically cleared, I will also trial cuff deflation and speaking valve trials in order to improve subglottic pressure, facilitate weaning, and manage secretions.

Advancement

Our plan worked. 9 days later, Octavia was doing trach collar trials during the day and staying on the vent at night. Speaking valve use extended to 8 hours a day and clinical signs of secretion management improved. Her phonation is weak, but with ongoing use of the speaking valve and training on breathing techniques, I’m confident we will get her voice up and running again. Octavia brings up the possibility of ice water again. She tells me that whenever she has had a long workout or a stressful episode in the past, a tall glass of iced cold water would always soothe her. Given her tolerance of thin liquid during the prior FEES, signs of improved secretion tolerance, and her understanding of the risks and benefits, I see no reason not to advance to both water and ice as tolerated at this point. This recommendation tides Octavia over for another 10 days while respiratory continues to wean, cap, and decannulate her.

Recommending a diet

Before I recommend advancing Octavia any further, I take another look at the risk chart to see if I should manage anything differently…

Final Recommendations

Octavia is clearly improving in almost every aspect. It’s a success story to say the least. When making my final recommendations I consider how far she’s come, the current risk factors that still exist, how they are being managed, how she’s responding, and her values and expectations. From the very beginning, Octavia has expressed that she has a high tolerance for risk and wanted nothing more than iced water. She has bigger dreams now and is asking for pasta and fruit. I want to say yes, but risks still exist. She remains at a high risk of infection as she is just now recovering from her multiple infections and finally being observed off of antibiotics. Her respiratory system remains fragile having just been decannulated and still desaturating with activity. I consider a repeat FEES, but decide against it given her improvement in secretion management and the fact that her results on the previous one indicated only mild residue with adequate airway protection. She has only improved since this exam. I recommend a pleasure puree diet with thin liquids given her high risk for desaturation which she tolerated for one more week. The main reason I didn’t advance her to a full diet is because she would desaturate throughout the meals secondary to swallow apnea and needing to frequently remove her venti-mask for PO intake. Nasal cannula alone is not an option at this time given her CO2 retention as per my discussion with the pulmonologist, but the team did agree to both nasal cannula and venti-mask to improve oxygenation during meal times. She was agreeable and happy with the pleasure puree, but eager to be advanced.

One week later her respiratory status began to improve from a SpO2 of 88-91% during meals to 94-96%. At this point, I advanced to regular solids and thin liquids with slow pacing and double swallow, which she followed religiously. I knew she was capable of utilizing the compensatory strategies given her mentation, but she also had a sister who acted as her “Rock” and made sure she did everything needed to keep her safe. I followed her chart closely and reassessed her everyday, monitoring for signs of aspiration, infection, and/or respiratory distress. No signs. No problems. I was ecstatic for her. Octavia had come a long way and after about 6 months of NPO was now eating and drinking anything and everything she wanted. And loving every second of it.

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