Respiratory Issues and Intubation in Stroke Patients in ICU

Inquiries regarding respiratory issues caused by stroke and intubation in the intensive care unit?

Hello, my father experienced weakness in his limbs and inability to speak (while conscious) on August 7 and went to the emergency room.
After more than nine hours of waiting, he finally underwent X-rays, a CT scan, and an MRI.
Before the MRI results were available, he experienced shortness of breath, and upon notifying the emergency nurse, it was discovered that his chest was filled with phlegm, making it difficult for him to breathe.
We were asked if we would choose intubation for treatment.
After agreeing, my father woke up more than two hours later.
At that time, he expressed his desire to have the tube removed and to forgo any chance of survival.
He has now been transferred to the intensive care unit, where the MRI revealed severe blockage in the brain.
My father has had two strokes; initially, he had weakness in his left arm and leg, but now he also has weakness in his right arm and leg, along with damage to his throat, making it highly likely that he cannot speak or swallow food.
His blood pressure often spikes to 200, and he has heart weakness with a stent placed.
He has a history of diabetes.
Due to the need to assess his stroke condition, he is receiving pain medication every eight hours at a lower dosage.
My father's will to live is very low, and our family has been discussing with the hospital doctors whether it is possible to expedite the removal of the tube to alleviate his suffering, as the patient himself wishes for relief.

I have a few questions: How long does intubation typically last? Can we choose to remove the tube? What is the difference between tracheostomy and intubation? If we choose to remove the tube without performing a tracheostomy in the case of inability to breathe independently, how long will the hospital allow the patient to stay, and will they provide him with palliative medication? My father's will to live is very weak, primarily because intubation is too painful for him.
I fear that a tracheostomy might only prolong his suffering, as he is continuously intubated while fully conscious, and his pain management is inadequate.
There is also a high possibility that even if his body recovers, he will be bedridden, unable to speak or eat.
Currently, he has an endotracheal tube, a nasogastric tube, a urinary catheter, IV fluids, and is undergoing suctioning.
I genuinely feel that I am causing suffering and am in great pain myself.
I hope the doctor can inform me of any medical options that might make him more comfortable.
Thank you!

ALAN, 60~69 year old female. Ask Date: 2018/08/12

Dr. Hong Weibin reply Neurology

If the patient truly does not want to suffer excessively, and the family wishes to alleviate the patient's discomfort after discussion, it is advisable to request the attending physician to consult the hospital's palliative care team.
Since September 1, 2009, the following conditions have been included in the scope of palliative care: (1) organic mental disorders in the elderly and pre-elderly (i.e., dementia) (2) other brain degeneration (3) heart failure (4) chronic obstructive pulmonary disease (5) other lung diseases (6) chronic liver disease and cirrhosis (7) acute renal failure (8) chronic renal failure, etc.
The patient, having suffered multiple strokes, should qualify under "other brain degeneration." This point can be further discussed with the attending physician.

From your description, it seems that your father not only suffered a stroke but also developed pneumonia, which has led to severe respiratory failure requiring intubation and mechanical ventilation.
If the endotracheal tube is removed, the patient will be unable to breathe independently and may initially exhibit significant respiratory distress, with pronounced chest and abdominal movements.
Gradually, as the respiratory muscles weaken, these movements will diminish, blood oxygen levels will drop, and the patient will ultimately pass away.

To ease the patient's labored breathing, some may administer morphine to alleviate discomfort; however, this medication is a double-edged sword as it can accelerate the loss of respiratory muscle function.
Intubation involves inserting an endotracheal tube (a plastic tube placed through the mouth into the trachea) and connecting it to a mechanical ventilator to assist with breathing, typically used in emergency situations.
Prolonged intubation increases the risk of hospital-acquired infections.
Therefore, after a period of intubation, the patient's respiratory data will be assessed via the ventilator.
If it is determined that the endotracheal tube cannot be removed, a tracheostomy may be recommended, which involves making a small incision near the Adam's apple in the neck to insert a plastic tube and connect it to a mechanical ventilator.

The advantage of a tracheostomy is that it allows for regular tube changes, making long-term care more hygienic and providing the patient with a longer duration for airway management.
After a tracheostomy, the physician will continue to regularly assess the patient's respiratory status; if the respiratory condition improves, the tracheostomy tube can be removed, and the stoma will heal on its own.

Given your father's condition, I believe that after the removal of the endotracheal tube, he would quickly succumb to respiratory failure.
Current palliative medications (analgesics, morphine, sedatives) typically worsen respiratory failure, so physicians are hesitant to use them in patients with poor respiratory status who are not on external mechanical ventilation.
Unless the family strongly expresses their wishes and communicates clearly with the physician, confirming that they will not pursue medical disputes due to the administration of palliative medications accelerating the dying process, the physician may be reluctant to proceed.
I hope you can consider your options, and I wish your father a swift recovery.

Reply Date: 2018/08/12

More Info

I'm truly sorry to hear about your father's condition. It sounds like a very challenging situation for both him and your family. Understanding the complexities of respiratory issues and intubation in stroke patients, especially in an ICU setting, is crucial for making informed decisions about care.

When a patient experiences a stroke, especially a severe one, it can lead to various complications, including respiratory distress. In your father's case, the accumulation of mucus in the chest, which you've described as "痰," can obstruct airflow and make breathing difficult. This is a common issue in patients who have suffered a stroke, particularly if they have impaired swallowing or cough reflexes, which can occur due to neurological damage.

Intubation is often necessary in such situations to secure the airway and ensure that the patient can breathe adequately. It allows for mechanical ventilation, which can provide the necessary support until the patient's respiratory function improves. However, intubation can be uncomfortable and distressing for patients, especially if they are conscious and aware of their surroundings, as seems to be the case with your father.

Regarding the duration of intubation, it varies significantly based on the patient's condition and response to treatment. Some patients may be extubated within a few days, while others may require longer periods of mechanical ventilation. The medical team will continuously assess your father's respiratory status, neurological recovery, and overall health to determine the appropriate time for extubation.

If your father expresses a desire to have the tube removed, it is essential to communicate this clearly with the healthcare team. They will evaluate whether he is stable enough to breathe on his own and whether the risks of extubation outweigh the benefits. If he cannot breathe independently, the medical team may discuss the option of a tracheostomy (氣切), which is a surgical procedure to create an opening in the trachea. This can be a more comfortable long-term solution for patients who require prolonged respiratory support, as it reduces the discomfort associated with endotracheal intubation.

In terms of palliative care, if your father’s condition is such that he is unlikely to recover to a quality of life that he would find acceptable, the healthcare team can discuss options for comfort care. This may include medications to manage pain and anxiety, ensuring that he is as comfortable as possible during this difficult time. It’s important to have open and honest discussions with the medical team about your father's wishes and the goals of care.

The emotional and psychological aspects of this situation are also significant. It's understandable that you feel a sense of anguish watching a loved one in distress. Palliative care teams can provide support not only for the patient but also for the family, helping you navigate these tough decisions and offering counseling services.

Ultimately, the decision to continue aggressive treatment or shift to comfort-focused care should be made collaboratively with the healthcare team, taking into account your father's wishes, his current medical condition, and the potential outcomes. It's essential to advocate for his comfort and dignity during this challenging time. Please ensure that you communicate openly with the medical staff about your concerns and your father's desires, as they are there to support both him and your family through this process.

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