the Final Stages of Pneumonia in Elderly Patients with Tracheostomy

Q: the Final Stages of Pneumonia in Elderly Patients with Tracheostomy

Hello EDDY： Here are my personal insights for your reference： 1. <br>All elderly individuals may potentially face acute conditions such as acute myocardial infarction, arrhythmias, and strokes due to vascular sclerosis and narrowing. <br>2. <br>Long-term bed rest and the use of v

Elderly patients with pneumonia who have long-term tracheostomy may ultimately face several complications that can lead to death. These complications can include respiratory failure, recurrent infections, aspiration pneumonia, and other comorbidities such as heart disease or chronic obstructive pulmonary disease (COPD

I would like to ask the doctor about the long-term outcomes for elderly patients with pneumonia who are dependent on a ventilator after a tracheostomy.

Background of the issue: My grandfather is 90 years old.
Two years ago, he had pneumonia and was intubated, spending about a month in the intensive care unit before being extubated and recovering.

In early July of this year, he again contracted aspiration pneumonia, leading to intubation for a month and subsequently a tracheostomy.
He is currently still in the respiratory ward.
Due to the second infection and his advanced age, although the infection is now under control, his lungs have suffered severe damage and fibrosis, and the doctors have indicated that recovery is unlikely.

He is currently somewhat alert, but his blood pressure fluctuates, and he has pre-existing heart and blood pressure issues.
Occasionally, he experiences pulmonary edema, intermittent fever, and elevated white blood cell counts, currently around 13,000.
His treatment involves reliance on a ventilator, with adjustments made as issues arise.
He is receiving 40% oxygen, with a respiratory rate of 25-35 breaths per minute, and his blood oxygen saturation ranges from 95-98%, although he sometimes experiences shortness of breath.

Our family is small but very close.
My grandmother still cares for him daily, while we, the children, take turns visiting from Taipei to support her.

We all understand that my grandfather's lungs are unlikely to recover.
I would like to ask the doctor what complications might arise from continuing tracheostomy treatment over time, or what changes might occur in his lungs, such as complete necrosis rendering them unusable.

I want to be informed and prepared to gradually communicate this to my grandmother.

Thank you for any insights you can share.

EDDY, 20~29 year old female. Ask Date: 2009/09/05

Dr. Yang Wenda reply Pulmonology

Hello EDDY: Here are my personal insights for your reference: 1.
All elderly individuals may potentially face acute conditions such as acute myocardial infarction, arrhythmias, and strokes due to vascular sclerosis and narrowing.
2.
Long-term bed rest and the use of ventilators can increase the risk of life-threatening infections (such as pneumonia, urinary tract infections, and pressure ulcer infections leading to sepsis and shock).
3.
Patients experiencing significant changes in their condition are at risk of upper gastrointestinal (esophageal and duodenal) ulcer bleeding, which can lead to shock and heart failure.
I believe that as one ages, these situations may occur, and at that time, the attending physician should discuss further treatment options with the family.
Best wishes!

Reply Date: 2009/09/05

More Info

Understanding the final stages of pneumonia in elderly patients, particularly those with a tracheostomy, is a complex and sensitive topic. Given your grandfather's situation, it is essential to approach this with compassion and clarity.

Pneumonia, especially in elderly patients, can lead to significant complications, particularly when combined with other underlying health issues such as heart disease and hypertension. In your grandfather's case, he has experienced multiple episodes of pneumonia, which have resulted in severe lung damage and fibrosis. This condition makes it increasingly difficult for the lungs to function properly, leading to a decline in overall respiratory health.

When a patient is on a ventilator due to pneumonia, the primary goal is to support their breathing while the body fights the infection. However, prolonged mechanical ventilation can lead to several complications, including:
1. Ventilator-Associated Pneumonia (VAP): This is a common complication in patients who are intubated or on mechanical ventilation for extended periods. It occurs when bacteria enter the lungs through the ventilator.

2. Tracheal Injury: Long-term use of a tracheostomy can lead to damage to the trachea, which may result in complications such as tracheal stenosis (narrowing of the trachea) or tracheomalacia (weakening of the tracheal walls).

3. Pulmonary Fibrosis: As you mentioned, your grandfather's lungs are already showing signs of fibrosis. This condition can worsen over time, leading to decreased lung capacity and function, making it harder for him to breathe.

4. Respiratory Failure: Eventually, if the lungs cannot adequately oxygenate the blood or remove carbon dioxide, respiratory failure may occur. This can be acute or chronic and may require increased support from mechanical ventilation.

5. Cardiac Complications: Given your grandfather's pre-existing heart conditions, the stress of respiratory failure can lead to heart strain, arrhythmias, or even heart failure.

6. Infection: The risk of systemic infections increases with prolonged hospitalization and mechanical ventilation, which can lead to sepsis, a life-threatening condition.

In terms of prognosis, it is challenging to predict how long a patient can survive in this state, as it varies significantly based on individual health, the extent of lung damage, and the body's response to treatment. The fact that your grandfather is currently stable, with reasonable oxygen saturation levels, is a positive sign, but it does not negate the underlying issues.

As for the decision to continue tracheostomy and mechanical ventilation, this is a deeply personal choice that should consider the patient's quality of life, the likelihood of recovery, and the wishes of the family. It may be beneficial to have an open discussion with the healthcare team about the goals of care. This includes understanding what the family hopes to achieve with continued treatment and whether palliative care options might be more appropriate if recovery is unlikely.

Palliative care focuses on providing relief from symptoms and improving the quality of life for patients with serious illnesses. It does not hasten or postpone death but aims to ensure comfort and dignity in the final stages of life.

In conclusion, it is essential to prepare for the possibility of further decline while also ensuring that your grandfather receives the best possible care and support. Open communication with healthcare providers and family members will be crucial in navigating this challenging time. It may also be helpful to seek support from palliative care specialists who can provide guidance on managing symptoms and making informed decisions about care.

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