What Does it Mean to be on Life Support?
When you hear the phrase life support, you often think of someone on the brink of death due to a severe illness or injury or someone who is hooked up to a machine that is helping him or her stay alive.
Life support is usually deployed as a short-term, temporizing measure to buy sufficient time for the patient to recover from a critical illness and be able to sustain life without help of life support devices.
There can be different forms of life support and all, multiple, or one of them may be deployed at one time, depending on the patient’s needs. The best known life support device is a mechanical ventilation machine, which helps patients breathe when a patient’s lung is too sick to function on its own or when a patient is in too deep coma to effectively breathe.
Other life support methods include certain drugs that may artificially keep the blood pressure elevated, keep it from dropping to zero or keep the heart pumping adequately. Even in some severe disease conditions, emergent hemodialysis (the usual form of kidney dialysis used to clean the blood of toxins) can be a sort of life support tool. Then there are more advanced and complex life support machines that bypass the lung and the heart and take over these organs’ core functions. This sort of life support device, known as Extracorporeal Membrane Oxygenation (ECMO), is only available in specialized medical centers.
Understanding Mechanical Ventilation
We’ll discuss all the life support devices in future blogs on this site, but it’s important to understand a bit more about the use, experience and impact of mechanical ventilation. In addition to being used for severe illness to replace the non-functioning lung, mechanical ventilation occasionally is used electively for a short time during surgery. For surgery, patients need to be in an induced coma with anesthesia. The deep coma may impair their ability to breath adequately, necessitating the use of temporary mechanical ventilation for the duration of surgery. This is one way to use mechanical ventilation and this use is not necessary for life support.
Sometimes patients need mechanical ventilation to deal with a short-term medical issue, like severe pneumonia, asthma, COPD flare-up or acute pulmonary edema due to bad heart failure. In these cases, mechanical ventilation is used to support or replace the function of the lungs while the patient recovers from an underlying illness. A machine called a ventilator (or respirator) is attached to a tube, inserted in the mouth and down into the windpipe, which forces air into the lungs. As a pulmonologist and critical care specialist, these are the kinds of patients I take care of day in day out. While an overwhelming majority of patients get better, start breathing on their own and get liberated from mechanical ventilation, a small portion of patients may remain ventilator-dependent for an extended period or even for the rest of their life.
In addition to critical illness or lung or heart diseases, patients with upper spinal cord injury or disease or a progressive neurological disease like Lou Gehrig’s disease may need long term or lifelong mechanical ventilation. Some people on long-term mechanical ventilation, especially those with spinal cord problems, may be able to live a quality of life that is important to them. However, for a patient with a disease state that is progressive, not curable or not being treated, mechanical ventilation merely prolongs the dying process until some other bodily system fails. It may supply oxygen, but it cannot improve the underlying condition. Patients who have end-stage lung disease or other incurable lung diseases, such as lung cancer or end-stage COPD, often aren’t put on a ventilator because it makes their quality of life very poor, as they must remain in the hospital until end of life.
When is Mechanical Ventilation Administered?
The physician at bedside decides when it is appropriate to put a patient on mechanical ventilation. The doctor considers when to initiate mechanical ventilation based on whether a patient is struggling to breathe on his or her own or whether the patient is able to maintain enough oxygen in his or her blood or exhale out enough carbon dioxide from the body. Also, when a patient is not alert and awake enough to breathe adequately or unable to handle the secretions, a doctor may also decide to put that patient on mechanical ventilation to prevent aspiration of secretions into the lung.
A patient is usually put to sleep when the breathing tube is inserted into the windpipe through the mouth. This is usually done at the bedside in the patient’s room. Once someone is on mechanical ventilation, he or she has to be in the ICU. Although in the past patients were kept in an induced coma while they were on mechanical ventilation, these days recent research suggests that it’s possible to keep patients comfortably awake and alert while they are on mechanical ventilation. At Orlando Health, we try our best to keep patients comfortable and as awake possible while they are on mechanical ventilation. If they aren’t comfortable, they are put on light induced sleep.
When the tube is continued beyond two to three weeks, it’s no longer safe to keep it in mouth and it becomes necessary to do a tracheotomy, a procedure in which we make a hole in the front of the neck and insert a small tube into the windpipe to help the patient breathe. A tracheotomy is much more comfortable than a breathing tube in the throat and the patient may even speak or eat while breathing through the tracheotomy tube. If there no longer is a need for the tube, it can be pulled out and the hole closes promptly.
An alternative to invasive mechanical ventilation is non-invasive ventilation, commonly known as BiPaP, which involves placing a large mask strapped tightly over the patient’s face and delivering pressurized air into the patient’s airway. We often use this approach for patients with COPD and heart failure. At Orlando Health, we often deploy non-invasive ventilation to prevent putting someone on invasive mechanical ventilation.
When someone is on mechanical ventilation, we instinctively try to see whether the patient can come off the ventilator. The moment a patient is put on mechanical ventilation, we begin trying to liberate the patient from the ventilation. We put the machine on its lowest setting to monitor how the patient breathes on his or her own. If the patient can breathe comfortably, the test will last 30 minutes for us to observe. If the patient cannot breathe without the help of the machine, he or she will remain on the ventilator. However, if someone can’t come off the ventilator in two or three weeks, then we perform a tracheotomy, which is done in the patient’s room so that it is much more comfortable.
Several types of conditions can cause breathing issues that require mechanical ventilation, including pneumonia, chronic lung failure and heart conditions. According to the American Association for the Surgery of Trauma, more than 790,000 hospitalizations in 2005 involved mechanical ventilation, and between 20 to 30 percent of patients admitted to the intensive care unit (ICU) required this kind of medical intervention, according to The Society of Critical Care Medicine (SCCM).
Risks of Mechanical Ventilation
Being on a ventilator has its own consequences. Every day on a ventilator, patients are more at risk for ventilator-associated pneumonia. They also are at risk for blood clots and other complications like stenosis (narrowing arteries) and scarring. I often tell patients’ families that it’s not a matter of if, it’s a matter of when the next bout of infection will attack the patient. In many cases, such infections are the cause of death instead of the condition for which the patient was put on mechanical ventilation.
Life support helps many patients, especially when we use it as a short-term measure to aid their breathing. However, when life support is an option in critical care situations it often becomes a hot button issue, particularly among families. That’s why it’s important to discuss your end-of life wishes with your loved ones and make clear to them and your physician whether you would want mechanical ventilation if you’d never regain the ability to breathe on your own or return to an acceptable quality of life. For patients with serious lung diseases, having this conversation is a necessity.
Hopefully, no one you love ever has to go on life support. Still, the information in this blog can prepare you if your family is ever faced with this decision. At Orlando Health, we’re here to help and provide families with all the assistance and guidance they need to get through this challenging time.