Sunday, July 30, 2006

Looking ahead, again

Woody is getting comfortable again. He was really tired out by the effort of trying to keep his system in line, and all last night he slept like, well, a baby. His blood gas tests last night and this morning confirm that he is doing better. His CO2 dropped into the low 70s and his bicarb reading is inching down steadily as well. He will have a full battery of metabolic tests tomorrow morning, so we can get a systemic view of what's going on with his electrolytes and other kidney function diagnostics.

He has a couple of anti-anxiety meds prescribed for him in order to keep him calm and not fighting against the tube, but he hasn't needed any since yesterday, mainly because he's just worn out. His first blood gas reading after the reintubation showed that his CO2 was still going up, which a specialist (a pulmonologist, to be specific-- you'll be seeing a lot more mentions of them coming up) said means that he was just worn out and had no pulmonary reserve left, a process that we've now reversed. The failure of this extubation attempt makes me realize how stressful these things can be. While we knew that there was a substantial chance of not making it on the first try*, it doesn't really make it any easier to see him re-intubated again.

So, two things-- first, what went wrong here? Second, where do we go from here?

1. What went wrong? The short answer is that Woody just wasn't ready to make it on this attempt. He didn't have enough workable lung tissue to be able to keep his CO2 levels in check, even though he did seem to be able to keep himself in enough oxygen to stay comfortable. All his processes are interrelated, though, and the more his body's chemistry got out of order, he was unable to recover for himself using his compromised lungs. A little high CO2 is one thing, but when he was unable to manage that in conjunction with his too high bicarb rates and his too low electrolytes, he had to be reintubated to take the pressure off of his life support systems and let him get rested, grow more lung tissue, and make another attempt.

It was a frustrating week for us, because we saw first his apparent progress in being able to do well on the cannula, but then we also saw his continued worsening on his tests and it seemed like the doctors didn't have any answers for it. His high bicarb rate, for example, appeared to go unaddressed even though we knew there was a drug that could have potentially lowered it; his bicarb rate is also driven up by the use of the diuretics, but because his lungs were still so 'wet' they couldn't or wouldn't back off on the use of them beyond the attempt to go every other day on the lasix last weekend, which was also a source of frustration because if he really couldn't handle being taken off the lasix, why did they try that at the point that he needed to keep his lungs as clear as possible to keep purging his CO2?

Speaking rationally I don't think that these things, though, had anything really to do with Woody's inability to stay extubated. The bicarb lowering drug itself could have further taxed his already stressed kidneys; trying him on every other day lasix could just as easily have lowered his bicarb readings and bought him another couple of days; and even being on the lasix then probably wouldn't have kept his lungs clear enough to let him make it on his own. I really do feel like he was given every chance to succeed, and I don't feel like he was intubated lightly.

2. Where do we go from here? At this point, Woody's developmental progress has to figure strongly in our decisions on how to approach his respiration. The danger of leaving the tube in includes giving him a strong oral aversion; we need him to be able to learn to suck and feed on time, and so we can't have him be intubated indefinitely. On the other hand, it would be nice for us to not have to go home with a tracheostomy, because that would extend his time being supported with artificial respiration well into his first year of life. But obviously, if he needs it, he needs it; apparently one of the mantras of the pulmonologists is that 'we don't care what machine he goes home on; we care what bus he goes to school in.' In other words, we don't want to compromise his development in order to keep trying extubation over and over again.

Woody will get at least one more try on the extubation, at 36 weeks. If he doesn't make it then, we will probably give him another attempt as long as it can happen before his due date (~September 9). For the next week and a half, we'll let him rest and build lung tissue, and maybe that will be all he needs. After all, he made it over two weeks before needing the re-intubation, which tells me that he was probably pretty close. But we'll stay on top of it. Thanks for the support!

*I will note here for the record that I commonly referred to this as "Extubation attempt I" in previous entries, so if you go through the archives and see that written it was not, in fact, one of my retcons.


At 5:48 PM, Blogger Bill Hooker said...

I am sorry to hear that Woody has had a setback, but I remain confident that he will overcome all obstacles. He just needs a bit longer to build enough mature lung tissue, I think.

At 3:43 AM, Blogger abster said...

my heart goes out to you. we have a 23.6 weeker (hallie) who is a surving twin (her sister passed at 17 days). Hallie is now 50 days old. She's in the same position Woody was in---she's on high vent settings, has undergone one brief attempt at weaning (that ended in her vomiting her food, needing to be reintubated, and settings returning to their vastly high level) and we're not sure where we are going, either. I hope Woody does okay on his next atempt at weaning and will check in with you regularly.


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