That one question

Ever since last Wednesday, a number of people have asked me, in different ways and at various levels of tact, the big question for us and Woody: when can we relax and declare his extubation permanent?

It's a complicated question, because there are a lot of assumptions that I've noticed that people make when they want the answer. The real question, at least for me and Maggie, is "is he going to have to get the trach?" And of course, we can't answer that question yet, because we don't know what direction he's going to go in, and we don't know how other babies really respond in his situation, and we have the nagging doubts from Extubation I, where it looked really positive early but then steadily went downhill. Because of that, one of the things I'm doing is just watching carefully all of the leading indicators that predicted Woody's problems then. They are:

• CO₂ levels that slowly but steadily increased, starting at the third day of the extubation (going up to 70), and inching up a point or two a day, until the day of re-intubation, when it was over 90.


• Woody's bicarb rates also slowly increased, in tandem with the CO₂. Metabolically, this happens both because the lasix metabolizes into bicarb products, but also because the kidneys retain the bicarb because it's alkaline, and offsets the increasing acidity that the retained CO₂ imparts to the blood.


• Woody got more and more sleepy, and wasn't as subjectively active as the Extubation I continued.


• Woody's electrolytes starting dropping, especially as his bicarb levels increased.

Based on these standards, Woody is doing awesome. He's still very feisty, his electrolytes are still up, and his blood gas today showed, for the first time while extubated, actual improvement. Yes, that's right, his CO₂ was lower than Sunday's, and his bicarb decreased with it. The only real issue has been that since yeesterday, when he switched to the high-flow cannula, his oxygen needs have remained around 50%, which is up by 15-20% from what he needed on the CPAP. While this worries me a little-- and Maggie too-- it's important to recognize that even if he needs to go back on the CPAP, it's not like he needs to be reintubated, nor is he even close right now. Which is why the answer to the question is that as long as his CO₂ remains in check, and he is still looking good, his extubation is permanent.