Wednesday, April 29, 2009

Awaiting Extubation

Tina Fraser has made a very important contact for us that you all need to know about. Melissa Montgomery is an activist and speaker for MADD (Mothers Against Drunk Drivers). MADD is a group with much political clout and can help us make sure that this tragedy is not merely given lip service and forgotten. Far too many families have been affected by drunken driving and every effort should be made to put an end to it. If even only one life is saved by MADD’s efforts and our own, then it is worth it. Please e-mail telling her that you are concerned about Ava Lopez and the Lopez family and that you want the District Attorney to pursue this case, in an effort to prevent and deter future such tragedies. Please include your name, phone number and/or e-mail address. This is the equivalent of an electronic petition. Please do this for Ava. Much appreciation to Tina for getting this information.

Tonight we should talk a little medicine. For those of you who want the short and sweet… small gains continue to be made. They were not able to take Ava off of the ventilator today, but will try again tomorrow and are very optimistic that they will be able to do so. She is slightly more alert than yesterday, but is still not tracking people or things with her eyes. Her chest x-ray was a little better, but she continues to need suctioning pretty often to get some of the secretions out of her lungs. Manny and Traci’s spirits are very high. They look GREAT! (I feel like Tony the Tiger… “They’re GREAT!!”). They are so happy now that they know they will have a future with Ava, regardless of the obstacles they face getting there.

For those of you how are interested in a little doctor/nurse speak… read on.

I have mentioned previously about the endotracheal tube, the ventilator pushing air into Ava’s lungs, the need for the ventilator to push air into her lungs because she would not be able to pull air into her lungs on her own; given her injuries to her rib cage and lung. We should discuss extubation (removing the endotracheal tube and ventilator support)and weaning her from the ventilator.

Getting her through the “72 hour” window was objective number one. Check.
Objective number two is getting her off of the ventilator and getting her breathing without assistance.

Why is it so important? The longer the tube stays in, the greater risk of further infection and the greater chance of causing the trachea to scar and narrow. The longer she stays on the ventilator the greater the likelihood of damaging the lungs. And, of course, she must be able to breathe on her own in order to go home.

We rarely ever actively think about breathing. It just happens. Take a few slow, deep breaths with me and pay attention to the following…The diaphragm contracts and pulls the lungs down. The intercostal muscles (muscles that connect between the ribs) contract and pull the ribs up. These two things together do one thing… they increase the volume in your chest. The diaphragm goes down. The ribs go out. Physics again. If the volume in your chest increases, then one of two things must happen… either the air pressure in your chest goes into the negative (like trying to take a breath with your hand over your mouth and nose), or air gets pulled in (breathing). Fortunately for all of us, it is almost always the latter of these two.

Why even mention this? It is to help you understand why getting her off the ventilator can be difficult. If you have ever been sick and stayed in bed for a day or two, you know that when you try to finally get out of bed, your muscle tire very easily. You haven’t used them. Your body has quit wasting resources on what you are not using, hence your muscles weaken. Breathing is not much different. As the ventilator has assumed the job of getting air into her lungs, her diaphragm and intercostal muscles have not needed to work, hence they weaken.

So how do we know whether or not she can breathe on her own? Well, as you can imagine the only thing worse than being intubated once, is being intubated twice. The doctors/nurses would really like to assure themselves that she will be able to breathe on her own, and continue breathing on her own, before removing the endotracheal tube. This is not so simple as just shutting off the ventilator and seeing whether or not someone turns blue. The endotracheal tube is still in place. Have you ever tried to breathe through a straw. It takes a lot of work. It is impossible to sustain. There is a lot of extra resistance in pulling air through the narrow tube and for the extra distance that the straw adds. Doctors get around this by putting her on CPAP (pronounced “see-pap”). It stands for continuous positive airway pressure. The CPAP pushes just a little bit of air into the straw continuously, but only enough to overcome the resistance that the straw creates. This way it is much like breathing normally, without the straw.

Today, the doctors put Ava on CPAP and watched her oxygen saturation and how hard she looked like she was breathing to get the oxygen that her body needed. Things that they look for, other than oxygen saturation, are her rate of breathing and how hard she has to work to get the air that she needs. When a person, especially a child, is trying really hard to catch their breath, the spaces between the ribs indent, or get pulled inward. These are called “retractions.” This is what Ava was doing early in the day. The doctors know that if they were to take her off of the ventilator and remove the endotracheal tube that she would not be able to breathe like that for very long and eventually her muscles would tire and her oxygen levels would start to drop, then… she would need to be re-intubated. This is a form of respiratory failure. Not fun.
As it turns out the doctors tried again in the afternoon, and she was breathing more comfortably, but with a slightly increased rate of breathing. They decided to put her back on the ventilator and try again tomorrow.

If she breaths comfortably, then they leave it like that for a while, then give her a break, then try again later. Once they feel comfortable that she will be able to sustain her breathing on her own, then the endotracheal tube comes out. This is what we are hoping for tomorrow.


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