Day 139 - James Turns Blue and gets Bagged

Tuesday, May 18th, 2021

Changes/Updates:

• Feed increased 115 mls
• After bagging episode - increased clonidine, added  PRN morphine, increased PEEP to 13
• Home vent was in ordered
• Working on increasing the tidal volume; need to change to a pediatric ventilator
• Moved all trach care to day shift

James had a pretty rough night and so he slept a lot today continuing this cycle that we can't get out of!

We noticed that although James was sleeping he was having pretty severe lung retractions.

Around 11:30am James had a severe bronchospasm while having a bowel movement causing his heart to brady and his oxygen level to desat into the 20s. He went down quickly and turned blue/purple. Mom asked the respiratory therapist to bag him. He was not going to come back up on his own. The RT forced breaths with the bag getting James to come out of it. A lot of people were in the room including the new doctor that we just transitioned to today. Mom's heart can handle this!

After this scary episode they decided to increase his PEEP from 12 to 13, increase his clonidine to Q4 instead of Q6, and have a PRN morphine on hand. They also ordered an x-ray for the morning.

Today James was held by our nurse, Mom, and Dad.

Before our nurse went home for the day she noticed that James was still having severe retractions and asked if they could do the the X-ray now instead of waiting until the morning. They did and saw that he had atelectasis (collapse) in the lower lobes of the lungs according to the RT. This would show more white and hazy on the X-ray. 🫁 

Actual x-ray results For our RT friends:

FINDINGS: Interval improvement with increasing aeration of the upper Lung zones. Increased parenchymal opacity still persist unchanged in The mid and lower lung zones. No pneumothorax or large volume pleural Effusion. Enlarged cardiothymic silhouette from cardiomegaly, magnification effect due to use of portable technique, and/or pericardial effusion. Stable tracheostomy. 
 IMPRESSION: IMPROVING UPPER LOBE AERATION🤷🏻‍♀️

James had a very similar episode at 9:30pm where he desated extremely fast into the 40s. However this one had nothing to do with a dirty diaper or stooling. It was right after his albuterol treatment but usually he does not have episodes that correlate with his nebulizer treatments.

During evening rounds they decided that if he has another one of these BPD episodes where he is desating very fast and very low they are going to do a full CBC panel, blood gas, and another x-ray.

James does have a leak that goes up to 70+ percent! It is very positional. 

Into the early morning our RT and RN spoke with the nurse practitioner for several hours discussing and brainstorming what else they could do for James. Currently we are waiting to get changed to a pediatric ventilator so we can increase the tidal volume. The Night RT Took time to explain to Mom exactly what was happening with James' breathing and how the ventilator was out of sync with his breathing. James was air stacking. This is when unintended high tidal volumes occur as a consequence of incomplete exhalation between consecutive inspiratory cycles delivered by the ventilator.

(Photos of him getting tightly swaddled back to sleep.)

P.S. You can email James your love and support as often as you’d like. Mom and Dad read these emails to James as they come in. We all love them! JamesWestonAbramowitz@gmail.com