Monday, December 1, 2008

A Step Forward! (And Some Technical Stuff, too)

As of last night, it feels as if Brynn has finally turned a corner. They always say in the NICU that babies take 2 steps forward and 1 step back. Lately, however, I'll admit it's felt more like 1 step forward and 5 steps back. But like Erin, one of my students at church, said, "You can't draw a smile without a steep downside and a low point in the middle!"

I knew Brynn's steep downside had happened, with the PDA complications and resulting inability to eat; the lung infection; her raised vent settings; her worn out veins having nowhere left for them to insert IVs; and her drastically increased spells (as defined by her blood-oxygen levels and heart rate dropping to dangerously low levels). But I also knew that the steep upside HAD to come sooner or later.

Whereas a few days ago, we didn't know what was causing her high vent settings and inability to be weaned, now we are making progress. The culprits could have been (1) the PDA, which would've meant surgery; (2) a new infection, which was suspected because she'd had a lot of yellow secretions even after the antibiotics had finished from the pneumonia; or (3) the chronic lung disease, which was getting worse because she'd been on the ventilator for so long. The treatments for each problem would be different, so nothing could be done until we knew. Finally, this weekend we got a bunch of results back: the PDA has remained quite small (still no surgery on the immediate horizon!), and the culture from the lung secretions showed no infection.

That left us with the choice to treat only the chronic lung disease and the doctor was able to start. We chose to do some very mild steroids. Unlike the other steroids I mentioned in the last post, which can potentially damage her brain, these steroids are given much like an asthma treatment. They are sprayed into the lungs and help the tissue alone, without getting into the blood stream. Although these steroids are not as instantly effective as the others, the Doctors figured they might do the trick without having to risk brain damage. And the best thing about these steroids? NO IVs! Brynn's little arms, legs, and head can finally heal from all those pin pricks!

Anyway, given this first steroid treatment, Brynn showed signs of finally going up the opposite side of this 3-week long trough! I was so excited when I walked into the hospital room last night to find she'd started the weaning process on the ventilator! To describe this, I'm going to get a little bit technical--but this blog is a journal for me to remember things as well as an avenue to inform others, so bear with me as I explain.

The vent has the capability to breathe a set number of times per minute without Brynn doing a thing. When Brynn does decide to breathe on her own, though, the vent can either give her a supported or unsupported breath. A supported breath means that if Brynn takes a tiny half-breath, the vent will blow enough air to fill her lungs, just as if she'd take a long, deep breath. An unsupported breath means that the vent will allow her to take in only as much air as she decides. Up to this point, Brynn has been on fully supported vent settings--and rather HIGH supported vent settings, at that (which means the vent really has to blow hard in order to keep her lungs inflated).

But last night, I'd noticed Brynn had started the weaning process. The vent was NOT supporting her when she'd breathe! I got so excited I could hardly contain myself. Our FIRST STEP FORWARD in a really long time!

In the following little video, you can see what I mean. If a peak starts with red, it means Brynn initiated the breath. If the peak starts with green or yellow (depending on which line you're watching), it means the vent initiated the breath. You'll notice the green breaths are fully supported and max out to the designated settings. But you'll also notice that some of the red breaths are short and shallow and some are long and deep depending on either how much Brynn is actually breathing or whether her breath coincides with a vent-supported breath.

The 66 number is the oxygen they're giving her (she's usually between 35-55 but she's high in this video because she always gets mad when the nurses mess with her). The 24 number (top right) that is bouncing back and forth between 15-25 is the amount of pressure the vent is using as she breaths. The vent gives her 24, she takes 15-25 depending on how strong she breathes. The 4-7 (top right) is how LOW the vent will allow her to deflate her lungs. She can't go to zero or it'd take way too much pressure to get them back open.

The last screen in the video is showing Brynn resisting the vent. Those tiny little green blips are when she's clamping down on the tube and not allowing any air in at all. You'll notice that even though the vent is supposed to give her 40 breaths per minute, she's only getting 29-31 (see the right-middle numbers) because she's refusing to let the air in. Sometimes the whole line across the screen will look almost completely flat and all the red alarms will start going off. The little stinker.

This resistance is actually common as they get bigger because they have the strength to fight the vent. Sometimes the babies desaturate really low (not enough oxygen saturation in the blood) when they do this and the nurses can't do anything to prevent it or help them. Until the babies relax and accept the vent's help, they'll literally suffocate themselves. Brynn is notorious for doing this WAY too much.

She's also notorious for lifting her head clear off the bed, turning her nose toward the matress, face planting, and kinking the tube (and subsequently desatting). Although all preemies are behind in their development compared to full term babies, the one thing they excel in is their ability to lift their heads and control their necks. Brynn, I think, is even ahead of the curve compared to other preemies in this area. One nurse, who wasn't even in charge of Brynn but had to come rushing in quite often to help, said, "THIS is the one that gets her head in all sorts of weird contortions!" It is true. Brynn really is a fighter these days--and anything she can do to let us know she's not happy with the tubes in her throat, she will try.

As soon as she gets on the CPAP (no more tubes down her throat), all this will stop--until she starts resenting the tight suction of the CPAP around her nose!

Anyway, I'm sure this is all very boring for some, but I think it's fun to record--especially since the monitors pretty much define our life in the NICU and since this is the first real move forward in a LONG time.



Anonymous said...

hi nat i came across your blog one day while reading one of alida's posts and every now and then i'll find yours and read up on how Brynn is doing it's so great to hear that she is doing so good she's definately a little fighter and already has a mind of her own (which is gunna keep you guys on your toes in the years to come). My daughter Breanna loves to look at the pics of Brynn and how cute and small she is...... you both must be the proudest parents having such a strong beautiful baby girl.
take care
kel XOXO

Monique said...

The upside is that she's not hyperventilating, but giving proof of her capacity to take full independent breaths.

I think that's very promising. . .

I must say I'm impressed by the family teaching that must be going on at your hospital. You're very informed!