ARDS

[joyfulwoman]

I had started another thread and then I tried to add more replies and for some reason they are not showing up. So, this, I guess would be part of that thread called (Any advice or suggestions?)
I spoke with the intern today and she said that my dad's airway pressures were high. What does that mean exactly?
He is in the hospital now on a ventilator with copd asthma flu and pneumonia...
Thank you for any replies. It really helps cause he is in New York and I am in the west coast. And I am just trying to put all the info I can get together as much as I can.

[Davy9]

Hello again joyfulwoman....

What the Intern is referring to is the peak positive pressure the ventilator uses to deliver a set volume (tidal volume = one breath). This value is related to 2 things. The first is the elastance of the lungs. If the lungs are stiff it will take more pressure to distend them. The second is airways resistance. If the airways are restricted it will take higher pressure gradients to deliver the set volume. They could be restricted by obstructions, such as mucous, or from constriction, as is caused from bronchial spasms (related to asthma, which I know your dad suffers from). The 2 values can be discriminated with a simple test that is commonly performed on ventilator patients. The values are called static and dynamic compliance. Simply they allow the mechanical ventilator to deliver a breath noting the peak pressure delivered, then immediately stop its exhalation temporarily capturing the volume in the lungs. They then note the pressure the lungs hold when that volume is held static (as opposed to being pushed into the lungs). This way they can determine if the increasing peak pressure is caused by a stiffening of the lungs or from an increase in airways resistance, or a combination of the two. They can also do this using images of the flow volume curve while a breath is being delivered (hard to explain).

So that is what you need to find out, whether the high peak pressure is from the lungs themselves or the airways resistance. If the peak pressure are high from increased airways resistance then they should be working to reduce that resistance. Using bronchodilators to lessen bronchospasms, looking for major obstructions (as in mucous plugs), maintaining adequate pulmonary drainage (mucous clearance), etc..... If the lungs show stiffness then they need to address that cause. There are many things that can cause an increase in lung stiffness. Frequently it is excess fluid (pulmonary edema), but it could also be from other things as well.

There are also methods that can be employed in how the mechanical ventilator is used that can decrease the pressures. Modern ICU vents have a number of operational modes devised specifically to allow implementation options for ventilation (CO2 clearance) and adequate oxygenation. It will be up to the physician running the vent (usually a Pulmonologist or Intensivist) and the Respiratory Care department to monitor how the vent is interfaced and determine how it is best utilized.

ICU ventilator management is not simple but not hard either. It is a lot about trends in how the patient is doing. In other words how the values change over time. There is a better direction for them to be headed, and higher delivery pressures is not a good direction. The COPD patient is more complex than most as they typically have multiple systems involvement and not a wide margin of reserves. The lungs are central to many things and when severely diseased many things tend to be effected.

[joyfulwoman]

Davy9, I can not thank you enough for your thoughtful and thorough replies. I will ask about what is specifically causing the high pressure.
Also, she told me that his x rays don't necessarily show the pneumonia but that he has secretions? and so they are treating him for it, as well as the flu.
She also told me that they haven't even discussed the tracheotomy(I guess we misunderstood something), because that would be only after there was some kind of improvement with his lungs...and there is not, they are still the same. She said right now we just need time.
I don't know necessarily how COPD has been a part of your life, but I thank you for being a part of a message board like this, because for people like me, any info I can get makes a difference.

[Davy9]

Pulmonary secretions are common to COPD, chronic bronchitis in particular. They also are found in asthma. Infection can be inferred by any number of tests, sed rates, white cell counts, etc.. They may have done a culture and sensitivity on a mucous sample from his lungs and found a particular bug.

The tracheostomy procedure is not related to whether his lungs "are getting better" or not. It is related to time. That ET tube can only be left in place so long without damaging oral and upper airway structures (vocal chords and the like). If it has been longer than a few weeks it really needs to pulled and a trach done regardless of his lung status. It is not a very involved procedure and I've seen them done at the bedside.

I am an asthmatic, but I also happen to be a Registered Respiratory Therapist with a background in medical research, teaching and about 25 years of clinical experience of all sorts. In this time I've witnessed and managed more COPD patients than you can imagine. This countries lack of tobacco control policy is a national travesty. In the future this time will be recognized as having failed in this key public health issue to the unfortunate demise of literally millions of our citizens (almost 1/2 million per year). I'll advance what I can to help you with your dad. To be honest his situation does not sound positive and you might want to try and arrange to visit him.

[joyfulwoman]

Wow..I am glad to have contacted you.
I totally agree. I actually, and I am not an environmentalist type gal, feel strongly that tobacco should be illegal. I loathe having to take my small children to the store and walk through a cloud of smoke. That is just starters. Thank God, in my state we voted no smoking in restaurants. We can actually take the family bowling and to the restaurants without having to worry about the smoke.
Yeah, my dad has years of abuse on his body with smoking, alcohol etc. vietnam vet lived through the 70's nightlife and all that.
I also have a younger sister who is has asthma. They said it would get better as she got older, it has gotten worse...we have lots of allergies here. That's a whole other story.
I have still had going out there on my mind. It is tough for me to leave, I have my husband and 3 small children from 1 -4 years old, but we are still kinda expecting that due to the other family crisis going on there simultaneously at the same hospital. Davy9, you couldn't write what is going on out there for a movie. I will talk to the hospital probably tomorrow for an update. But for some reason, even though my family seems to think he will be okay, I am just emotionally staying prepared and in the middle. I'll check back here later on the boards...

[joyfulwoman]

He has been on the ventilator, since the 18th of Feb. I believe, give a day or two...

[joyfulwoman]

Ok. So the intern Dr. called me this morning and told me that since my dad has been on the vent for 10 days they are probably going to be planning a tracheos...She told me that he had an incident last night when his oxygen got really low. Dr. said that the problem is he not getting worse, but that he is not getting better. So, since I am the next of kin they will be calling me for consent, she just wanted to keep me in the loop and let me know when any changes had happened. Also, she said that when they tried to lessen the sedation the blood pressure, again, got way too high and that he was aggitated? She knows, as well, that I have very little ones to care for, and she said that when/if they do the trach he would be more aware and that if I wanted to visit he would know it was me. Because up to this point everybody was telling me basically, not to come, because A. I could get really sick, and B. he wouldn't know I was there......

tough day today....

[Davy9]

Happy leap day...... The trach will help some as it does reduce the deadspace and the resistance in the circuit. It will also allow for easier access to mucous removal and ease the weaning process. The episode of low oxygenation shows how tenuous the lungs are with COPD. They do not leave much margin for safety or error. Consider how much reserve capacity normal lungs offer. You can go from a rest to doing a lot of work and the lungs effortlessly accept the additional demands. As COPD advances that exercise reserve erodes away and eventually the victims barely have enough lung capacity to sustain sitting around and doing nothing at all. Another trait you often see is the absence of emotional displays in those with advanced COPD. They do not get sad or happy or anything because that changes their breathing patterns and sends them into feeling short of breath.

On a more positive note, if he does eventually improve and wean there are particular approaches to rehabilitation devised just for people with COPD. If he is diligent and committed he might be able to return to a higher level of quality of life and live a healthier one as well.

There are also some surgical approaches to emphysema that have been successful. They are called lung reductions. If they can identify a large section of wasted lung space (AKA Blebs) within the lungs they can sometimes surgically close them off. These spaces in the lungs take up a lot of work of breathing and provide little gas exchange. They are very inefficient. Once removed from the breathing loop (so to speak) the rest of the lungs can be more efficiently employed. But this is not possible for every patient and the procedure does not always work well for those who are candidates. Sometimes doing the procedure actually worsens the situation. Also these procedures are not done while patients are having an episode of acuity, which is where your father is now. They need to be as healthy and strong as they can be to tolerate to procedure (general anesthesia, etc...)

[joyfulwoman]

Thanks Davy for the very useful info...and a happy leap day to you, as well!