COPD

[joyfulwoman]

Hi ..
Sorry for the thread jumping. I think I am where I need to be and I understand how this works now.

Anyway, the doctors just called me to ask for my consent to place a feeding tube in my Dad's stomach. They are also planning on doing the trach on Thurs. (for background on what is going on with him see the thread I accidentally placed in the ARDS group)
They also said they stopped the sedation yesterday...he is still not awake yet. She said that that happens when somebody is on for so long it can build up and store up and take a bit for the effects to wear off. Also, she said that they are going to give him a cat scan. I asked what are they looking for? She said there is no event that is leading them to do this, but that since he is not awake they want to rule out stroke or brain bleeds or anything of the sort. I also asked would she consider that he has severe copd She said I guess so since he has been here like this for this duration. What do you think about the situation?

[Davy9]

joyfulwoman....

The gastric tube (AKA G-tube) is just a simpler way to get nutrition into his body. It replaces a nasogastric tube that is run up through the nose, then passed back down to the stomach. Like the trach procedure the NG tubes can only be left in place so long before they start to erode nasal structures, etc. The G-tube can remain in place forever if well maintained

The trach we've discussed.

The CAT (computerised axial tomography) scan is to look for possible stroke events. It is accurate that people can take awhile to come up from long term sedation. But they have seen something in his mental status or other signs that is giving them enough concern to conduct a brain scan looking for evidence of a bleed. That he was hitting high vent pressures also can contribute to this possibility. The high mean intrathoracic pressure can keep blood from draining from the head. It can back up causing an increased pressure in the vessels in the brain lending to the possibility of a bleed. Ask them about other neuro signs like the status of his pupil responses or lateral gazing.

[Davy9]

......To expound, the G-tube is a tube surgically implanted directly into the stomach through the abdominal wall. From the outside you will see a small tube protruding from his abdomen about 10 inches, or so. It sounds worse than it is. They are tolerated fairly well. (It is nothing like a colostomy).

[joyfulwoman]

I talked to the doctor today. She said that the cat scan show some kind of inflamation or infection in the sinus cavity and what some of the doctors think might be evidence of an old very mild stroke(he is at a teaching hospital so they have a team of doctors working on him) some of them don't. Regardless, she said this has nothing to do and no effect whatsoever with what is going on. She then told me that he has 105 degree fever. She said they have him on cooling blankets and antibiotics and tylenol. They need to get this fever down so they can do that trach on Thurs. Anyway, that is the latest. She did say that he slightly responded to her when she spoke to him today. She said he slowly moved his head in her direction, but he is still coming off the sedation. So...now I guess we just need this fever to go down. She said he is a young man(60 yrs old) and that they are taking good care of him and doing everything they can ...I started to get emotional at the end of the conversation and she was trying to say nice things to comfort me and I thanked her for her care.

[Davy9]

A 105 temp in an adult is very high. Something is infected and it could well be the sinusitis they noted. Sinus infections are a frequent complication of the nasogastric tube (they pass right by the nasal sinuses). Given how high the fever is and the proximity of the sinuses to the brain, they should be looking at the possibility of encephalitis or meningitis (a spinal tap would be the clincher study to rule this out or in). They should also do blood cultures as a routine matter (with such high temps). That high temp will also diminish his level of consciousness (it would anyones). That high temp will also increase his metabolic demands for food and his needs for adequate cellular respiration. In other words, because of the fever his body will consume more calories and will use more oxygen and make more CO2.

If they can get the correct antibiotic(s) on board and get them to the infection this should dissipate soon. Using the cooling measures will help reduce the temp and its impact on the system. The concerns are the possibility of a neural based infection and/or generalized septicemia (blood poisoning). Both can have dire implications. They need to get that nasogastric tube out ASAP and get the G-tube placed (if they have not already done so).

[joyfulwoman]

Yesterday, the fever went down and he opened his eyes and was a teeny bit responsive, so they canceled the trach and g tube. They said they were going to try to get him off that ventilator and breathing on his own. So, I called today to see what happened and the Dr. said they couldn't extubate him and that tomorrow is another day. I asked her if it was her blood pressure shooting way up again, she said yes, and his heart rate. I said okay and she said again tomorrow is another day...trying to be positive, I am sure. So, I guess my question is, physiologically what would be causing the blood pressure and heart rate problem. Is it due to the lack of oxygen that might happen when they try to extubate...and in any way could this be caused by any type of anxiety and nervousness in him, because he went into the hospital in a extremely high state of anxiety and nervousness???

[Davy9]

I would think that the conditions to wean are not ideal but I do not have the complete picture. Even with the temp down he's still fighting that infection. They don't completely resolve this quickly.

There are a number of reasons his cardiac parameters are up. There's the infection and there's his level of anxiety and there's the weaning. As explained earlier, people with COPD have elevated costs of breathing. As the the ventilator is slowly removed they have to resume this high cost of breathing, and they often find that very hard to do. Add to that having fought off the flu, pneumonia (as I recall), a high fever of unknown origin and a still active infection and his situation even is more complex. I assume they have his asthma under control (?).

When anyone exercises their blood pressure rises first, then the heart rate, all along with increased minute ventilation. This is a normal response to the body doing work. The heart and lungs have the reserves to supply the musculature with the needed nutrients and gases to do the work, and that's how they do it. This applies here as well. The clinicians have to make certain he can safely sustain his work of breathing before they remove the ventilator. If not, he will tire and likely return to needing the mechanical assistance. That's what got him on the vent in the first place. He was sick and breathing compromised enough to not meet his ventilation needs on his own.

Let me know how it goes.

[joyfulwoman]

I most certainly will. I'll be calling the hospital tonight to see how the day went and I usually jump on the computer after I talk to them to try to do learn as much as I can about these horrible diseases.

[joyfulwoman]

I spoke with the nurse. They did not extubate him. She told me that he had a fever of 101ish today, but not right now. And that he still has secretions. So, I asked her, I said it is coming up on about 21 days of him being intubated in this way, I gave my consent for the g tube and trach, are they still considering that now? She said, I think they will try to give him a little more time before that. But, something in my gut tells me a doctor will be calling me tomorrow to talk with me about what is going on.....I will update you again. I can't thank you enough for your interest and help davy. I hope your health is well. Take care.

[Davy9]

Have they acknowledged the existence of a sinus infection? If so, then that NG tube really must be removed and the G-tube placed. As long as that NG is in place it will perpetuate that sinus infection. They are at the upper limits on the use of the ET tube.

The secretions just go along with having asthma/COPD, being intubated and the use of suctioning catheters. They will have to be managed with good bronchial hygiene techniques. Most important is keeping them thinned and not allowing them to pool. If they let him stay in a single posture too long secretions will pool and become a source for infection. They should roll him from side to side every several hours to try an prevent this. Ideally they could have him on a motion bed that moves automatically but these are not common as they are quite expensive.