Pneumothorax

So I know a lot of you get confused and can't keep up with all these medical terms and here I throw out another new one.

Early (5:30) each morning they come around and do an x-ray. This mornings x-ray came back showing that James had a pneumothorax on his left side. What this really means is a collapsed lung or more specifically it means there is air in the pleural space, which is the membrane between the chest wall and the lung. When air gets into the pleural space it deflates the lung, or gives the lung less room to function and can eventually cause the lung to collapse. The first picture below shows what normal lung and pleural space should look like. The second one shows what a pneumothorax looks like, in this picture the pleural space is filled with air leaving little room for the lung.

The initial x-ray this morning showed a very small amount of air in the upper left pleural space of the left lung. They decided to decrease the pressure they were giving James through the ventilator and increase the amount of oxygen they were giving him to 100%. Hoping with less pressure and lots of air coming in the lung would reinflate and stabalize on it's own.

Just after lunch time they did another chest x-ray. Unfortunately this approach had not worked and instead James' lung had collapsed half way ... too look almost identical to the picture above (except on the left lung). A few more hours and it would have completely collapsed.

How did this happen? It's hard to say for sure, but it likely is a hole in the lung at the biospy spot which is allowing air out of the lung into the pleural space. Similar to a bicycle tire ... if you pump to much air in the tube it will burst. The lung will also burst or open if you pump air too hard into it. It is possible that the higher pressures they had to use when they reintubated James caused a hole in his lung. Considering he just had a biopsy the most likely spot would be the biopsy spot as it probably had not completely healed. That being said, the actual spot cannot be confirm and it is also possible that the hole developed in a completely new spot, that we don't know, we just know the problem needs to be fixed.

Fixing the problem means inserting another chest drain tube. This new tube was inserted at the upper left side of his lung, where the air space was found on the first x-ray. Suction is applied to the tube once it is inserted. The idea behind this is that they suck the air out at a greater speed then it is coming in, therefore drawing/sucking the lung back to it's full size and hopefully allowing it to heal again.

So tonight James is recovering for another mini-surgery and aneasthetic. This procedure was done right in his ICU room and took them about 45 minutes to do. At this time it appears all went well and they talk about clamping the tube tomorrow and removing it the next day. But they also told us the last tube was going to come out the right away and it ended up staying in for 5 days ... so we know not to count on it out that quickly.

Earlier this week we were concerned about James' "attitude", or lack thereof. We would try communicate with him, talk to him, read, play, etc. but he would just stare past us and was unresponsive, except maybe to tell us to move because we were blocking the TV. We discussed this with the doctors and they said this is not uncommon and considered ICU Depression. At that time we had hoped he'd be out of ICU soon and so we were not overly concerned as they said usually children snap out of it within a week of getting out of ICU. It's funny how the recent days seemed to have snapped him out of it. Ever since they re-intubated him he's had more life to him, been more responsive and more fiesty when he doesn't want something done. It's hard to have to fight to do things, because then we know what's really going on in his head and how much he dislikes everything, but we're glad to see it as then we don't feel like he's already given up on us.

I left off my last post with a very big question: if they can't extubate now, just after having MethylPrednisolone, will they ever be able to?? We of course can't know the answer to this until we try again, but the doctors were very honest and upfront with us, confirming that our fears are not unwarranted.

Tomorrow the Respiratory Team has it's usual Monday morning meeting at which time they will go over all that has happened and at some point then sit down with us to discuss what they feel is the best plan and to find out how we would like to proceed. Whatever the plan becomes, the biggest decision next time will be whether we re-intubate if he cannot do it on his own. We had (and still do) hoped and prayed that this decision would not fall into our hands once again. If we thought it was a hard decision the last time we had to make it, we definitely realize that this time will be 10 times harder. Our heart breaks for our boy who is suffering so, and yet we must always remember it is not our decision to take a life. God will bring him home when the time is right!! We pray for strength when that time comes.

We have been asked several times and I keep forgetting to address this question. So before I forget again, the question often comes to us is if they could do a lung transplant. This has been attempted in one other case that they know of, unfortunately that lung also developed PAP, and eventually that patient passed away. The problem with LPI PAP is that it is the underlying LPI that is causing the problem, and until they can find out how to prevent the LPI from causing the problem to reoccur a lung transplant will not help.