There are three basic settings that we worked with on the ventilator: CMV, MMV, and CPAP. CMV stands for continuous mandatory ventilation. It is where the machine breaths for Ethan. It supplies a pressure support and gives Ethan breaths whether Ethan wants it or not. It is a great setting for after surgery when Ethan is sedated because Ethan can't breathe on his own. MMV stands for mandatory minute ventilation. It supplies a pressure support but allows Ethan to initiate taking breaths. However, if Ethan doesn't take enough breaths or big enough breaths in a minute, the machine gives him breaths. This is a great setting to help Ethan learn to breath on his own with the safety of the ventilator. He can initiate breaths but if he gets tired and decides to stop breathing the machine will step in to help. Sometimes it just takes one breath from the machine to get Ethan breathing on his own again. CPAP stands for continuous positive airway pressure. It gives just enough pressure to help keep the airways and alveoli open but no more than that. You can do CPAP without the ventilator.
The pulmonary specialist believed that Ethan continued to fail extubations because he didn't have the muscle strength to keep his lungs open. The lungs would partially collapse and his respiratory rate would increase (or his oxygen concentration would decrease) because there was less area to exchange oxygen from the lungs to the blood. Ok, that makes sense so how do we strengthen those muscles? When Ethan is on the ventilator, the vent gives him continuous pressure support so Ethan relies on the vent rather than his muscles to keep his lungs open. It's just like weight lifting. To strengthen your muscles you have to do a little at a time with no support. You start small and work up. So we don't want any pressure support from the ventilator but we want the information from the ventilator... and so we get Ethan's respiratory "weight lifting" program.
The two week schedule included CPAP sprints for a predetermined amount of time THREE times a day. The amount of time followed the schedule below.
Day 1: 20 min (60 min total)
Day 2: 30 min (90 min total)
Day 3: 40 min (120 min total)
Day 4: 50 min (150 min total)
Day 5: 1 hours (3 hours total)
Day 6: 1.5 hours (4.5 hours total)
Day 7: 2 hours (6 hours total)
Day 8: 2.5 hours (7.5 hours total)
Day 9: 3 hours (9 hours total)
Day 10: 3.5 hours (10.5 hours total)
Day 11: 4 hours (12 hours total)
Day 12: 5 hours (15 hours total)
Day 13: 6 hours (18 hours total)
Day 14: EXTUBATION #5 (24/7)
And Ethan ROCKED IT! He did so well during the sprints. And after each sprint, he went back to MMV not CMV! I was so proud of him. I couldn't believe at the very end he was basically breathing on his own the whole day. Yay Ethan! He was extubated to high flow and we slowly reduced the flow to 2 liters per minute on room air during the day and BiPAP at night. We can go home on a flow of 2 and BiPAP so we stopped to work on another road block (milrinone).
After we tackle road block #2, we will try to reduce the breathing support even further and hopefully get rid of the nasal cannula during the day and be left with bipap at night. :) Go Ethan!!!
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| Ethan intubated. |
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| Ethan after extubation #5. |
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| Asleep with BiPAP machine. |
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| Ethan on room air and flow of 2! |
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