The adventures of Joshua Alexander Cobb: Bad morning, good afternoon

So today did not start out good at all. Mom and Dad woke up for their early morning pumping, and called in to the hospital to see how Josh was doing. The nurse told us that Josh had "a few" apneic and brady episodes during the night, and that he had been suctioned (maybe a couple times). Dad then went back to work for the first time since Josh's birth, and Mom headed out to the hospital.

Apparently "a few" episodes was more like several per hour. Josh probably had 10 episodes within the first hour that Mom was at the hospital. The episodes all required some pretty vigorous stimulation to get him to start breathing again. This was very scary because Josh's hands and face would become dusky during these episodes. The nurse had already informed the weekday nurse practioner, who ordered a chest x-ray and blood work. When the weekday team rounded on him, the doctor was surprised that something wasn't done to correct the problem during the weekend. The results of those were actually very positive. The x-ray showed no signs of PIE (lung disease with air escaping the air sacks), and Josh's blood work showed no signs of infection. This meant that the most likely reason that Josh was having apneic episodes was that he is still very small, and his brain has not developed enough to tell his body to breath all the time. So the doctors decided that the best course of action would be to re-intubate Josh, and put him on low ventilator settings (minimum 10 breaths per minute, room oxygen, low pressure settings). The doctors said that they would keep Josh on the ventilator for a week and see if that gave his little brain the time needed to develop a more consistent breathing pattern.

Mom called Dad at work and talked him through what had been happening in the morning, and she was pretty at peace about the whole situation, especially since the ventilator should keep Josh breathing constantly, and he wouldn't be having such a hard time breathing. So the doctors gave Josh a sedative, and started to intubate him. They put the tube down his throat, and could not hear any good breath sounds. So they took the tube out, and put another tube down. They still could only hear minimal breath sounds, and so pulled the tube out again. When they pulled the second tube out, they also pulled up a large mucous plug from deep, deep down in Josh's throat. They then used a suction catheter, that would be used on a full-term baby, to pull out the rest of the mucous plug, because it was so large.

After this, they decided to put Josh back on the CPAP, since the mucous plug was the most likely cause of Josh's apneic episodes. From 11:00am until Mom and Dad left at 6:00pm (Dad came during lunch, and again after work to visit Josh), Josh only had 2 apneic episodes, and only one of them required stimulation from the nurse to get him to breath again. The doctor said that his episodes would be monitored, and that starting at 11:00am, if Josh had more than 6 to 8 episodes in a 24-hour period, then they would go ahead and re-intubate him and give his little body a chance to rest from working so hard to breath. They said that they wanted to give him another chance to stay on the CPAP, because keeping him intubated for extended periods of time increases the chances of him developing an infection (like pneumonia) and the mucous plug could have been causing him to work harder to breath.

Poor little Josh was so worn out from the difficult weekend and morning, that he spent most of the day sleeping. He did wake up in the early afternoon and started fussing, and Mom and the nurse discovered that he had wet through his little diaper and soaked the bed underneath. He also had his very first poop this morning, which Mom and Dad were very excited about. We never thought we would be this excited about someone's bowel movements before! Josh feedings were also doubled to 2 mL per 3 hours, and he is showing no signs of bile in his stomach after feedings, or increased stomach size, which means that the feedings are going well. Josh still weighs only a bit over 2 pounds, but his weight should start increasing now, especially with the increased feedings.

After Josh got his diaper and bed changed, he was a pretty upset little boy. The nurse decided to try to laying him on his side, and he seemed to like that position. He also got his first experience with a little pacifier, which also will help him to begin to develop the suck/swallow reflex later. The tip of the little pacifier is about the size of a Q-tip. Josh was also taken off of the bili lights in the afternoon because his blood work came back with bilirubin levels (Jaundice) below the level that requires phototherapy.

What started out to be a pretty rough morning, turned out to be a pretty encouraging afternoon. Josh may still need to be intubated if he continues to have multiple apneic episodes, but Mom and Dad feel good that it is mainly caused by his age and developing brain (which will correct itself with time), and not caused by an infection or by worsening lung disease (PIE).

Prayer Requests:

Josh have less that 6 - 8 apneic episodes (actually that he have none) in a 24-hour period, so that he does not have to be re-intubated
Josh's nose and throat stay clear of mucous, which so easily forms from the dry air related to the CPAP
Josh's bilirubin levels stay low (it is common for premature babies to have fluctuating bilirubin levels, and require phototherapy multiple times)
Josh continue to increase his appetite for breast milk and that he digest it well and start to gain weight.
Josh continue to pee and poop like a big boy.
Mom and Dad get used to the schedule of pumping (which is increasing per the lactation consultant), as well as Dad going to work and visiting Josh during off hours.
Mom continue to heal from her c-section.

Praises:

Josh's apnea appears to be mainly caused by mucous in his airway, and not from PIE or an infection.
Josh did not have to go back on the ventilator today.
Josh is digesting his breast milk very well.
Josh pooped today!!
Josh's bilirubin levels are low enough to not need the bili light, so he doesn't have to wear the shades for most of the day.
Mom is moving around better, and is less sore from her surgery.