On Tuesday September 4 th Lee had a routine and follow up appointment with the liver team in Murray. His kidney function was elevated so they admitted him to IMC in Murray to help hydrate him and see if his kidney function would improve. Lee's mom, Jesse, Dee  and Jeri made it out to visit him on Wednesday.  

That day they also placed a small bowel feeding tube to help with nutrition and hydration. With his achalasia he was to the point that he was able to hold down food and sometimes not fluid. Achalasia: In layman's terms, the esophagus does not propel food towards the stomach, and the muscle of the lower esophagus does not relax to allow the food to advance from the esophagus to the stomach. The result is accumulation of food and saliva in the esophagus that needs to go somewhere. When upright, it can eventually trickle into the stomach by gravity. When lying down, it  can go back into the throat and even possibly get aspirated into the lungs. Thursday they took Lee to endoscopy to have a Botox treatment this it to help relax the pyloric sphincter and reverse the effects of the achalasia.

During that treatment Lee had some debris that consisted of undigested food and fluid in his esophagus he threw up and aspirated he was coughing and needed oxygen when he returned to his room. One positive note I can see life-flight helicopter pad from the window.

During the night he continued to cough and throw up. Yesterday morning they took him down to interventional radiology to have another small bowel feeding tube place they were not able to get it down. He once again threw up during the procedure and has a significant aspiration. Upon arriving back to the unit he was coughing and his o2 saturation's were 60%. A rapid response was called. A rapid response team, also known as a medical emergency team and high acuity response team, is a team of health care providers that responds to hospitalized patients with early signs of deterioration on non-intensive care units to prevent respiratory or cardiac arrest.  They acted quickly and stabilized his airway. They moved him to the Shock/trauma ICU and intubated him. He is currently on a ventilator with sedation. 

The doctor showed me his chest X-ray and you can see the areas where fluid has collected. Currently he is resting well and he seems to be stabilized. He will be ventilated for at least over night and the plan is to place the feeding tube before they extubate him. 
Today the doctors have decided to keep him intubated through the night and do a spontaneous breathing trial (SBT)in the morning to see how well he will tolerate being off of the vent.  

SBT involves the following steps:

• It be conducted while the patient is still connected to the ventilator circuit, or the patient can be removed from the circuit to an independent source of oxygen (T-piece)
• When using the ventilator a PS of 5 – 7 cmH2O and 1-5 cmH20 PEEP (so called ‘minimal ventilator settings’) will overcome increased work of breathing through the circuit (i.e. ETT)
• If still on the ventilator the patient should have ‘minimal ventilator settings”
• Initial trial should last 30 – 120 minutes
• If it is not clear that the patient has passed at 120 minutes the SBT should be considered a failure
• In general, the shorter the intubation time the shorter the SBT required

80% of patients who tolerate this time can be permanently removed from the ventilator

The hope is to place the feeding tube before the extubation.  SO the plan is to stay the course, increase the lactulose to help get the ammonia down and let the lungs heal a little better.

I hope to keep this updated so that all his family friends and followers can stay informed and keep him in your prayers. Thanks for following his story.