Well, after finally speaking with the pulmonologist it was decided to resume the discontinued Atrovent and monitor the progress to determine if it's absence was truly playing a role in Elias difficulties. She also ordered a gram stain culture from his trach to test for potential bacteria and infection. This is because of the odor coming from the trach. We called his pediatrician to set up a test at the closest lab, fortunately we only need to take the specimen and not Elias. The problem was no one has the proper equipment to capture the secretions. We improvised yesterday evening drawing it up into the catheter chamber, turning off the suction and drawing it out with a syringe. Then placing it into a specimen cup. I transported it to the designated lab and when I got there they told me there was no Doctor order in the system. Of course, by then it was after office hours and even if I had reached our pediatrician on his cell, he was not at the office to do anything. Besides the lab was only open for another 20 minutes for the day so it was a lost cause either way. So we are trying to get this set up all over again and try today. Our only other alternative is to take Elias to the hospital to get it done, and we really do not want to have to do that. I think we are going to try and color his feeds again today, because there is a hint of formula smell to the trach odor now. It is so difficult to tell for sure and of course the nurses are not helping with any definitive observations despite our requests for their trained knowledge. Hopefully the gram stain will be negative and this is nothing serious, along with the restarting of the Atrovent maybe we can get this back in control.