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Good morning, everyone. Welcome to tonight's webinar. We're gonna be covering some venous and arterial gasses and a bit of N IV. Um But just before we start the session and I go into a bit more detail, we've actually got Dan here from the BMA. He's just gonna be chatting to some of you aimed mostly at ones. Um Just a little bit about the recent um pay deal and a bit of information on that. So I will hand over to Dan and then in a few minutes time, I'll just introduce today's session. Thanks. Yeah, I'll just share my screen super quick. There you go. Right. Um Yeah, I'll be, I'll be really quick so you can get on the session. Um Hopefully everybody watching is, is a member. Um If you're not first things first, if you join using this specific link, you'll get your first time free. So that's not something that we usually do, not something that's online or anything. So make the most, that sort of a mind the bleep special. Um It's going to be pretty useful once again, obviously with the pay your pay this month, hopefully everything's as it should be. Um, so I was trying to find my, there you go. Cool. So, yeah, a little bit about the BMA, I'm sure everyone knows what the BMA is. Um, I'm down, I work for the BMA so I've been on the BMA eight or nine years now. Um, and I work sort of the membership side of things and also, um, helping out with sort of, um, careers in, in London. So I'm London based. Um, so what the BMA, um, essentially your union, sometimes we get a bit of confusion, er, around sort of BMA MDU. What aren't they the same thing? So those companies like MDU mps are obviously indemnity. So if you, if you have an issue uh clinically, so if you cut a patient's arm, you go to them, um, anything sort of nonclinical around your pain and just, er, rotors and contracts and whatnot. You come, you can to us, um, three ways of looking at what we do, um, helping you individually locally and nationally. So, individually, again, there's something that's specific to you, there's something that's going on with you. You can come to us locally if you're say a group of F ones that are having the same issue with roads or whatever, we have people on the ground every trust across the UK and we can help and then obviously on a national basis, things like the pay restoration campaign where, where we're helping entire groups out, um, as part of membership, you get full access to all of our tools. So there's lots to go for, I won't go for all of them, but BMA and uh and its archives. So we've got one of the biggest medical going um and everything's available sort of online. So we don't post, post, things are necessary anymore as we used to do. Um You should be getting, if your final year or, or F one you should be getting um the B MJ through the post every, every week. Um British medical journal. So if, and if you like to turn off, we can also get that turned off as well, cos you can access them online. Um We run a series of webinars as well ourselves. Um and lots of courses that you can sort of watch back so you can watch the main time. There's just a few of the proper topics for F ones on there. Um We've got a really good specialty explorer tool. So it's essentially like online psychometric tests. It takes about 20 minutes to completely ask all sorts of work life balance questions then breaks down what specialties would suit you according to the answers you've given. So it's worth having to go on that if you've not done it. Yeah. So this is the kind of, this is the kind of questions that you can get used to sort of coming to us with. It's not just obviously the pay restoration campaign that we're here for, um, we're here to help you do your day to day stuff. I know that sometimes speaking to hr and sort of getting answers on certain things can be like getting blood from a stone. So, so we are there as well and like I said, we've got people on the ground um, at every trust. So we've got employment advisors. Um, we've got industrial relations officers as well. So, so we've got people that can get answers for you. Um A lot of what we do is obviously recovering pay. So uh overpayments a thing, but underpayment's a massive thing as well. Um So yeah, the last 14 years we've got back 18.4 million lbs and we'll see, we'll see what happens in the next coming weeks um with your pay, but hopefully everyone's getting paid what they should be getting. Um But yeah, we envisage there being some, some issues. So we'll, we'll get to that. Um Yeah, lots more that the BMA does. Um If you remember, you would already be getting emails about this, but if you're not um taking advantage of that, that first month, especially around what we're going to talk about next. Um So obviously the the pay dispute um is accepted in September. Um Everybody will be getting their back pay although they should be getting their back pay um in November's pay packet. Um So yeah, we're just hoping that it's all done as f one, it should be less complicated because you should have only been at the one trust. Um, I met a doctor on Friday who'd been at five trusts since, since the, since 2023 April. So, so that's a lot to, to sort of chase up if, if it doesn't come through. Um, so yeah, so it'll be paid, paid in November. Um, and if there's any issues with it just get in touch with us. So all the more reason to be a member, um, this is, so I've got some figures here, but they are, they are sort of, um, averages and they don't include, um, um, pay up lists and stuff like weekends and, and, and um, London waiting and that kind of thing. So, so sort of the basic pay, um, you can see has increased, um, um, effectively 9.6% from, from where it was, um, back in 2022 2023. So as an f one sort of basic starting salary 2022 2023 it was 29,384. Um But with obviously the, the pay restoration campaign, normal work that the BMA and members have done. Um, that's up to 36,616. So great result, that's an uplift of 24.6 6 1% overall. Um And you'll effectively see an increase from November going forwards of 9.6 of that, of that. Um, 24.61 if that makes sense. So you've got, you've got about 14 of that already built into what you're getting, but you'll be getting 9.6% increase from November going forwards anyway, plus the back pay. So, I hope that makes sense. So you're sort of on the 32,000 figure at the moment. Uh Yeah, I think, II think I've explained that. Well, um so yeah, like I said, this is, this is the basic pay only figure, but you should be as an F one getting this back pay in November. So you should see a figure of around 1400 pre tax, obviously pretax on your pay packet. And again, this is basic pay only so well, most likely will be off, but this is the most basic it can be. So, yeah, nice little chunk of pay before, before Christmas, obviously, more payer going forwards 10% more next steps. Um It's no secret that this is sort of a bank and build strategy. Um The the ticket lines were getting less and less um attended. There was a bit of a drop off on the mandate voting. So we took this offer, we recommend that everyone take this offer and then we'll see in April what the next pay award is and if it's not in line with pay restoration, um then we will most likely ballot um again and then that will obviously be further strikes again if, if the, if the ballot goes through. So, yeah, so we're sort of a midpoint where we've got an incredible results so far, but it's not as far as we're concerned, there's, there's more to do and we want to raise pay for, for doctors, um, more, more so. So we'll see, we'll see what the next pay order is. Ok. I won't talk any more. Um, But yeah, if you're not a member, be a member, if there's any issues with your pay this month, um get in touch with us, obviously get in touch with the trust first. Um But yeah, but any issues you can come to us and we'll help. Thank you. I try to be as quick as possible. Uh And I take a hand back to a bit now. Yes. Thank you so much, Dan, definitely recommend joining the BMA. Um And I found the career tool very helpful. So we'll just move on to the talk. So that's my last slide. We'll just go back to the beginning. So, hi, everyone. If you've been to previous um talks with this series, you might recognize me. I'm viv, I'm part of the mind, the Bleak F One team. So we're responsible for all of the f one specific events, including this webinar series called Hello at CF one. We're basically trying to help support you with your own calls and we're trying to do sessions that you've requested. So at the end, when we send you a feedback form, if there's anything you think would be helpful to do, then please let us know um we have Mark joining today and one of the things from last week's respiratory session was that N IV was an area people feel nervous about. So he's changed sort of the plan for the day to help accommodate that. Um We generally on Tuesdays 7 to 8. Obviously, today, we're on a Monday, which is the exception aimed at F ones, but we're very happy to have medical students here as well. So welcome. Um Very quick disclaimers. The full list of disclaimers is on the website, but in essence, all of this content that we produce is only intended to be viewed by healthcare professionals. Um Any case used is anonymized. Um And we try our best to make sure the content is fully accurate, but there may be some inaccuracies inadvertently. Um If you are watching live and you notice anything, just put it in the chat or if you're watching a recording of this talk, um just let us know so that we can try and modify it. Um So next week we've got um a session on tackling wellbeing that will be back to a Tuesday time and date. Um And that will be with Jordy. Um And that should be quite a good session covering sort of ways of managing and looking after yourself whilst on busy phone calls. So I will hand over to the last thing I'll say is the website is a great place to go for any resources. We've got lots of f one specific articles, but also across the board um for different specialties. Um And if you follow us on med, which is on the far, right, um You, that way you'll see all of our upcoming talks and you can decide which ones you want to go to. So I'll hand over to Mark um who is a respiratory consultant and acute medic in the day, but also a key and coder um part of many initiatives to try and improve health care through the use of technology. Um He's got lots and lots of interesting things going on at the moment, but today he's gonna be covering his sort of daytime job of respiratory medicine for us. Um So I'm gonna hand over to him. This session will be pretty interactive. So keep using the chat. Um And we'll get go. Thank you so much. Thank you Daniel as well. And I was curious to see on the list of specialties, you know, is there a digital one as well? There isn't a training program in digital medicine, but that is my other hats. Uh So on a question of codes, I can build um apps like your E Pr. So those are a little bit harder than the sort of things I build. And then there's my respiratory hat as well. Um So I'm the director for let's do Digital, which is a place where we do education, encoding and clinical informatics, which is health care informatics, digital health or whatever you want to call it. But today I'm here to talk about respiratory. But if you've got questions about either, I'm more than happy to answer any of them. So, um this is a talk that I've given to I NT doctors before and I was asked to talk about ABG S. But I've also got a, an IV talk that I do for Juniors on the respiratory ward and I'm gonna try and squeeze that in the end. It depends how things go, but let's kick off. So uh overview, I've always got one of these lines in there, but I don't spend much time on there. Um So ABG you've probably done it on mannequins, haven't you? How to, you know, find the arterial pulse and then with your two fingers, feel the pulse. Um and then put your needle and so on, but let's talk you through it. Um How you're going to do it on the wards. There's many different ways to do it. Actually, it depends if you like, you know, you've got an unwell patient in front of you, uh who needs to have a blood gas for, you know, respiratory distress or metabolic distress. Um But also we do it a lot in outpatients who respiratory, see how people have controlled their sort of respiratory failure and stuff like that. So, what you need to do, I should have actually numbered these bullets. What you need to do is record the two which is basically the oxygen that you're breathing in. And if they are not on any extra oxygen, they are on 21% oxygen. That's how much oxygen there is in the air. Unless you're burning a fire nearby or someone has let a nitrogen cylinder loose and it's filling the air with nitrogen. Normally there is 21% oxygen in the air at sea level. But of course, if you are flying, that can drop down to 15%. So it's interesting to know the patient has compromised that actually your oxygen levels drop. But anyway, II can go off at tangent when you're, um, seeing a patient on the ward. You know, you're on call running around in the evening night, weekend or whatever, 21% is your, normally your F IO two. But if your patients on some oxygen do note that down because that, um, uh, in, er, changes how you look at the actual ABG results, you need a heparinized needle that stops the blood clotting. So some heparin in the needle, um, or actually in these capillary tubes, it stops the, the blood from, um, coagulating because if you've got clotted blood, the ABG machines don't like it and they don't work very well. Uh, and you shouldn't analyze it as quickly as you can because the oxygen that you take out of the body starts sucking up. Oxygen actually cos it's around oxygen. Um, and, you know, they, they say you can put it on ice. I've never done this to myself, but you can put it on ice and then, you know, delay how quickly you do it. But as quickly as you've got the arterial blood gas, uh, go off and, and test it. And interestingly you can actually, um, do blood gas analysis on more than just blood. Um, we do it in um, for pleural fluids to find out if it's acidic because a phys acidic, that normally means there's an infection going on. So you can use your ABG machines for different things. Um, so normally you take it from the uh radio artery. Uh, you can do it from the femoral artery or any artery really, especially with an it. And you've got, uh, you know, uh different arterial lines in, er, and then you take it off to your machine. Uh, and then there's the arterialized capillary sample. So this is normally in the capillary tube and you go to your, your, uh earlobe, you put a lancet on there, get a bit of blood to come out and you can put it into these tubes and because of pilary reaction, it sucks into the tube. We do this a lot for pediatrics when we're taking blood samples for neonatal jaundice. Um We use these tubes a lot and they put little um magnet inside to keep the blood moving. So it doesn't actually clot. Um Now you can also um what we call arterial, the blood coming out of like the capillary blood from an ear by rubbing the ear loads. Or you can put on deep heat and things like that to actually um make there be more arterial blood in the sort of mixed blood mixed in terms of um venous and arterial blood to come out. That's a lot and just taking the blood. But it's quite important stuff to think about because if you're going to get good results, you need to have good stuff going into the machine. Now, normal ranges. II never remember these really. Um I always have to look them up and they print out on the ABG machines and print outs normally. But, you know, if you can remember these great, if you got one of those um memories that can sort of memorize numbers like this or, you know, a picture memory and stuff like that. Fantastic. But you know, your PH range is 7.35 to 7.45 P AC two. So that's your partial pressure of carbon dioxide 4.6 to 5.9 um APA two. So that's your partial pressure and partial pressures of all the air, um different gasses in the air. How much of that pressure is this one gas, this is how we look at it. And so for oxygen, it should be more than 1210 in the elderly, you can get away with seven, which is around 87%. But of course, if you're giving the patient more oxygen that pa two should be higher. So if they are on 100% oxygen by a non re breva or something, which is never really 100% very close to and their pa two is 12, which technically is normal 15. But because they are on the oxygen, that's really abnormal because it should be so much higher. Uh bicarbonate. That's your sort of looking at your um metabolic side of things. Is there compensation or respiratory problems or is there a metabolic cause for um actually your um acidosis? So an acidic state uh with a low Ph or with uh you know, vice versa for the alkalosis and base excess is just looking at how much of um the uh um the sort of metabolic parts of the ABG are away from a normal range. Um So a bit of a mess, but we don't have to dwell on this too much. But Ph technically stands for the minus log of the concentration of hydrogen atoms floating in your blood. So if the way to think about this, if there is more hydrogen atoms floating around in the blood as in more acidic, your ph is lower because of the minus log. So it's more hydrogen means a lower PH. Just that's how it works. That's how you remember it. So, if you're, if you're getting a low O PH, there's more um acid around and there's more something causing there to be more acid. Um and something's making more acid and then, you know, that's how I look at it. Um Yeah. And ph of less than 7.35 acidic acidosis, uh more than 7.45 is alkalosis. So, acidosis, alkalosis. Uh No, when you look at your AVG, there's normally there's a respiratory component to it. So the breathing side you are moving of airs, whatever those gasses are in and out, there's different airs that you breathe. And then there's also the metabolic side which is, you know, everything else going on in your body, you know, liver, kidneys, heart and all that sort of stuff, moving blood around and so on. Uh now carbon dioxide uh makes your wa any water, it dissolves in acidic. So your Coca Cola, you know, your fizzy drinks got Carmo in there to make it fizzy, it makes it acidic, hence it wears your teeth. Um and it associates that means um the hydro atom moves from one element uh car to car uh carbon di uh uh carbonate as well. Now looking at the P CO2. So the partial pressure, carbon dioxide, this is the way we start looking at what's causing your respiratory problems and are coming to the different types. If your partial pressure of CO2 is more than six, that means you're under ventilating and reasons for this is sedation, neuromuscular compromise and so on. And that makes things acidic because more carbon dioxide, like I mentioned just earlier, dissolves in water and makes things more acidic. So if you are not getting rid of carbon dioxide, your body gets acidic and the reverse is true as well. So if your partial pressure of CO2 is less than 4.5 that means you're under uh sorry, over ventilating. Uh so it could be type one respiratory failure or breathing really quickly. You can't get oxygen in and out um of your body very well. You can breathe it in and out very well, but you can get into your body through the lung tissues into the bloodstream very well. But carbon dioxide um moves much easier than oxygen. So you can just blow it all off. Uh And you can also have k mouth's breathing um which would do with diabetes and so on now. So lower CO2 makes alkaline conditions. And also it's part of conversation for metabolic acidosis, Kao's breathing. Now, we've done step 12 and three of how you are looking at the abgs. Now, there is a metabolic component. We look at the respiratory, let's look at the metabolic component. So, base excess is a measure of how much more or how much less of base there is in blood compared to normal conditions. So, base excess to be of less than minus two is a metabolic acidosis. Um as it could be a metabolic component, metabolic acidosis. So, lactic acidosis from anaerobic aspiration, so not able to breathe in oxygen, then your cells use anaerobic respiration as a lack of oxygen respiration. I know it's called respiration, but it means actually the cells are turning over and doing different chemical reactions. Um It makes lots of lactic acid when you haven't got enough option around cells. Hence, you get a la a lactic acidosis and then you've got your diabetic ketoacidosis as well. So that's your metabolic acidosis with your be is less than minus two. Now, if they're more than plus two, then it's more likely metabolic acidosis. If it's a metabolic thing causing things and this could be from vomiting or loss from kidneys and so on. Now, step four, the anion gap. Um So you can do a lot of calculation of this. Um I'm not sure how frequently people do this. Um But it's something you can do when you're unsure of what's going on with a patient. Um especially if it's a metabolic uh underlying cause. Um But um the anion gap is calculated by taking the concentration of sodium potassium minor, the concentration of chlorine and bicarbonate and a range of 6 to 18 is normal and this normally increases when there's more anions. So if there's ketones around or lactic acid around or phosphate and a normal anion gap, metabolic acid doses. And you might not remember all these things. You can look them up, make sure you have your cheese and onion knots of handbook around if it's in digital form or your paper form. Um And so the normal anion gap metabolic acidosis is renal tubular acidosis, um acetamide and diarrhea can cause these things. Uh Now an increased gap. Well, we've got a list there. Acute acidosis, lactic acidosis, salicylic poisoning, methanol and antifreeze. So, compensation step five. So you've got, you've taken your blood, there's some metabolic or respiratory um components causing problems or both. You can get both. Um for example, on cardiac arrest, the patient stops breathing and they haven't got blood going around. So you get both metabolic and respiratory um problems. Um But normally, let's say a patient has a rest problem. So their breathing is not working that well, let's say um they have a COPD like not able to get rid of the oxygen. Uh sorry, get rid of the carbon dioxide that well. And the body compensates because they are getting a respiratory acidosis and the body goes, I don't like things to be outside of that nice range of 7.35 to 45. I'm gonna buffer it back and buffers is basically something that takes an uh either an acidic state or um a alkalic state and brings it back to a nice range. It just brings back things to the equilibrium. So the body by the kidneys actually um make more um bicarbonate in the blood which soaks up the hyd ions that are floating around to bring the ph back to normal. It can take the body uh 24 hours for the kidneys to adapt to respiratory acidosis. Um So, if someone's acutely unwell with type two respiratory failing, I think I'll go into that. Um which means you can't get rid of carbon dioxide. And then uh so um it can take 24 hours before you to see a change. So it's actually if you see there's no compensation for respiratory failure in terms of metabolic components, you know, it's a very acute thing. You know, if someone's had time to respiratory failure for a long time, you can see that they've got raised by comic for a long time as well. And so, yeah, 24 hour window, you can see if it's acute or subacute or, or not sort of more chronic. Uh Yes, respiratory failure. Um Now, the way I like to look at this as a pneumonic is um type one has one with, has a problem with one gas and type two has a proper two gasses. It's easy as that. Uh Now let's go into a bit more detail, but that's how I remember it. So type one, there's probably one gas, type two and there's probably two gasses, type one hypoxia. Uh So there's a failure of the lung parenchyma to actually get um oxygen into the body from the air. Carbon dioxide is 20 times more soluble in tissue and fluids and water and so on than oxygen. So, it's less affected by problems between the air in the Aveo and the tissue in between. And the blood supply can move very easily through walls, shall we say between air and blood 20 times faster actually. So you can have, you know, fibrotic lung disease and it gets through fairly easily oxygen coming the other way from air into blood that is 20 times less efficient. So it's, you know, that's the reason why it's more affected by problems in that barrier, shall we say between air and blood? Now, in type two, respiratory failure, two gas are problematic. You've got low oxygen and high um carbon dioxide. So, hypoxia and hypercapnia with either compensation or decompensation or respiratory failure. So it's a failure of ventilation. So another way to look at this is type one, probably one gas, which is oxygen. That's a problem of the tissue between the air and the blood and the type two, it's difficulty. There's two gasses that are problematic, low oxygen, high carbon dioxide and it's a problem of your body to move air in and out because of respiratory compromise, you know, muscular fatigue or muscular dystrophy or any sort of MS or anything that makes you weaker you know, sedation, you're just not breathing that well, it's, the muscles around the lungs are not doing their job properly, whether it's because of, you know, a neuromuscular problem, the sedation or other things related to that. Uh, how are we doing for time? Uh, ok, at the moment, um, I put this in here for sort of an fyi don't memorize this but, uh, respiratory failure, your, your, um, hb dissociation curve, you probably remember this from your textbooks or studying it. Now, if you're doing uh finals or anything like that at med school and in severe pneumonia, you've got a dissociation curve that moves to the right because of the increase in acid um, acidosis and temperature. Um, and this leads to lower saturation of hemoglobin. So, if you've got, let's say terrible pneumonia, you're not moving air that well, in and out, you've got some lactic acid doses going on as well because you're just not breathing that well. And then that makes it even harder to get oxygen around the body. So, you know, it's just a vicious circle. Um It's just something to be aware of that, you know, um, if somebody isn't acidotic, they're not gonna, and they've got a high temperature, they're not gonna have as much oxygen bound to the hemoglobin, which is going around the body as well. Now, the a, a gradient, uh to be honest, I've only used this a few times. Um, but, but the nerds out there, it's probably useful to know and I do go through it in with one of the um um cases. Um But it's the alveoli arterial gradient and it can help determine the cause hypoxia because if it's abnormal, it points towards what might be the cause, especially if you haven't done a scan or something special, which I won't go into detail because that give the game away. Um So it measures how efficient uh how efficiently you mix the venous blood. Uh was equilibrate with the alveolar gas? That sounds a bit long winded. But it's basically how well is oxygen going from the air uh into the blood? It's, it's all about seeing how efficient things are. Uh And moving in terms of the um the gasses, the equation is as their AA two gradient is uh concentration of F two times atmospheric pressure minus h2o pressure minus pa two divided by 0.8 minus pa two. Now, you're not going to memorize that, use a medical calculator like MEDC CALC. If you want to do this, it's very simple, then just throw in the numbers. It'll tell you if these things are abnormal or not. Uh 1 to 2 kg pascal as a result is normal in young and 2 to 3 is normal in the elderly. Uh And if it's normal, it could just be hypoventilation. So you're not breathing that well because you're just, you know, it's, it's some sort of muscular thing. But if it's raised, it can point towards something that's blocking air getting to, uh, parts of the lung, uh, and mixing with the blood. So, if there's, uh, pneumonia that's got consolidation, if there's pee, there's a clot to start stopping blood getting too that long, but it's stopping basically oxygen getting to blood. There's something stopping that, uh, process, uh, and also right to left cardiac shunts can do the same. So, um case one, if you want to start throwing down questions or if you want to start throwing down answers even to these cases or questions about anything I've said, please do and I'll try and answer them as we go along. Uh But let's talk through case one. So your call to see a 54 year old lady who is on air. Sorry, remember the F IO two is 21% at normal sort of height not far from the sea. Uh She is three days post uh cholest and has been complaining of shortness of breath. Now, these are her AVG results. She's got a PH of 7.49. She's got AP two of 7.5 AP CO2 of 3.9. A bicarbon 22 base excess of minus one. What do you see? And what's your differential does no one to throw anything in the chat? Let's see what you guys think and there's 76 of you. So somebody should at least try and type something. If not, I can just move on, I'll give you one minute. Oh, here we go. Ok. So asper alkalosis type two, respiratory failure. Ok. We've got a few there. Pa is uncompensated, respiratory alkalosis, right? Let's have a look. So there's mild respiratory alkalosis. Definitely that as some of you have said secondary to uh type one, not type two. If we go back um with type two, you need to have a low P two, which we have normally, it should be above 12, but you should have a high CO2. So it's only a type one. Uh Now I put the a, a grade uh tested on here and it was raised. Um So this was for a 54 year old lady. So uh anything above three is abnormal and it was 7.5 which P ei think Laura you put in pe so fantastic, well done there. Um High five to yourself. Let's go onto a case two. So slightly different demographics. A 75 year old gentleman C two is being assessed for home oxygen. He has no peripheral edema uh polycythemia or pulmonary hypertension. Now, the reason that he put in that last sentence because the BT S guidelines on home oxygen look at those kind of symptoms. Now, his uh ABG shows a PH of 7.36 A po two of 7.3. And if you know the answer or I think you know the answer to start typing. Now, a PCO two of 7.6 A bicarb that's 31 and a base excess of plus five. What do you see? And what is it differential? Now this time I'm going to talk through them. So the PH is not bad. Actually, the two is a little bit low for my liking. That's probably going to be around 85 88% on the saturations machine. The PCO two, anything above six, I start saying that's not good. So actually this looks like type two which you see a lot with um uh emphysema patients. So COPD chronic obstructive Pulmonary disease. Uh Yeah, here's some answers. Now. Um We've got a bicarb that is raised and a base excess that's raised. Um oh I think Edmund had it and uh yes. Oh yeah, you guys are getting it. Yeah. Yeah. Well done everyone. So compensatory um acidosis. Um I presume you guys can't spell fraud through the slide if and if you can't fantastic that you got the results. So, LT um long term option therapy, you might hear the term SBO as well. Short burst option therapy. There's lots of um abbreviations out there, but it's basically, are you giving oxygen a lot or a little? And LTO is basically 15 hours or more a day of the patient being on oxygen. And if they have a PO two, that's less than 7.3 they need LT. But if it's less than 0.8 and they have signs of peripheral edema polycythemia upon me hypertension. They should be on LTO as well and this is the BTS guidance on their uh if you ever need to get it in a hurry. Um Normally around a respiratory register or consultant when you start thinking about this, but it does happen in actually quite a lot of hospitals thinking about it um where you're being asked to make a LTOT assessment look at or just type into Google or any search engine use, you know, BTS LTO. And I think that should get you straight to this um guideline on how to assess. And also, you know, should you prescribe op for a patient, an s short or burst oxygen therapy is basically for patients that get short of breath and or have desaturations when they mobilize, when they walk around and they just have oxygen on while they're walking around. And you can get little canisters that they wheel around. They carry or sometimes concentrators which are little machines that just take oxygen out of there and they squeeze it out of the air and give it to them by a nasal cannula. That's a, a slightly higher I two than normal air around them, right? Case three. this is a 64 year old gentleman with a history of COPD presents with worsening shortness of breath and increased sputum production and you know, start writing your answers as you think you've got them. Don't worry if you get them wrong as we're all here to learn. He is on air initially. So his ph is 7.21. 0, that's a little bit low, isn't it? His PO two is 7.2. That's a little bit low. His CO2 is a bit high 8.5. His bicarb uh it's a di a bit high and his base access is um plus four. What do you see Harris? That sounds like a good one type to Respi failure and needs N IV. Let's just go with that. Cos actually, I wanna get onto the M IV talk as well. Yeah. Uh So case three, acute on chronic respiratory acidosis. So why is it acute on chronic? So, um chronic because the bicarb is compensating but still the there's acidosis. So he's, this gentleman has had chronic type two respiratory failure and his body is compensated for it, but he's not able to get rid of the CO2 that well. And then he's become more and well and he's got more CO2 and his body hasn't had time to, you know, uh acclimatize, you know, make more bicarbonate. It takes 24 hours, doesn't it? So it's an acute on chronic situation. Uh It's time to re failure is a, a grade, it was 2.2 and diagnosis. In fact, of COPD, right case four. No, this is 21 year old woman presents feeling acutely lightheaded and short of breath. She has her final university exams next week. Oh, God, this could be one of you guys, couldn't it? Um, but it's no, you're not. Where near um, final exams are you? But anyway, she's persistently tachycardic. 100 and 20. Her PH is 7.48. Her po two is 12.1. Her PC two is 3.5 of rar but 22 and the base excess is plus two. What do you see what is differential? Anyone uncompensated respiratory alkalosis, resp alkalosis, hyperventilation, hyperventilation. So, yeah, it, so you're thinking hyperventilation because they're anxious because of the exams and you know, it's a differential. But if I said this lady was on the pill, would that change your diagnosis? Potential diagnosis? Let's just see if anyone picks up on that. Yeah, exactly Michael and Harris. So she's got mild respiratory alkalosis. So her um PH is raised and that's because the CO2 is low. So she's blowing off the carbon dioxide which means she has less carbon dioxide in her blood, which means she has less hydrogen acid in her blood. And if you've got less acid, you're more alcon or alkaline. So she's got Respi um alkalosis. The AA gradient is a little bit raised and she has a diagnosis of pe let's look at her ECG and this is not her ECG, but this is what you would get in a textbook with the S one, Q three T three. So in the, um the first lead, the lead one, you would have S waves in your QRS complex, you would have Q waves and sorry, Q waves in the third lead and you would have inverted T waves in the three. You rarely see it. I've seen it once. I think most of the time you see tachycardia now, a tachycardia of 120 is a little bit too fast for someone that is anxious. Um It implies there's something else going on. Of course, you could have SVT or something else that's causing that and look at the ECG. Of course, for those sort of things. Always anyone has got a pulse rate of over 90 that's mildly concerned about getting ECG and repeat the ECG. Is you think something is still going on that you think is cardiac or something around the heart or the major arteries? I can never go wrong with an ECG and AVG uh honestly, right. Um Any questions I'm going to load up the next sets of slides while um I'm just waiting for anyone to uh ask a question, I'll try and answer it. So let me just stop that. It takes about 30 seconds to load the slides on the system, but otherwise they work quite well. No questions. If not. Don't worry if you do have some, just throw them in the chat while I'm talking about the next bit. And I can talk through them anyway. Hm. How do you interpret PO two? Depending on what percent two they are on. Uh, there's little, um, er, calculation for that, which I've forgotten. But, um, you basically, the more oxygen they're, they, they're on, the more their po two should be. Now I'll have to look it up myself because I don't really bother thinking about it. But if, if it's a lot lower, the PO two, the um uh pa O2 is the oxygen in the bloods, then the, that they're on definitely less. If it's less than 12, then I'm starting to worry. Good question. Um Now let's get on to Niv. So uh what are we like at time? Uh 941 right? So N IV. So let's say for example, that patient who had that acute on uh chronic uh resp type two, respiratory uh acidosis. Um Now they might need some N IV. So let's talk about that. So there are different types of NIV. So NIV stands for non invasive ventilation and it provides pressure and volume of air. So pressure of air and volume of air support. Now, there's common commercial names, there's Bipap and Nippy, but at the end of the day, it's just a machine that moves air in and out. Um Now you can also use um ab machines, adaptive server ventilation for chain breathing that you can get with um cardiac failure. Don't worry about too much about the names here and the fine detail because this is meant for doctors on the surgery wards that need to load this a lot more detail. And there's also CPAP, which I probably a lot of you heard about um, during the COVID pandemic because it's a very useful treatment for COVID pneumonitis. And in Italy, they didn't have the mask, they had these plastic helmets, which you can see on that bottom picture there. Where in the UK, we had the full face mask which you can see on a little gentle on the top there. So it's all about pressures and volumes, but mainly about pressures. This is all you need to think about. If you need to look at a machine, adjust a machine set up. Normally you don't need to set up a machine that will be done by a respiratory registrar consultant or med reg on call. But you know, you'll learn about these things eventually and also useful to know if you are looking at the machine, if it's maybe not working that well or something is not set, right? And you can then raise it to the seniors because you might be asked to look at a patient that is on NIV. I don't think you'd be asked to start on NIV, but definitely unless there's lots of things going around the hospital and me just needs you to and they'll talk the cure, but you might be asked to look at a machine and sort of assess it and see if it's working well. Normally patients are niv on acute medical wards or respiratory wards, but it's not always the case across the country. So, who knows, you might unfortunately come across this and have to, you know, manage it. Um, anyway, there's two pressures you need to think about. There's pressures when you're breathing in and those pressures when you're breathing out two pressures. And so you have your inspiratory pressure, that's a higher pressure. It's blowing air in to get air into your lungs. It's opening up your airways and filling up with air. And when you finish with your breath, there's the expiratory pressure as well. So it's a much lower pressure. So you don't have to breathe against that. Otherwise you can't breathe out. So you got your I PAP and your EPAP and the difference between the two pressures is your pressure support and that's the pressure that's helping you move air in and out. Now you use it in CO PD. Don't worry about the hot and IV, but that's for CO PD patients um who have type two respiratory failure. Um There's sleep apnea syndrome. So OSAHS, you can use CPAP. Um But if that's not working, you go into N IV. So CPAP is basically, if you go back a slide CPAP is just your EPAP, your expiratory positive pressure, that bottom line flat all the time. It's basically keeping your, so sleep apnea syndrome. Is an upper airway problem where basically your tongue falls into your airways, lots of other things to do. Basically, most of the time it's your tongue falls into your airways or your airways collapse and that some, for some other reason and what you're doing is putting a slight bit of pressure, your or your EPAP, your expiratory pressure. Normally five, but it can be much higher to keep the upper airway open and then your chest is able to move the air in and out uh with that upper airway being open. So CPAP is very good for uh sleep apnea syndrome, which is the problem with your airways closing off in your sleep. But if that doesn't work, you can go on to N IV. Uh there, there are overlap um syndromes, uh COPD and sleep apnea syndrome. Uh or even obesity hyperventilation syndrome is you're basically so overweight that the weight on your chest is stopping, you able to breathe against it in your sleep. So it's like someone just sitting on your chest and you can't breathe in your sleep. And of course, you know, you're, you're, you're not um as shall we say as strong in your sleep, you're not trying to breathe as hard in your sleep, you're going into sort of cycle rhythm of sleeping and much a more shadow sleep. So, of course, if your breathing is not that good to start with and you fall asleep, but there's a problem with the breathing because of all the weight, you are gonna struggle breathing at night. So something called obesity hyperventilation syndrome. Uh and like I mentioned before, in your muscular weakness, now there's lots of contraindications, ask her for any med reg or respiratory or consultant. But cardiac or respiratory arrest don't go on to an IV impaired consciousness or confusion, severe hypoxemia, copious respiratory secretions, hemodynamic instability, facial surgery, trauma, burns or deformity, upper area, obstruction, undrained pneumothorax. Because if you know, if you have a pneumothorax, let's say on one side, you can, well, actually, but normally one side and you put CPAP on or NIV on, you're blowing air into the lungs, which can then blow air. If there's a hole in the lung, for example, that's causing your Frax, you're going to blow air into that potential space around the lung and fill up the air around the lung, sorry, fill up the area around the lung with air and that squishes the lung and the lung. It's about that big when it's squished down, it's just expanded in the chest because of the vacuum that is around it. So, you know, get a chest X ray before you do uh an IV. Uh Just to make sure you haven't got pneumo for, I was almost caught out by that once as an F one. Uh Luckily I got a chest X ray before the um my colleague um started it uh the uh N IV uh the patient having inability to co uh cooperate or to protect their airway or if they're vomiting, this has happened before. Don't really put them on a IV because they're just gonna, you know, it's gonna go into their mask and then, which is horrible on itself and then they can, you know, aspirate that back and we don't want any of that and look out for recent upper gi surgery because you don't want to blow apart the aosis and also esophageal injury. So use the CPAP, um you can use it for acute cardiogenic edema. So, you know, you've got maybe a recent heart attack. Your heart is not pumping, left side is not pumping that well. It's basically leaving fluid in the lungs is how I like to think about it. And so you can actually use CPAP to, well, a lot of people think it's blow the air, sorry the water out of the lungs, but it's not, it's actually you're increasing your lung in terms of air space and um enabling more blood vessels to open up and then that helps circulate blood around, uh helps to offload the blood around the heart as well. And so actually, it's just to do with expanding the lungs, allows blood to flow easier that gets rid of the fluid rather than blowing fluid out of the lungs. So CPAP is also used for sleep apnea syndrome. BC Hyper Ventilation syndrome, like I said, COVID and PCP. Pneumonitis. So watch out for your in io compromised patients now, uh using an IV in acute infected exacerbation or exacerbation of COPD. So this is quite a common thing um for respiratory patients. Um and I think you see a lot of these on the acute take. Um of course, we see them a lot in respiratory, but of course you're sending them that way. It's a buy sample. But II think a lot come through the door who has respiratory problems will be COPD patients. Hopefully this will get less, less people smoking. But at the moment, it's quite a big problem. Can you explain that again, please? How does expanding the lungs affect the blood vessels? So it's called recruitment. That was the word I was trying to look for. Uh you're recruiting more lung, which is recruiting more blood vessels. So basically, let's say um your lung is, this is how I like to think of things. Lung is squashed. So blood can't get around as easily. If you inflate it more with more air, it's recruiting more uh lung space. So air space and also blood vessels in the upper uh parts of the lung. And when you do that blood can flow easily, uh which helps with the heart pumping as well, which helps get rid of the fluid in the lungs. Uh A lot of people like to think of it, you're blowing air to push the water out. But actually, it's just recruitment of blood vessels. Um Now we most, where was I? Um Oh, yes. Um So you're seeing a patient in on acute take. Um Now what you do when you see a patient that has a, you know, b or history of COPD smoker for many years, um maybe on, you know, strongest inhaler ZB trim Trelegy or something like that. They've had a few zanger patients with steroids and antibiotics from their emergency packs at home with the GP. And um they've come in on, well, you do ABG it looks like, you know, respiratory acidosis type one, type two, most likely. Um they've got low oxygen saturation that needs and remember most patients with COPD, they sort of um they don't use the oxygen levels to help them breathe, they use a carbon dioxide level. So a raised carbon dioxide level to actually stimulate them. So don't over oxygenate your patient because then that can actually comatose them. So don't do that. Give their saturation between 88 and 92%. Very important. Your CS consultants going around turn that oxygen down too much. Oxygen is a bad thing actually many reasons, but for COPD patients because it can comatose them. Um But anyway, you've got a patient in front of you, they got some respiratory compromise, do some medical things first to help them. So they've got COPD, give them some steroids and that takes a few hours to kick in anyway. But, you know, 30 mg pred, but get that into them quicker and then give them some nebulized salbutamol. You can give them some nebulized ium, um, give them some oxygen but saturations of 8892 and call your friendly through to your registrar consultant and say there's this unwell patient here, get that good history. See what their comorbidity is like. Do you think they'll do well with NIV, because a lot of patients don't like NIV? Um the whole thing on their face also, if they are really frail, you know, they've got loads of comorbidities. Will they actually recover from this illness? And would niv be just a horrible way to sort of die? You have to think about that as well. So not all patients are appropriate for NIV most, but just, just remember sometimes they're not. Um now if respiratory um compromise has not helped with one hour of medical treatment, um then get your respiratory consultant. Uh definitely involved again, uh consider for patients that should be invasive ventilation and use discussion of it and they use with the it early to discuss, especially if there is a sort of younger patient with really just a single organ problem like COPD. But the rest, you know, less coord a bit younger, it's sort of, there's a lot of juggle here. I appreciate that. But these are important things to sort of assess. Uh we most commonly use a full face mask because there's lots of different masks you can use as uh especially a CPAP. You can have just a nasal one, a nasal bridge, a nasal mask, uh like in Italy, they had that big dome and at least, well, the trust I work, they have a full face masks over the sort of forehead around the chin, allow the patient to hold the mask against their face. They should be conscious, be able to take commands and so on. If they are not, then you're thinking, oh, this is much worse than they shouldn't be for niv, probably there should be more for it for discussions, but they should be able to hold the mask on their face, get used to it. It's a really weird thing to hold on to have on your face to breathe with and some people struggle to synchronize with the machines, but they need to be our confidence and then tightness straps, but not too tight. Like I said, you probably won't be involved with setting these patients up. But you know, you might want to with a, a med reg um respiratory reg um watching over your shoulder. So, you know, you've got a bit more knowledge, knowledge is power and all that sort of trying these things out and setting patients up. Um Now there's a lot of details here. Uh I'm gonna try and pick out, pick out the bits that you really need to know about because most of the time you'll have a uh well trained nurse, uh either an acute take uh or respiratory helping out with these things. But I like to start with pressures uh of four of EPAP that's expiratory pressure and 16 of inspiratory pressure. Now, forget about the ratios. Forget about the back up bits because you know the story about those bits, the most machines are set up to. Um you can even, but I think there's even a COPD setting or sleep apnea snd settings on some machines now. And there is in the Philips. So you can just take the right thing. But you start on a low pressure is what I'm trying to say, 4/16 and then increase the upper number of the 16. The inspire your pressure slowly to get the patient used to it. And you want to get that pressure up to about 20 or 24 the higher the better. But of course, the more the pressure you're up, the more there's a difference in pressure and the more the patient might not be comfortable with it. And if the patient is not enjoying it and gets really agitated with it, then you fail it, getting in to use it. It's really about them getting as comfortable as possible with as high as high pressure as possible. And it's a trade off. It really is a lot of the times I've seen patients that just can't do it and you know, make the best supportive care and so on. So it's, it's, it's a joggling act, but really important. Now there's no need for ABG S. Now we talked a lot about ABG SS, but there's no need for ABG S. Uh, after your, your initial one, of course, when you see them, uh, um at the front door while you're, um, increasing your pressures, cos some people are like increase the pressure, doing an ABG, increase the pressure. I doing a G. No, get the patient used to it. Start on a lowish pressure for over 16, get them to hold it, start the pressure once they're happy, put the straps over the head and you know, let them breathe of it. And every 1020 something minutes increase the pressures a little bit and just try and get it up to see where and just keep an eye on them. Get up to a pressure where they look like they're still comfortable. But um now if they're really obese and you're seeing, well, we are seeing more and more of this. If they're really obese, you might want to have that lower pressure a bit higher because they might have so much fat around the neck that they need a bit of the EPAP the uh expiratory pressure to open up the airway between breasts as well. This is again, quite nuance now, I appreciate um, but make sure you've got the oxygen saturation of 80 H 92. Er, and er, if they need a bit of extra oxygen. Um So you can put it normally to the back of the CPAP machine. Uh just to keep that saturation up and the patient should be in the sniffing in the morning air position like this. And that helps open up the sort of pharyngeal resistance. Um So, using NIV in acute COPD after maximum IPAP achieved doing AVG at one hour and then four hours. So that's when you start doing AVS again. Once you've got the patient under pressure that they can tolerate and that's high enough for them and you might have to bring down the pressure again. If you are not tolerating it, some pressure is better than nothing. And wean off n happens around three days. It's interesting, the longer the build up for the patient in terms of illness and then developing worse and worsening respiratory compromise, the longer it takes for them to get off surface and they are very acute, you know, um events where, you know, let's say that you had too much oxygen at home and all comatose for a minute or two, they'll very quickly get better. But if there's a longer um build up to their admission, there's not any longer for them to get off of the N I and nocturnal NIV. So N IV at night is normally the last to been off. And that's why we do these early morning AVG after you have, they've been on um IV overnight. So you can see how much CO2 they've been retaining overnight, which you will, you, because you're asleep, you're not breathing as well. You will retain more COPD. Now, if they're not improving on N IV, get another chest X ray. Um check for oxygen delivery. Is it too high or too low or it's not plugged into the machine or it's not, you know, it's not getting to them. Uh check for leaks. The machine normally tells you there's a lot of leaks, it leaks around the mask or it leaks around the tube. There's always a little leak, that's intentional because if you think about it, the patient has to breathe in when they breathe out, where does air go. So there's a little leak valve normally around the mask or on the tubing with a bit of air coming out and the machine knows that. But if it's more, there's more leak going on than coming in, you can normally hear it when the mask sort of rattles around their face. Um Then actually it's just the, the pressure is not doing its job of helping their lungs breathe, it's just going elsewhere. Um And you can get leaks at the thing with the masks are too tight, so it's like a perfect, it's like goldilocks, tightness of masks. Um You can, you can see this, it's like if you ever look at a full face mask, it looks like a Hovercraft skirt and it works the same way as well. Uh And so when you're, let's say you got, you're looking at the mask, but that way around. So you got your dome with the mask and you've got sort of, uh you got these plastic silica sleeves on the sides and when you inflate, uh when you tighten them and you inflate the mask, if the mask is too tight, the sort of skirts at the side, uh squash and then they don't do a good seal around the face. And so you've got leaking, but if they're too loose, you can just see a lot of skirts are flapping in the wind, so the air gets away. So there's this perfect tightness of the mask to get that sort of Hovercraft silica skirt to sit. And of course, people have different face shapes. So you sometimes have to have a different mask on. That's normally not a problem for the full face ones, but for different smaller masks, it is a problem. Um I check for patient eventually asynchrony. So like I said, they sometimes aren't really good with the machine if the PCO two is still high, considering the IPAP, if you can, the higher the IPAP versus the EPAP, that pulse pressure, the better your moving area and out and the better patient can get rid of the CO2 and also get oxygen in. But you are using an I normally to get rid of CO2 and then you just put extra on to get the O2 up and if not improving despite troubleshooting, then consider intubation. So that it conversation early on if you really need it hot. IV, I'm not going to go into this uh NIV in chest wall deformity and neuromuscular weakness. So you will not see this much at all in acute medicine. This is more of an outpatient thing for respiratory. But let's say you've got motor neuron disease, MS or some other sort of motor neuron problem. Then actually, niv can help. And normally, like I said, at night, your breathing is more shallow, you're not breathing as well. It's at night when your breathing is more compromised when you have these conditions. So you need quite a lot of time breathing support at night and it does help with mortality risks and so on. There's a possibility people say that NIV resets a central respiratory drive, respiratory muscle rest or improve chest wall and lung compliance. But I'm not sure anyone's shown this conclusively yet. Uh and you start uh NRA based on symptoms. Uh so morning headaches, morning headaches, especially frontal. That's your CO2 build up. It's going to give you a headache. Uh hypersomnolence really sleep in the day fatigue, poor sleep quality and so on evidence of venator failure. So daytime Ray CO2 bicarbonate uh and or nocturnal hyperventilation. So low average s overnight h sleep. So looking at oxygen and we review the patients in clinic every few months of abgs or VBG of these capillary BGS as well. Right. Oh, it's eight o'clock 01 God, I got it all there in time. Um, that was a whistle stop tour of an Ivy. And I'm sorry, if it might have been a bit too much detail. Uh, I had that last minute throw. I've been, II was asked last minute to throw that in, but I thought very appropriately. So considering you were talking about A B GSI do have a bit of time if anyone wants to ask any questions. Um But if not, I'll hand over back to viv. OK. So we've got a question from a FSR. What situation would you use? BBg over ABG? Can you interpret two levels from a G? No good question. Um So uh VBG. So taking blood from the venous side rather than uh arterial blood. Well, if you're just looking for a lactate because you think someone's got lactic acidosis um because of maybe diabetic ketoacidosis or septic abdominal sepsis, especially around surgery, you just need the lactate. Yeah, you can do ABG. Um The CO2 levels are not too dissimilar between um BG and ABG. So if you're looking at um BBg, you can interpret them, they are going to be a bit higher, of course, but you can interpret them and sort of see how things are going. If you, if you are finding it hard to do an ABG. Um but ABG very much if you think of it as r problems, I would try and do an ABG, but then you can do that sort of capillary mixed capillary um test which a lot of places do. Um And that gives you fairly accurate carbon dioxide and oxygen readings. All right. Was there any more questions? No. OK. Over to you. Thank you so much, Mark. Hopefully everyone has found that as helpful as I have even just as a refresher, um I will, will stop the recording here and I'll just release the feedback for.