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uh huh. Welcome, everybody, this is Doctor Al. You're I am Terry Sheffield's partner in anti lectures. I teach at Rutgers University and County College. Morris edit Egan's fundamentals of respiratory here into whether textbooks and I still work in the I see you at a major medical center in northern New Jersey. As a lead, therapists there want to welcome you to presentation on capnographer. See some practical applications, which will include, by the way, both some historical ones. So you know, we've been using capnographer for a long period of time, as well as some of the brand new but some of the more recent applications that have occurred over about the past decade or so. So let's take a beeper dive into some the learning objectives and title CO2, again looking. This particular presentation is really explained. Indications for measuring entitle carbon dioxide Excellent oh, are entitled See oh, to illustrate some of the equipment that's used reviews and related research to find what is normal. So in some of our presentations, we define what the normal values for things like vital signs and you know, EKGs and what a normal EKG or normal you know, heart rate value looks like likewise will examine what the normal values are as well as what a normal capnograph capnograph. So the graph means what it would actually look like. The graphical depiction define what are abnormal values, waves, and they're causes. And again, we're not gonna cover all. Then we can't. But the ones that you would most commonly see eyes what we're really focus on today identify the different way forms. And perhaps most importantly, because we're limited in what we can cover in 45 or 50 minutes, some additional resource is for those of you who are interested in drawing down more on these topics. So some of the related terminology so capnographer on the analysis of the wave form. So the way form will, you know, in large port depicted that if you will, the peak of the way for will depict what the maximum value is okay for you, not a breath of breath basis. Um, but the shape of the wave also matters. We'll talk a little bit about that as well, and some of the key abnormalities, whether it be with the patient or in some cases with the equipment that we're using to to either ventilate and or oxygenate the patient as well. Ah, cap non metric Metreon is the actual number, so often they're measured concomitantly or at the same time, not exclusively. But often we're measuring both of them. And then we have what's called color Imitrex. Color em a tree, which we, we have, for instance, in our intubation boxes at the hospital at which I work. We actually will have the color Remicade. Um, if you will a measurement tool, so it's not giving you a number. It's not giving you a wave form. It's giving you a color change. Okay, Purple versus yellow. Okay, it's not. None of this is foolproof like any of things that we go. But when you when you're basically in the trachea, you're looking for the state, you know, color change that you'll be able to actually see again. There's certain things that can affect that, But you know, there's there's other things that you will actually be able to definitively or more definitively tell by using any one of these 33 methods. The other thing I want to state, I probably mention it more than once they're in this presentation is the standard of care is basically changed with regard to using waveform uh, capnographer particularly would a, um with with a resuscitative effort in a code blue which which may will involve intubation or just intubation alone, that if you if the if the care team has access to kept nonrefillable, they're the standard of care is use it If you're in and I see you and your intubating and they have you know I can't not too many or most I see you have today use it. Don't just use the collar emmick methodology of doing it. Color is good not as reliable as cartography or cutting on a tree. So who we monitor and why this This is a theme that's kind of threaded throughout this presentation, immediately following intubation for to placement during CPR, the effectiveness of compressions in ventilation. You think of it this way, the more effective or compression or compressions are and be more effective. The ventilation, the more entitled Oh, to we're going to get even in an a systolic situation. Okay, I'll talk more about that. But the effect is affecting this is CPR really didn't use as much 20 years ago, a PSA for his. For his entitle. We didn't use it much to determine the effective CPR that something's really shifted over about the past decade and a half. Monitor mechanically ventilated patients, especially for something more traditional indication, achieve the ill, since they're the espacio weaning patients transporting patients. So really, we're looking at, you know, is a case of a transport. We're bringing the patient down the MRI pretty much the standard of care is used to say, Why do we really need to monitor the entitle? We pretty much do that in a lot of places will, and it's becoming the standard of care patients at at risk for hypoventilation. So neuromuscular patients, patients that are receiving moderate sedation what we used to call conscious sedation okay, today what we call moderate sedation. So patients that may be receiving moderate sedation for things like, um, you know, endoscopy So spontaneous breathing and oscopy patient, it is advisable to use modern TV actually use on, entitled to measurement when we're using moderate sedation for patients a little bit on the old world cycle here. So you got the final issue at the 02 going and and you have metabolism that's taken place to go to this. Being exhaled out, you know, is being actually, you know, basically produced okay, carrying the blood, pumped through the heart back to the lungs and eventually exhaled. So kind of little bit of the cycle that's actually going on and the ventilation part of which point in this cycle is it actually measured? Well, it's in between, you know, the heart, and then what's going to the lungs. And then what's really being measured is what's being exhaled. And hence the terminology and title. So, too, the collar emmick detectors, which you will have again. And you know, this is just a specific. So the one on the left, the larger one left me more for adults, and the one on the right would be shoot for younger patient population to help. To help ensure that that you know you're in the in the correct place. Breast sounds airy, useful on to determine whether or not that the tube is in the right place. But they're not. They're few more limitations than what you get with cholera. MC. When you move up the spectrum to using waveform capnometer e and kept kept nonrefillable. That's where you get your very reliable information. Some of the combo cannula. So you actually have two inputs one is actually looking at delivering option to the patient. That's the call it translucent port that you see on the left hand side. The orange port is going in the opposite direction is actually have a monitor in port. Okay, um, there are some limitations with most of these devices for adults. When you go north of about 4 to 5 leaders a minute with the with the the nasal cannula you with the oxygen flow, that is, you will do more delusion, the CEO toe. So these devices are, ah value. But they're like like any of the devices we use their of limited out, and they need to be used in conjunction with keeping those limitations in mind. Um, when you have things like, you know, the patient develops if they're hypoventilating. Okay, you think that there's so two needs to be Actually, you know you should be rising. It probably will. Okay, undoubtedly, But again, you need to be mindful. And, you know, with the individual patient, you know what's going on with that patient. If the patient has a P E, think about what's going on. So now they have a block. It's not only is oxygen less able to traverse the Abiola Kappler membrane, okay, but also the in the opposite direction. The CEO to is less able to be liberated from the blood across the Advil or capillary remembering go into the lungs and the exhaled. So while this thing, uh, data and this equipment and the data that's extracted from it is useful, it needs to be used with those limitations in mind. A newer, not new but newer indication is in CPR to assess the effectiveness of compressions Teo to determine if there's been a return of spontaneous cardiac activity on objective data, potentially not alone. But in conjunction with other data to seize the resuscitative effort, for example, let me just say this much. One example would be this. If a patient suffers a massive p a and the team has been resuscitating this patient at that, they're going to know that a massive pee, but what they know is they put in advance their way in place. Okay, It appears to be properly placed. But at the same time, the entitled to After you Know 15 2025 minutes is exceptionally low and then the other indicate indicators are also not good. The patient, perhaps, is a a systolic. At this stage of the game, the pupils are fixed and dilated know together All that that it may be used to say, This isn't gonna cease this resuscitative effort and just categorize it has happened been not successful. Some of the data on CPR. So so so some of the statin we discovered was around late eighties early nineties, so Sanders, But it was published, and Jonah, the Journal of the American Medical Association entitled Correlates with Outcomes and CPR. Really. The first was kind of a milestone piece of literature that was published 2005 study comparing field in the patient. That use kept Naeger a fee confirm entitled Placement versus not basically the ones that used it had a 0% unrecognized misplaced ET tube with almost a quarter 23% in the non entitled to monitor group. So as a respiratory educator and a clinician, you know one of things that you've indicated enough patients, whether it's done by the paramedic. That physician, the respiratory therapist. Anesthesiologist. If you if you've assisted, have done them, there's gonna be a percentage of them that initially they're not successful, but perhaps placed in the esophagus inadvertently. Um, And what you want to do is it's gonna happen. You want to recognize it quickly. You want to deflate the cuff. You want to remove that to resume ventilating and oxygen in the patient. You know, without that advanced airway making this collective decision to attempt it again, you know, are using L m a of laryngeal mascara or some other methodology. Um, and then, you know, basically look. But the standard of care is to confirm the endometriosis intubation ETI with waveform capnographer a little more on CPR survival. And I always try to steer clear of these, you know, dichotomous rules. If it's you know, if the entitle is 4 to 10 tour millimeters of mercury, it correlates with non survivors versus greater than 30. What they're saying here is again is prolonged period of time. Well, you have a very low entitled coatue okay, versus a different greater than 30. That's achieved over period time. But they're saying is basically very low, is not good in a resuscitative effort. They're survivors tend to have a some point, really on in the resuscitative effort, you're able to achieve an entitled oh two rated and 30 tour more data on CPR. So again, so that was really survivability. Wasn't looking just a CPR. This one was actually looking Mawr CP or quality. So bad. Good. You know, again, I try to steer clear and particularly this one. You actually have a level. They're less than 15 greater than 15. So what if it's 14 versus 16? Not not a big difference. They're really trying to say, though in the main in general, you're aiming for an Intel CEO to North of 15, okay? And ones that are some that are substantially below and sustained that much less than 15. The correlates with a worse outcome, Rosco, or return of a spontaneous cardiac activity where the entitled to will increase suddenly and sometimes by as much as 15 or 20. So the entitled to be hovering at like 10, 12, 14 and then also they pop up to 30 or 35 or something a seat, 40 little bit of a graphical depiction, you know, time here. So we're looking at Tour Millimeters of Mercury, but you can you can see, even though there's some Vaseline in here. Maybe that's due Teo things like pulse checks or something along those lines. But clearly you can see it at a point in time where the entitled to rises significantly. And though it's not, it's not, You know, a steady state. It's basically if you were to take the average there, it's averaging out at a much higher level than what it was before. You have that. If you will, that rapid rise there. That's what they're actually looking for. And when they're measuring cap on Ah, graffiti. And it's one of the things Not that you're going to see this particular depiction what you will see. Those is. You begin been hovering at, you know, 8, 10, 12, 14, You know, sudden over, you know, very short period of time. Over 10, 15, 20 seconds. You know, the the entitled to rice up to 30 or 35 predictive values of these again, not the same thing. You think about some of the value that may be a direct relationship between and and titles 02 level and mortality in Airbnb and A L I A l I s acute long injury. Okay, Air DS is acute respiratory distress syndrome. They're not the same thing that main differentiation is. Think of a l I as a reading a a slight. Where is the P two f ratio? Okay, is higher. It's less than 300. But for acute lung injury, it's probably somewhere north of 1. 50 to 200. Where is with full blown aired es depending upon which definition. Berlin The definition gives you these aliquot of mild at at a pdf ratio of 2 to 300 moderate at at 1 to 200 less than 100 is severe. Aired es to really depends on you know, whether you're looking at American Thoracic Society or you're looking at, you know, other other ones that will actually Berlin definition er and any others that are out there and a little bit of research that talks about this did in fact occur in the late nineties. And, you know, let's say between between 4010 that looked at this stuff. Other major indications so spontaneous breathing patients than there are muscular patients who may be weakening and the entitled CEO to ask The patient Disease progresses, and they become weaker that over a period of time that they may well be there entitled See how it Is with one measurement that will that will be depicted a swell COPD patients just generally to see if they stop smoking. They're in a kind of a relatively steady state, but they're entitled. See, what is this? May be chronically elevated. You can't leave and elated patients, which is one of the again more historical, traditional indications. You know, I've been at the medical center working in adult intensive care for literally 25 years, and we were measuring and entitle so two with those patients at even 25 years ago, we were the early adopters. Now, pretty much you go into most I see use and you'll see you know, continuous entitles go to measurement going on. And now you know the use has been expanded. The patients who are you know, again, as I said, moderate sedation patients who are at risk, you know, various forms of narcotic and allergies on board, not just for moderate sedation, but it's for ongoing. You know, patients that or being monitored that absolutely your obstructive sleep apnea that may be monitored for a precursor to it. You know, things like periodic breathing or, you know, other other forms of sleep disturbances that may not be, you know, full blown obstructive sleep apnea and also looking at me in ability. You know, the ability of the patient if they're if you have them on pressure support and they're entitled to go to the rising on. Dave, been on our two hours into spontaneous breathing trial, which really should be, should be ending in around two hours and deciding you the they're gonna extubate them or put the back on full sport. But there were ability, if they're entitles, been increasing during this time. You know, significantly and maybe a good idea to get blood gas and on the Crestor to see whether, actually and see that it's whether or not it's an accurate number of If it is, maybe they just not ready to be weaned or or if they're headed to being tracheostomy. Eyes is maybe if you're going to make the decision collective decision extubate them extubate them to let's a bypass to bridge them over normal values. So, you know, normal range know normal range of of a pH 7.3545 and normal entitled CO2. This is probably worth looking at really fastest. The relationship between entitled oh two and P A CO2. So at the lower end of the range, you know, I'm gonna call it the normal range. You have a wider difference between entitled oh two, which would be around 30 which would correlate roughly to a P h 02 of about 35. So the difference is about five that level. When you go the upper end of the normal range, it narrows. Okay, so you get an entitled of around 43 at the upper end of the scale. First is a P A a 02. You know what's in the in the arterial blood of 45. So just it's a relationship on title tends to be lower, but it's not linear. A response to abnormal and total CO2 stabilizing entitles you to buy adjusting the minute ventilation. So you get your you're entitled back, and maybe you hopefully you've correlated it with it with a blood gas. If the Antara si or two is high, you increased ventilation at the entitled to is low. You're decreasing the ventilation. Stabilize the pneumovax entitled Greater than 43 increasing your title, increasing your and or increasing your respiratory rate typically to make the determination, Which are you gonna work? Okay, so we do some review work for the NPR See exams, which for you, nurses. Or there's a national board for respiratory care that administers the credentials exams for respiratory therapy. Respiratory care. Um, they will give problems where, whether it's entitled or the blood gas will small, it will indicate that the 02 is greater than normal on then. The question is from the exam taker or at the bedside, do we increase the type of iron or the respiratory rate, The answer that often resides with where is their title volume with regards to the number MLS per kg? Okay, so if they're already at nine or 10 ml per kg and their respiratory rate is low to maybe 12 14. 16, work the respiratory, obviously providing they're not, you know, auto peeping where you're gonna be robbing, you know, time from the, you know, from the expert towards side of the equation. Okay, The converse is if their title volume is low and their peak and plateau pressures and driving pressure's a refund, okay? And but their title of limes or let's say six ml per kg plateau pressures or 20 where, you know, you want to keep it below, uh, Adam below 30. So you probably have room to go up on the title. I'm so it really depends on where you are. You know what the settings are currently in order to determine which one you should work and again looking at Ah, a little bit more. So if the entitles you to is less than 30 tour millimeters of mercury, decrease the respiratory rate or decrease the title by, um again, you would do this same thing the opposite, the same concept of do it opposite. So that if your if your title volume is already you know, if it's if it's kind of low and you have room there, you can you can kind of work it on where the other if the total volume is already high and you want to reduce the minute ventilation. You can sit probably safely come down on that. If the respiratory rate is no is already you know, high and you want if you will, you know, increase the entitled Oh, two. If you can come down a little bit on that, what we don't do a lot of but it is not to be for gotten is you can always add dead space and we don't do that much. But for patients that sometimes just breathing over the ventilator significantly because they have a severe head injury one that has affected the medulla oblongata. Um, in some cases, you may actually add 50 ml of dead space. They could re breathe until obviously a decision is made out. How to handle that movement? You know, downstream. Let's take a look at the actual capnograph now. So you have a normal cat. The graph for gram, you know, stable trend. Some of the features you have here it doesn't quite come to an exact plateau. But it's a random 35 36 37. Something along those lines looking at the scale, the left hand side on, and we're looking at Grady in again just giving you an average a guideline if you're grading between the entitles Oh, two of the pas you to now around four and again, Weight told told you earlier, in the lower end of the scale, It's great, you know, before five at the upper end of the scale. Maybe it's two or three something along those lines, but just a guideline for kind of take away point know away form, you know, get similar only structure structure. You know, the concept is the different stages represent different things high chose the amount of CO2 that length of picks the actual time. Okay, just a little bit on a normal phases. Phase one, Are you basically beginning of expert? You know, X elation or expiration? It's anatomical bed space, which does not participate in gas exchange. Therefore, it really has very little or no CO2. Then you have a sudden rise you have. Actually, he's mixing of the gas that does and doesn't participate in gas exchange, you know? And then you actually have this plateau where you actually have this pretty much you know, all the gas you're looking at, it may not be a perfect plateau. This is really the illustrate the point. But it's really that the preponderance of this gas is from the albuterol, and you have your basically your decreased there were. You know, you're you've been on that steady state and the patient's getting ready to, uh, you know, to the exit, inhale again, abnormal capnograph. Here's your initially you're measuring somewhere around 25 or 30 and it's continuously going down. What's going on here? You know, it looks like you may get a breath or to the reason why you're getting a breath or two. Where it has no two is. The tube is actually passing through the or a fax. It's picking, picking up, some entitled to go to through that. So it's a mist intubation. Looks like it's going to the esophagus. Ah, little or no 02 is present after a couple of breasts. Plus, even if you get into this office is going to be some oh, two. That's in the belly. Okay, which is gonna be measured in that first breath or two. Um, and this is where if you're using a a collar emmick where the color changes? Not really. Maybe changed color a little bit and did not really changing much after that. The other I want to say is, even though it's an entitled to presentation, it's there's any doubt. Yeah, breast sounds. Were you hearing presence of the belly button here and some in the long as and you have some. If you have some serious doubt, you know, don't wait too long, you know, deflate the cuff, take the trigger to out and start ventilating the patients just manually for the time being. If it's if it's in the esophagus and you continue to, you know, to ventilate the patient as a team, not only will patient not get option, it ventilated, but you're gonna be putting air into the belly. And if you put enough air into anybody's belly there, they will vomit. And you got another problem on your hands a little bit more. Here on abnormal account the grass we looks like in this first breath on the left. There, you haven't really be normal. And look at how you have this kind of this scalloping or this, you know, things rise, if you will. It looks like it's an obstruction in the airway the breathing Stark. It could be a point. You know, it's partially Kinko's. You're measuring some kowtow Now are artificial airway, maybe a kink actual, You know, airway, You know, 82 presence of a foreign body where you're getting some. But you're not able to really reach that steady state obstruction in the external, um, of the breathing circuit. Someone stepping on it, I or that the bed, rail or the the wheel of the bed has kind of rolled over the expert oral in or even a broncho spasm. Progress passing won't look exactly like this, but I do want to say that that if there's such a thing as you never diagnose a bronchospastic based on the shape of a entitled oh two you know, capnograph you just wouldn't do that. But you will see, if you have it is interesting. Yeah, courage it Do they have. You have a patient who does? Is that a ventilator on day? Are you know you're doing capnographer on them many times they'll have not. Although we'll have a more of a shark thin shaped um capnograph. Okay, that will. It will take longer to get in that steady state or won't even getting that steady state. So it's something that kind of think about is, well, you wouldn't diagnose it on that basis, but you'll see that it may be a clue if you will inadequate seal around the ET tube. So the the cuff was positional and they moved the patient. And now this is big leagues. Leak urine cup in the trachea to what, officially with That's too small for the patient couple of causes here. So this is on the opposite side. This is actually it's not. It's not able to achieve if your patients bring that you're not able to achieve a steady state. But it's instead of a short, thin or, you know, accelerating this one is more like a deceleration in the way for shape little bit here. So what you actually have is your plateau on the top is still able to be achieved, but it's increasing, and again, this is three breast. This would occur the reason why we have the, uh, you know, the depiction. That trend I'm already inside of the's trends going occur over time. Okay, not it's like three breast of this change, for example, would occur over minutes or longer than that. Okay, you have, you know, an hour, two hours decreasing minute ventilation where you just, you know, maybe over compensated a change in Alkalaj state previously increasing the metabolic rate such a she'll have a fever you have with burns. You know things along those rapid rise in body temperature with a patient now is is, you know, hypothermic, which you may also seeing a, you know, in an infectious state, but not only and less common things just to keep in mind and in your hip pocket. So when when they do things like laparoscopic surgery, they pump the you know, if it's if it's a Donald laparoscopic surgery, the abdomen with kowtow, okay, and then they'll remove it. But they'll still be some in the belly there, and that will be absorbed and eventually will end up in the blood stream. Eso It's something to kind of keep in mind that that could be from that. And then, you know, I work in a in addition to having a lot of specialties were a trauma center. And, you know, occasionally you do see patients that come in from industrial accidents or motor vehicle accidents and they have a limb that's mangled it, a tourniquet on it. You have a lot that anaerobic metabolism that's taking place on that land. When they let the time you go. A lot of that, you know you're going to go to the lactic acid that's been building up well. Then he returned to the the the vasculature and eventually, you know, I say hopefully make it. It's way. Hopefully the limb is still, you know, still salvageable, and I will make it so eventually to be exhale. Decrease in entitled to So this one. Your baseline is steady, but you have your plateau. It's a cheap, but it's It's decreasing over time, even increasing the respiratory rate, which would also see in terms of the actual shape of the the number of ways that you see you see them more frequently to say. The respiratory rate increasing increase entitled line were blown off. More CEO to decreasing metabolic rate where maybe you're they're doing a therapeutic, you know, hypothermia with the patient or just a full body temperature because patient for some other reason, they're calling the patient with some other reason, increasing minute ventilation so against sudden decrease in in total CO2 38. That's a 20 respiratory in this case double. So you don't have pointed, you know? You know, you don't know. Put a half ing of the entitle CEO toe. You have a doubling of the minute ventilation. But what you also have is you have some dead space ventilation. So you know, these adjustments are gonna work out if even if you do the math, those adjustments where you can actually say Well, to the extent that the 02 is out of whack is, let's say hi, we're gonna have to increase the minimum relation by that same proportion. It'll give you good guy in line. But it's not gonna be perfect because gas exchange is not perfect. And you're gonna have some dead space that's in there as well. Hyperventilation. So patient receives 5 mg of morphine sulfate for pain on. You can have, you know, and there's no it know whether mitigating factors and tight. Okay, climb from 37 to 45 just isn't example you're looking for. You know, you're looking for things that happen, and then you're looking for plausible explanation. Is that why they're so it can happen way for patterns so you could have normal. And again I said to you earlier, the plateau isn't perfect in many cases, you know, you may you may see it closer to being something that's war is on all you may not. The main thing is the comparison between these two. The normal is close to, you know, a horizontal. If you will plateau, the Broncho spasm looks, you know, it's kind of steadily rising. And just to talk for a moment or two about what's actually happening with the bronchospasms you think about. Okay, so So the plateau means that you were getting all gas from the alveoli. Okay, that's been participating in gases. You like a steady state problem with bronchospasm is it takes longer because there's now an obstruction and with asthmatics okay, experiencing bronco spasm, the obstruction tends to be more on expiration on X elation or expiration. So you have because you have this obstruction it takes It's very difficult to achieve a steady state to get that so that the exhaling it will take longer. And you're going to get this because of that, you're going to get this. You don't get a perfect plateau. You get something that is kind of more of a shark fin shape in nature began a little more elaboration on the prior point bronchospasm and ham percent elation. And again, particularly in the X elation side of that you have the old lied unevenly filled on inspiration empty a synchronously during expiration. The asynchronous airflow and excellent dilute the exhaled. Oh two. It alters the ascending phase and plateau slower arises. So two concentration really kind of a little more again detailed on what's happening. Characteristic pattern for progress. Spasm again I would encourage you to. Not so much uses is a diagnostic tool, but more to kind of confirming. Yeah, I'm hearing wheezing. The patient has a history of bronchospasm. Maybe they're older people on the ventilator and we're seeing the short fin, you know, shape to the actual way for looking at causes of an elevated entitled to go to. So you got on there, if you will, the metabolism side of the equation. So you have to think of what's going on with you seeing a drug overdose. It's not a stimulant, it's just a a narcotic or station over those, um, so you have elevated entitled Oh, two. Um, you know, mainly oing to the fact that the patient is They're just they're hyperventilate. So that retain that When? When they're when they exhale, they're actually more so, too. Because their breathing, you know, if you will less often and or less deeply a malignant hyperthalassemia. Okay, well, you actually have just this hyper metabolic state it again. It may be due to something with the hypothalamus. Regulates the body temperature. If there's a brain injury that affects the type of alum, it's could be an issue along those lines on the circulatory system. Increased cardiac output with consistent ventilation. So, you know, you mentioned kind of earlier the heart accounts for, you know, about a quarter about 25% of the option uptake. Okay. Likewise, it accounts for a significant amount of the 02. So if you just have an increase in cardiac output, according activity without comment, with a constant of ventilation, so without an increase in their ventilation so you can actually get this, you know, evidence of elevated entitle CO2 respiratory system as per insufficiency. So you just get you know it could be asthmatic. It could be COPD. Could be something you know else along those lines respiratory depression so you can actually have instead of it being caused by, you know, drug overdose, whatever. Where you actually have, um, you know, some other some other issue going on with the brain, a brain injury or bleed Or, you know, a scheming stroke that it's affected that greedy breathing center of the brain. So it's it's, you know, it's you could you could say that it's actually neurological, but at the end of the day, it's neurological. It's affecting the respiratory system, and the ventilatory drive obstructive lung disease. So may overlap it respiratory insufficiency as well. Um, and then the equipment, the defective exolayer in the house or something to keep in mind that some of our transport ventilators, many of them basically have a single limp circuit. They use an X elation valve, various sorts, maybe a mushroom valve or something along those lines. And if those malfunction, then you're gonna have patient was actually retaining so two as a result. Um, you know, the other thing I was mentioning is, you know, doesn't happen often, but it even it's a double them circuit. You have some issue with the experience exolayer in side of the equation that's affected by it, some of the causes of a decreased. So you take kind of it proceeding slide and you take it and you're kind of flip it and you know, you you look at the theophylline it okay of some of these it occurred, so metabolism. So, you know, pay metabolism are exactly the same thing, But you think about what's going on there. The patients, the patients in pain there, hyperventilating. They're anxious. They're hyperventilating, Um, and they're blowing off their breathing quickly. But they're not breathing quickly because of a respiratory drive issue there, breathing quickly because of a ancillary issue that's not directly related that so pain and anxiety can certainly be big drivers in patients being of being two kidney without there being a A common it, you know, reason for it from a respiratory drive or, for instance, chemo. Septra is picking up excessive C 021 of lower. It's not that it's that the patient is just anxious. They're in pain, that reading quickly because of those circulatory systems or chordee at rest. So think about what's going on. This is kind of an interesting one. Or actually, these are interesting ones as a group. So you think of what's going on with chordee? Yeah. Caressed is that the 02 isn't the building up in the blood. So you take a blood gas, and sure enough there, so two is elevated. Okay. Recording arrest. If you can get blood gas could understand that they probably don't have a pulse. Okay, um, but you think about that. But they're not breathing. Okay? So if they're not breathing, you're not able to measure something. Okay, so it's building up in the blood, but the entitled to is not now, not a good or reliable measure. Okay, the embolism. Even though it's a different route, cause, er ideology is vaguely similar in this respect. Okay, you may have a lot of oh, two in the blood. Okay, but what you don't have is that blood because of the blood clot. And let's say that you know, pulmonary artery, because the the blood cannot reach the Advil. A catheter membrane. Okay, you have less of an ability to exhale that that toe on, then things like sudden hypovolemia or hypertension again similar in this respect that the blood itself may have a lot of 02 in it, but but it's not able. You have less volume or you have less. If you're driving pressure, that's bringing that that blood, um, back to the Advil or Capital Remembrance. Who could be exhale, those kind of interesting ones for respiratory system. So just simple Advil or hyperventilation. So it may be what we call I atras enic atra cardiogenic means we caused it. Maybe the ventilator settings that we put in that respiratory rate was too high. The the, uh, the title volume was was too high, or the patient is just not adequately. You know, this kind of overlaps a little bit with with what's going on with them mentally, but they're not adequately sedated, so they're very anxious. They're awake. You know, we're getting them settle the that we're trying to wean them or just getting them settle on the ventilator. They need more sedation that we get them set so they're hyperventilating just because they're anxious. So it does kind of relate back to the anxiety one. But it's no the breathing quickly equipments. You could have a leak in the airway system. Um, you know, just it's escaping, so it's artificially lifting. Will low partial airway obstruction? Um, just It's a measurement issue, if you will. On the entitles 02 is not in the trachea. It's elsewhere, including prop attention in the hypopharynx. So So in summary, Got not if he could be a useful assessment tool. However, Wonder Standing is a relatively straightforward value. Valuable tool. But a little bit of knowledge go a long way, including the indications in the limitations. So no, the indications know the limitations. Recognizing normal wave forms of values theat normal, abnormal, basically could be really important. And how did Teo defy that? You know what we teach the respiratory students, even my team teach that, but just kind of stress is that you know some of the problems that occur. You know, rising entitles oh, to be caused by a lot of things. But in many, many cases, there's a handful. There's a short list of things that account for most of those problems, and, you know, this presentation is really try to stress some of the more common things that could happen that cause it. And you know, some of the things that could be used to remedy them this well and know where there are additional resource is and how to access them toe always try to keep current. Similar resource is a realistic here. With that, we want to thank you guys very much for attending this lecture. Hopefully you learned something from it. And, um, we look forward to see See you guys come back. Most importantly, we're very much appreciate your you're attending today. Have a wonderful day. Bye.