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We try. Ok, hello everybody. Um, my name is David Gorda. I'm the, I, I'm not a doctor, I'm a nurse. I'm um, the, uh IC U nurse uh from uh Israel. So we'll start this, this course, this course is uh introduction to mechanical ventilation. So it will be ba ba basic things uh about mechanical ventilation. And uh we have only an hour and usually this lecture, it's for an hour and a half. So it may be, uh, I, I will, I will, if you, if you understand some things, I will run it over. But, um, I will try to be very, very, um, uh understandable. Uh um So, uh this is the first time that I give this lesion in English. So I'm sorry for my English. Uh first of all, uh, but sometimes I have to just to read what I wrote for myself because uh just maybe I can't uh um uh uh really remember the some terms in English. So, um, ok, we will uh start uh in, just wait a second like this, I think. Yeah. Um, we will start, uh just to understand what this course is about the course will be very helpful for people who are starting to work in uh um with, with ventilation patient uh in ICU units, uh internal works uh or er er uh uh other words that they have um a um ventilating patients the course um er in the end of these schools, I think we will understand what is this, this control? We will, we can er um er uh understand the ations between assist control, smv, partial support, uh pressure control ration and peep all these terms. We will uh just uh for this hour, I will try to explain it that you will be sure that you know what you're doing with uh um the your ventilator in your uh in your work. So we'll start it from the first of all, we understand that we have to understand that um the uh patient that is ventilated, we are, we are talking about uh ventilation patient. It is a system, uh it's closed system. Uh So we uh in this system, we have the ventilator, the patient, the ventilator and the tube that is connecting uh the patient with ventilator. And the, we have to s speak a about some, speak a little bit about the tube tubos um and understand how it um what is it? Ok. Say again. Ok. Uh So uh here is the tube, here's ventilating, here's the tubs uh one side um in the end uh we have a balloon that goes inside the trachea. The role of balloon is to pre prevent um secretions from flowing from the um um pharynx i into the trachea. Uh Some people thinks that it's just uh to be tight that it will not go, that the tubes will not go outside. But no, this is uh it have uh two reasons. First of all, the preventing from secretion is going down and second, preventing from the, the air that we inflate the lung going outside o of Traa. That to, to, to that we will create pressure inside a positive pressure inside uh the lungs. Uh We have to tell that this balloon we inflate with 20 t, 30 centimeter of uh water um column. It's 10 mL of air. It's uh the syringe of 10 milli of air. And uh we have uh different kinds of uh tu tubules, uh different sides of tubes is you have to hear the mm site of tubs 8, 7.5, 765. Uh And uh it is interesting that I in very uh small patient like um newborn patient, we have pubs without, without the bone, but we will talk today uh about uh the old uh patient, uh o adult patients. So, uh a little bit more about Tuss. Um uh Not today. We have a tube is that um uh that it perform uh inside of these, the subglottic suctions that so we will uh suck this um uh the uh exterminations uh from here. Uh, and another thing that we have to know about Tobu, that the balloon will be down the vocal cords. Ok. Uh, like I said, 10 centimeter M month is the water? Ok, let's go. Ok. So, uh what are, what are the reasons for mechanical ventilation? All the reasons for breathing can be, um, divide it into two? Ok. And you can see it on the slide. A inability to manage the open air is the reason to mechanical ventilation. And uh the second one, the patient has difficulties breathing on his uh his own. So mechanical breathing, you can breathe. And uh it's something is uh um make him unable to open the air. Yeah. And so we open with tube. Uh also uh our purpose uh just to, it's very simple, we have to maintain the homeostasis between gasses, uh blood gas, we have um carbon uh oxi oxide and uh an oxygen. So we uh have to uh only start them. So it will uh ex e in exhalation, I invent ventilate the CO2 and uh provide oo two with the machine um before we start uh the ventilation uh modes and uh how it works. Uh I just want to um to remind you uh that we are talking about positive air pressure, positive uh air, positive air pressure ventilation. It's uh the opposite that uh uh really happened uh that that happens in the physiology. Yeah, in physiology, we um we uh um we create a negative uh pressure inside our chest and then the air go inside in, in mechanical ventilation, we um push the air inside and inflate the um the lungs. So, um the um so, so it will uh cause uh a lot of um damages and problems uh in, in investing the uh normal uh normal physiology. But in the first, uh we, we have to understand then that when we want to inflate the lungs with air, so we need to know what volume we inflate inside which pressure will be inside after we inflate the lung, in which rate? Yeah. How many um uh inspirations per minute? Uh uh we will inflate the lung uh in which flow we will um pull the um the, the air uh uh air mix inside the lung. And uh of course, we have to understand how much oxygen we will give this for this patient. So, Fio two. Yes. Uh how uh what is the percentage of oxygen in the mix of goddess that we will give for this uh patient? Uh So all these um parameters uh and the mixes between these parameters create different breeding modes? OK. So we'll, we'll understand how we, we, we inflate the lung with uh playing with these parameters. And uh we will get another mode for our users. Uh If uh it's not uh understand, if you don't understand something, you can ask some questions now and I will go on. There are some questions. No. Ok. Uh, so, uh, w we, uh, we talked, we about, um, about, um, system and here we have a very simple system. Ok. Ventilator, the tube and the lungs of the patient. Yeah. Uh, and we'll start with a very simple mode. Uh, and the first mode that we, uh, used a long time ago, I, it's this control or this, uh, it's, um, SCMV, uh, uh, continuous mandatory ventilation. So, w we'll understand what does it means is and then we will go on with another month. Ok. So, uh uh this is a system that uh I told you already and the system uh OK. OK. Let's go on. So what we have here, uh I'm going to uh um in a system control method where the patient can. Uh So the, the, the, the month, the uh the, the ventilator have to have uh we, we say uh to inflate the lungs but in this method, uh the patient have already um his um yeah, ca can trigger, er have his uh perform and the a trigger to, to trigger the system when he want to breathe, how he trigger the system. He um and he produce um negative pressure inside the lungs. The mo uh the, the ventilator feels the neg negative pressure and provide the inhalation uh uh uh in Spirium. OK. The patient uh activate uh so the patient activate the breathing uh muscles uh and it create negative pressure uh inside the tube and inside the the the system. Uh and ventilator feels this negative pressure and uh give an in spare room. But uh in the in spare room, the ventilator will give the volume that we consider to be. Yeah. So in this mode, uh the patient can trigger the ventilator. Uh and we have to, we, we, we consider the volume that will be delivered to the patient in each breed, even in spontaneous breed. When patient trigger a little bit and ventilator ventilator uh mandatory um produce him this the volume that we uh wanted to give him. Uh uh that, that we consider to give him usually the tidal volume that we give. It's uh eight mL per kilogram uh per pill per, per kilogram of um IDL body mass. Um OK. Wait a second. Just I will see that. And so that will, will not be always um that, that, that if patient will not breathe nothing, we will set up the backup rate of Respi uh backup respiratory rate, for example, uh minimum eight respiratory uh uh inspirations. Uh Then uh the patient, if the patient is breathing down this uh respiratory rate, uh the the ventilator will give him um mandatory uh inspirations. Uh So if the patient, OK. OK. Oh Gold one, let's see it here. OK. So uh when we inflate the lung with volume that we need, uh it will, it will create some pressure inside the lungs. And uh, when we, um, when we speak, when we talking about the pressure, uh, that creates inside the system, we first of all have to, uh, talk about compliance, lung compliance. Ok. So how, uh, uh, I already said when we inflate uh the HM lungs with the, uh, when we inflate the system, pressure is increased, it created uh, this pressure can uh vary from patient to patient. Yeah. Uh It depends on the compliance of the lung of this. Uh What is it compliance of this patient? What is it compliant? The one compliance is to comply? Yeah. Uh How uh to be able to get uh the, the air? Yeah, you can uh considered like this. Ok. Wait a second. So we ask uh uh our machine, our ventilator uh to inflate of the lungs. Um And uh when we uh wait a second, I will just show it like this. Uh So uh is there with um so compliance is uh equal uh volume divided to a pressure. So, uh if we inflate the lu with a standard volume for fi 500 mL and the pressure raise up very high, uh we uh actually talking about the low compliance. So our lung can get this uh uh this much of air if we inflate it with the, the normal uh and the uh the, the, the normal tidal volume and the, the pressure is uh not rising or raising a little bit. We are speaking about very good compliance or high compliance for this patient. Why it's very important because when we inflating in uh a cy control, uh when we're inflating the, when we're giving tidal volume, uh we also have to measure uh the pressure that we get inside these lungs. Uh Another way we will just uh wait a second. Ok. This the same uh I in another way, we just uh will get problem. We will uh punch the lungs. So uh compliance, uh the ratio between the cha change in volume and the change in pressure within the system, this the uh with the change in volume, create the high pressure if uh it's high pressure. So uh we are talking about low compliance. OK. So we will see it here. Uh Why uh we are talking now about the disease control and uh look, we have tidal balloon, uh 550 mL and uh we have to monitor the pressure. OK. So in this um mode, we can't um we can say to the, we can we uh only um uh set uh set, set the tide, the volume that we want to give. And we also uh set the alarms of pressure. We have the scale and we can see the pressure going up and down, but we can't um we can't change the pressure in this, in this uh um kind of mode. Uh So, because we are talking about um, volume control ventilations so we can, ok, uh it's understood. Ok, volume control ventilations. So, uh, if we have patient with a low compliance, the alarm, the pressure will go with the will raise and uh, they, we will hear the alarm, high pressure. Uh and uh, we will learn, uh, in one mo I, I in more slides, we will learn how to, uh, to fix these problems. Ok. So we, we, uh until now we spoke about uh volume control uh ventilation. So we manage the volume and we get the pressure inside the system and we don't know what pressure will be. It is. It depends on uh compliance of patient's lungs. Ok? It's uh unders if it's understood, we are going uh uh forward. Um it's OK. Yeah. Uh pressure control ventilation, um pressure control ventilation. Like I, like we said we manage the pressure inside our system and we um get the volume that uh lu takes from this uh in Spru. It depends on compliance also, of course. Uh So mm mm mm mm. Uh because the compliance change in different situations, we will get a different volume from patient to patient. We must have a ventilator me measure like I we, we, we spoke about it. Uh we measure we the, that measure the volume uh that the patient uh uh received while breathing under pressure. Ok. Therefore uh uh any I I in inhalators, uh any inhalators. Mm that work with pressure control method will help the uh measure uh to measure the volume. Uh OK. Just a second. Just to see. OK. I it's just graph uh that uh shows what is going on inside. So OK, I will just turn it over and we'll stop here. The pressure, we usually um uh inflate the lungs in this pressure control mode. It's nearly 20 centimeter of water um o of water column. Uh And like you see, if we inflate lungs with this pressure, the volume will be considered, uh it, it will be changed. Uh depends on lung compliance. Ok. The same. Ok. And then now from uh understanding of uh AC control or CMV and CMV can be uh like CMV with volume control and it can be also CV CMV with pressure control. Yeah, you understand, it's uh never mind how you push uh the air inside the lungs. It's uh you decide if it will be CV, con continuous mandatory ventilation, that patient can trigger the system and the system gives him every time, um er oh every time the volume that we decided or another one, otherwise the pressure that we decided, but we uh it give it mandatory and the, the, the, the problem with this uh with CV or a CY control that patient um feel sometimes not comfortable because every time he really may be coughing, uh and it's create uh a negative pressure inside the tube. So he will give uh he will take this punch of uh uh 5 500 mL. Uh So uh it's not uh really, I, I sometimes it's nn not sympathy for a patient but it's uh this is the, the way it's working. This uh this mode is working. So we can usually uh this control is working of in uh volume control ventilation, but also it can be press control ventilation. It's the same. So we just uh moving forward and we, I wanted to talk with you about CPAP and Peep. Uh it's always um it's important to note that there is a lot of confusions in clinic between uh comes when it comes to a CPAP and pe it is the same method uh only uh just to understand and see in CPAP, the connection will be uh and the uh the ventilation will be uh uh with um in, in noninvasive uh mask. Yeah. And when we are talking about invasive ventilation, we will uh talk about Peep. So what is it CPAP? It's continuous pressure, uh continuous positive airway pressure, ventilation. Yeah, ventilation. It's uh uh continuous positive airway pressure. And we, and when we talking about peep is positive end expiratory pressure. So in end of exper room, we will get a positive pressure. Uh it's um uh the pressure uh in inside the system, we, we can decide from 5 to 20 centimeter of water uh of a water's column. Uh Yes, usually we, we are talking about water columns, uh uh in uh ventilation uh and in own physiology of uh of breathing. So just uh uh let's uh seat in CPAP II. I want that it will uh go on and I will explain what is going on here. So when we are, we are talking about clearly CPAP. So we, we are um inflating with it is um spontaneous breathing, always spontaneous breathing in settings. We are not uh uh set uh tidal volume and we are not setting respiratory uh respiratory rate rate. This is spontaneous respiratory rate. We just set the inspiratory inspiration in spiritual pressure and a experi pressure, it have to be positive. Uh So when there are, there are changes between insp and expiratory pressure, the uh this mode or this um uh apparat, this ventilate, it's not ventilators really. It's uh uh like um machines, we call it babbb because of uh the changes when we, we uh we have the changes in inspire and the is two modes inside of one. So we call it bup and the CPAP is the same pressure in, in spir room and spir room. OK. Mm So the and expiratory pressure will be positive. It never comes to zero. OK. And like I told you, uh the, the, the pressure will be uh it may can be between five and 20 centimeter of water. What it for? We will just talk about it. Uh a little bit later. But I wanted you to understand with uh the, the, the mechanism, the mechanicals of this uh uh this uh uh mode. OK. The same. So um another mode that we have to understand it's a pressure support. And when we speak about pressure support, we'll uh talk about uh some physics a little bit just to understand what we are going, going through. The pressure support is uh the method very similar to CPP and pe uh except uh that the mm positive pressure is only during an ins spir room. This is the breeze under pressure. Yeah. Uh Because the ventilator helps the patient to overgrow the resistance to overgrow the resistance of uh the tubes, the all the system and the, and the uh the the tubes of the system, usually we are talking about uh pressure support between 5 F-15 centimeter co worker and we'll go on and we are talking, we are still talking about uh pressure support and why is it supported? We'll just uh we'll understand in the next slide. Uh It's uh wrote here that it's usually uh winning uh winning mechanical in uh so it, we, we use it for weaning patient from mechanical ventilation. And you understand now why it's uh winning. So, OK. Uh First of all, uh these settings, it's spontaneous settings. A also we are not uh uh we don't have respiratory rate here. We are not setting respiratory rate. We, we are not setting tidal volume because uh the uh we just set the pressure support and the pressure support supports spontaneous breathing of the uh patient. So when patient trigger the trigger, the uh the uh the machine, the machine supports him, uh it press it increase the pressure inside the system. So uh the, the, the uh difference between pressures will be higher and patient can uh easily um in spirit the uh air through the tubes of the system. And WW when why we are talking a lot about tubes of the system because of uh resistance. Uh OK, I just uh there are a lot of uh um blue and red uh signs but you understand it, I just uh will understand it what is talking about. So every system of tubes have a resistance, it's resistant to airflow inside the system. Soon the bowel will it begin? Every pipe has the resistance to flow. The, the resistance is inversely propose proportional to the pipe oo of, to the diameter of the pipe. You can see uh the, the ra the the the radios of pipe er in virtual commotion to, to the, to the flow to, to the resistance resistance, virtual commotion to, to the radios of pipe. So uh when pipe is very tight, they're resistant that it uh uh um the the resistant of this system will be higher. Uh The diameter of the radios is uh small. The resistance will be uh uh racing. The highest resistant of airway in the bro, the, that are in the Bron, they are in the Broncho here. You see in red, in B bronchos. Er, because, uh, why it's bronchio is not bronchiolus, er, because bronchiolus in, set up together, they are, uh, they have a higher, uh, uh, radio, the bigger radios than, uh, uh, broncho. Broncho is together, they are smaller to all together, the, the values, uh, is smaller than, uh, uh Algo. Uh uh OK. Bronchiolus. Yeah. So uh the, the, the tightest uh in this system, if we have a tube, the tightest radios in this system is uh tubs. So when we put inside the tus uh the patient have over uh uh um have to uh work harder to overall this uh resistance. That's why we usually, when we want patient to breath himself before the weaning of the patient, we will uh put the higher the pressure support. Yeah. And we will, we have pressure support until we win. Uh If patient already in a pressure support, it's uh um we can say that he's already r he's ready for winning the tube because a pressure support. It's um mm delete the tube like OK. Um The uh I uh if there are the que I, if, if there are any questions I can answer and we'll go on. No. Wow. Um So we're going on and we are coming to a very um very mm useful method, useful uh mode it's called SI MV, synchronized intermediate mandatory ventilation. We also have another modes uh after uh this, this mode. Uh but it's, this mode is very popular for patients in uh um a lot of clinics. Yeah, till now. Um So si V synchronized intermediate mandatory ventilation, uh it's very similar, it's little bit, not very, but it's a little bit similar to assist control. Uh Usually we're talking about uh and now we will talk about uh volume control ventilation. So um s so, so far, wait a second, sorry, so far, uh we will uh determine uh settings. Yeah, we will determine respiratory rate. We will uh breathing volume, uh the tidal volume, we will determine tidal volume we can use here peep for uh uh in this machine. And we will say, ok, you deliver tidal volume and, but after uh uh you finished uh an exhalation exp room, uh leave positive airway pressure inside the lung and inside the algo. So we just measure peep. Uh we also can measure uh pressure support here and say, look er after you deliver the tidal balloon, uh if patient wants to breath himself, uh don't give him all tidal volume like mandatory like an er, his control um give, give him to breath himself, er help him with pressure support and you just uh set up pressure support that you want uh between, like we said, between uh eight and 15, you can 15, 10, 8, 11 uh also we set up uh a IU two of course. So in like you already, like we already sid like we already said, when the patient in this uh mode, in SAVV si MV mode, the patient can trigger a ventilator. But the volume that we considered in uh mandatory considered will not be delivered. He will take the volume that he, he, he he that he can take the er uh including his possibilities. Uh We pressure support of course and we just measure it and if we see the patient trying to take volume, but he can't, we can uh hire pressure support, we can hire respiratory rate so that the patient will be more um comfortable and get his uh Respi respirations on time and not, will not be um so able uh uh will not be um trying to get inspiration. So I just wanted to uh to see what's happening, what the graphs are and what's happening w when, when a patient is in disease control and ver versus uh SI V. So like you just want to see, first of all, you pressure, you see this pressure is going down is a start of inhalation and we uh oh wait, wait a second. I will take it uh like this. Ok. Let me see here. Is there um negative pressure uh trigger, it's patient trigger here. So patient triggers the system and the it's it's assist control grow. OK? Uh And you assist control uh the machine, the ventilator understand that he have to deliver uh some volume. And it's start the the flow of air flow of mix of air start from in the uh to, to, to go from inhalator. The flow start suddenly. Yeah, it comes to some measure here and comes to plateau flow. So every time there is inhalation, the p the the flow, the plateau flow, the the flow is the same. Yeah. So when the flow started the volume, the, the pressure inside the system goes up like this and the volume of course going up. OK. When the WW when we have the target volume that we consider the flow stops, the pressure is falling down. Why it's not zero? Because there is a peep here. Positive airway pressure, P peep positive and expiratory pressure. Oops sorry. Well, OK. Uh positive and expiratory pressure and why it's going down here? The flow is going the other way because of exhalation. Yeah. This time of exhalation P room, ex P room. This is an ex P room. The flow of experi Yeah, it's uh a pos uh it's um not active, it's passive. Um It's uh the experiment is passive here. Um So the, we have to give time to the air that will go out. Uh OK. We understood this. But uh what is happening in SI MV? Yeah, let's take another color in SI MV. The same. It may be uh the trigger with uh mandatory. But if we uh consider that it will be eight res uh respirations per minute. For example, there are some respirations that patient want to, to take between. So he is doing the trigger. OK. Uh But the flow is going up a little bit white like this because we are not mandatory giving the w with the, the, the volume, we are er just helping him to, to increase the pressure with pressure support. So the volume he will take may be uh less that we want it. So it's in this kind of uh uh mode, we have to see to look also uh above um a minute volume. How much uh volume this patient get at minute in minute and uh to decide how to manage this patient. But it's for patient for winning time. It's very, very mm easy. It's easier to wean patient with this mode. OK. Uh OK. How much time we have 10 minutes? Wow. Wow. Wow. Wait a second. Mhm. No. OK. So let's uh look to the orders, sorry. Uh let's see the orders that we have. Yeah, like that. Yeah. Um OK. The others that we uh we are to, we spoke about uh modes, modes. It may be access control is it may be SI MV. Uh it may be assist control. Uh It may be pressure support. Uh It's a SMV, assist SI V volume control, SAS MV. Pressure control. Uh if we have in our modes. When we uh uh settings in our settings, tidal volume, we set tidal volume. So we know it's uh volume control. If here uh it's not tidal volume, uh it is pressure, so we will call it pressure control. We set respiratory rate type volume fo uh fio two the uh and the peep also, we set the peep because uh in a lot of uh uh diseases, it's very important. So what uh if we want to affect? Oh, ok. Wait, wait a second. Just one more. OK. If we want to affect CO2 to affect the uh ventilation, we can measure uh we can change respiratory rate and tidal volume. These are the, the 22 settings that we change to uh influence of the own CO2 of our patient. And if we want to influence on um uh oxygenation, uh we change a IO two, of course. So the percent of the percent of the um uh oxygen in the mix or we change the peep, the higher the peep, the peep, the better oxygenation and we will see why it's why it is like this just now. Ok. Oh, sorry. Wait a second. I, I want to to talk with you about this. Yes. When we increase the pep, there are some problems that we uh make in the, in our mm system. Uh um Most of all, most of the problems we, we, we are doing for our patient but, but we also uh uh uh doing some uh some treatments. So, uh first of all, when we increase peep um in positive uh uh in, in positive airway pressure, uh we uh foot pressure on the heart, it's uh the pressure on the right side, uh uh right ventricle will decrease the um cardiac output. So every time you uh intubate patient and start to uh uh intubate and start peep, uh just know that the cardiac output will fall down and the pressure will fall down. Ok. Uh But the good thing that we increase the um uh wait a second uh oh weeks ago. Uh sorry. Ok. Sorry. Uh we increased the surface of um er, of alveoli and the more the bigger, bigger the surface, the bigger the gas in gas exchange. Yeah. Uh So that's why we uh when we want to, to influence on uh oxygenation of the patient, we can also hire the pe and it will influence the F five. and it will en uh influence the O2. OK. Wait a second. So uh uh you, you can see it here, it's peep, it's uh the blo uh the BP will go down higher, the peep, the pressure, BP will uh be um will go down but oxygenation it, it will uh be reminded. Uh OK. And uh the last one that I wanted to um to, to speak with you and we have, we have to finish, I think because it's already three minutes left. Uh This is another another um uh wait, wait OK, here. So we, we saw this drop already but just to understand that uh we spoke about, um we spoke about um uh compliance and we spoke about the resistance. But the uh the the problem is that in one patient, we have also compliance and also resistance. So we, when we inflate and uh the first of all, if the flow is going inside the pressure in the resistance, yeah, if it will be resistance, uh the pressure and resistance will go up. Yeah, will rise. Uh So, and if the um if there's a problem of existence, but also if, if it is the problem of compliance, the pressure also go uh up and we, we can't, we have to understand what is coming first if it's the problem of resistance or because of the high pressure, high pap, high peak inspiratory pressure. If this is a problem of re mother, what is it peak inspiratory pressure? It's here. Yeah. So if it's going like this high, we have to understand if it is because of the resistance, uh the tight, uh very tight. Um The, the there are some uh e excess inside the tubal, you have to do suction or it's the king of the tubal or something like this or maybe it's uh the changes in the lungs. So the um uh compliance is down. Yeah, the compliance is uh very low. That's why the pressure is raising. Like this. There is one method uh for, for to see it. Uh The other method, it's just clinical method. You can understand, you check the kink the suction and then you see which problem in and we will see the uh method in uh ventilators. There are mm uh Wait a second. How do you say there are, there is one function in some ventilators. They called breath, hold. Uh When you push the breath, hold the uh uh the here you, you see uh it stop, uh stopping breathing, s uh stops uh lungs, stop breathing in the end of uh respiration i in the end in the highest pressure here. So after we stop the breathing, after we stop the flow, yeah. S we, we have pressure down. So we, and we have plateau, the higher the change between uh the plateau and the PAP, the more reason for uh uh for uh resistance problem than for uh compliance problem. The lower pressure here, the lower um uh the lower um uh change in here will sign us, will mimic us to a compliance problem. And uh just want to, to, to show you uh the ta table of uh peach peak pressure versus plateau pressure. Yeah. So when the peak pressure is high and the plateau pressure is low, we are talking about uh resistance and what this can be, it can be uh airways So it's some, some ex accer accelerations in our airs uh airways, we have to, to check to do suction and something like this. Bronchial spasm also resistance secretions also, like I told you uh mucus plague. Yeah, all type occlusion uh was and the pla plateau pre plateau problems, plateau pressure. It's we are talking about uh compliance, low compliance when we have low compliance, uh pneumonia, pneumothorax A R DS pulma, these all conditions that we uh we are talking about plato uh pressure or uh we call it low complex. Uh So we, we will stop uh this uh till now. Um Yes, thank you very much mister Bad for a great lecture. Um Unfortunately, we do have another lecture starting right now. Um Yeah, yeah, I saw it already. So thank you very much for listening. Uh Another time I want to you ask questions. Yeah, of course. Thank you. Uh Maybe if you share your email in the chat, people can send you questions um by email. Comfort with that. No problem. I'll just end the recording.