Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
This PPT is basically based on the topic - Blood transfusion in Bailey & Love and mainly very useful for Final MBBS students.during their course as well as their in clinical practice.
OXYGEN THERAPY is vast diversified topic.
in the slide share, we have tried to compile all detailed information in brief.
the slides are well versed and all information have been garnered from verified sources.
all recent guidelines, standard textbooks have been referred.
COURTESY- DEPARTMENT OF CRITICAL CARE MEDICINE,
ABVIMS & DR RML HOSPITAL, NEW DELHI.
A brief explanation about Non invasive blood pressure monitoring intra operatively and few fit bits about oxygen analyser, much useful for residents in anaesthesia
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
Honest Reviews of Tim Han LMA Course Program.pptxtimhan337
Personal development courses are widely available today, with each one promising life-changing outcomes. Tim Han’s Life Mastery Achievers (LMA) Course has drawn a lot of interest. In addition to offering my frank assessment of Success Insider’s LMA Course, this piece examines the course’s effects via a variety of Tim Han LMA course reviews and Success Insider comments.
The French Revolution, which began in 1789, was a period of radical social and political upheaval in France. It marked the decline of absolute monarchies, the rise of secular and democratic republics, and the eventual rise of Napoleon Bonaparte. This revolutionary period is crucial in understanding the transition from feudalism to modernity in Europe.
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2. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
3. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
4. • 1943- luft –CO2 absorbs infrared light
• Ramwell – proved it beyond doubt
• 1978- holland the first country to adopt
• 1999 – ISA ‗desirable standard‘ in
anaesthesia monitoring standards
5. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
7. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
8. Oxygenation
• Measured by pulse oximetry (SpO2)
– Noninvasive measurement
– Percentage of oxygen in red blood cells
– Changes in ventilation take minutes
to be detected
– Affected by motion artifact, poor perfusion
and some dysrhythmias
9. • Capnography provides information about
CO2 production, pulmonary perfusion,
alveolar ventilation, respiratory patterns,
and elimination of CO2 from the
anesthesia circuit and ventilator.
10. Ventilation
• Measured by the end-tidal CO2
– Partial pressure (mmHg) or volume (% vol) of
CO2 in the airway at the end of exhalation
– Breath-to-breath measurement, provides
information within seconds
– Not affected by motion artifact, poor perfusion
or dysrhythmias
11. Oxygenation and Ventilation
• Oxygenation
– Oxygen for
metabolism
– SpO2 measures
% of O2 in RBC
– Reflects change in
oxygenation within
5 minutes
• Ventilation
– Carbon dioxide
from metabolism
– EtCO2 measures
exhaled CO2 at
point of exit
– Reflects change in
ventilation within
10 seconds
12. Why Capnography ?
• Capnography, an indirect monitor
helps in the differential diagnosis of hypoxia
to enable remedial measures to be taken before
hypoxia results in an irreversible brain damage
• Capnography has been shown to be effective in
the early detection of adverse respiratory events.
13. • Capnography and pulse oximetry together
could have helped in the prevention of
93% of avoidable anesthesia mishaps
according to ASA closed claim study.
• Capnography has also been shown to
facilitates better detection of potentially
life-threatening problems than clinical
judgment alone
14. Case Scenario
• 61 year old male
• C/O: ―short-of-breath‖ and ―exhausted‖
• H/O: > 45 years of smoking 2 packs a day,
3 heart attacks, high blood pressure
• Meds: ―too expensive to take every day ‖
• Exam: HR 92, RR 18, 160/100, 2+ pitting
edema, wheezing, crackles
What other information would help in
making assessment of this pt.?
16. Why Measure Ventilation—
Non-intubated Patients
• Gauge severity of hypoventilation states
– Drug intoxication
– Congestive heart failure
– Sedation and analgesia
– Stroke
– Head injury
• Assess perfusion status
• Noninvasive monitoring of patients in DKA
17. • History
• Terminology
• Why capnography
• Basic physiology
• Physics
• Types
• Components of capnography
• Clinical application
• Carry home
18. CO2 transport
• 60% as bicarbonate ion
• 10-20% binds to amino group of proteins
mostly hemoglobin
HALDANE EFFECT
• 5-10% directly dissolved in plasma
19. End-tidal CO2 (EtCO2)
r r Oxygen
O
2
CO2
O
2
VeinA te y
Ventilation
Perfusion
Pulmonary Blood Flow
Right
Ventricle
Left
Atrium
20. End-tidal CO2 (EtCO2)
• Carbon dioxide can be measured
• Arterial blood gas is PaCO2
– Normal range: 35-45mmHg
• Mixed venous blood gas PeCO2
– Normal range: 46-48mmHg
• Exhaled carbon dioxide is EtCO2
– Normal range: 35-45mmHg
21. End-tidal CO2 (EtCO2)
• Reflects changes in
– Ventilation - movement of air in and
out of the lungs
– Diffusion - exchange of gases between
the air-filled alveoli and the pulmonary
circulation
– Perfusion - circulation of blood
22. End-tidal CO2 (EtCO2)
• Monitors changes in
– Ventilation - asthma, COPD, airway
edema, foreign body, stroke
– Diffusion - pulmonary edema,
alveolar damage, CO poisoning,
smoke inhalation
– Perfusion - shock, pulmonary
embolus, cardiac arrest,
severe dysrhythmias
23. a-A Gradient
r r Alveolus
PaCO2
VeinA te y
Ventilation
Perfusion
Arterial to Alveolar Difference for CO2
Right
Ventricle
Left
Atrium
EtCO2
24. End-tidal CO2 (EtCO2)
• Normal a-A gradient
– 2-5mmHg difference between the EtCO2
and PaCO2 in a patient with healthy lungs
– Wider differences found
• In abnormal perfusion and ventilation
• Incomplete alveolar emptying
• Poor sampling
25. Negative a-A gradient
• Pregnancy
• Infants and children
• During and after bypass
• after coming of cardiac bypass
• Low frequency high tidal volume
ventilation
26. • History
• Terminology
• Why capnography
• Basic physiology
• Physics
• Types
• Components of capnography
• Clinical application
• Carry home
27. Raman effect
• Electromagnetic radiation and molecule
• The transfer of energy affects the vibration
energy associated with bonds between the
atoms in a molecule
• Absorption of radiation at a particular
wave length is associated with the specific
type of bond between atoms in a
molecule.
29. • Energy of radiation is proportional to the
frequency of radiation
• the transfer of energy between the
radiation and molecule results in a change
in the wavelength of radiation
30. Raman spectrography
• Raman Spectrography uses the principle of "Raman
Scattering" for CO2 measurement.
• The gas sample is aspirated into an analyzing
chamber, where the sample is illuminated by a high
intensity monochromatic argon laser beam.
• The light is absorbed by molecules which are then
excited to unstable vibrational or rotational energy
states (Raman scattering).
• The Raman scattering signals (Raman light) are of low
intensity and are measured at right angles to the laser
beam.
• The spectrum of Raman scattering lines can be used
to identify all types of molecules in the gas phase
34. Effect of atmospheric pressure
• FEtCO2=partial pressure(atmospheric
pressure-water vapour pressure)*100
• At atm pressure of 760mmHg,
FEtCO2=38(760-47)*100 =5%
at atm pressure of 500mmHg
FEtCO2=38(500-47)*100 =8%
35. Influence of water vapour
1. Effect of condensed water:
Water vapor may condense on the
window of the sensor cell and absorb IR
light, thereby produce falsely high C02
readings
36. 2. Effect of water vapor.
The temperature of the sampling gases
may decrease during the passage from the
patient to the unit, resulting in a decrease in
the partial pressure of water vapor. This can
cause an apparent increase in C02
concentration of about 1.5-2%
FEtCO2=partial pressure(atmospheric
pressure-water vapour pressure)*100
37. • History
• Terminology
• Why capnography
• Basic physiology
• Physics
• Types
• Components of capnography
• Clinical application
• Carry home
39. Time capnography
Advantages
• Simple and convenient
• Monitor non-intubated patients
• Monitor dynamics of inspiration and
expiration
Disadvantages
• Poor estimation of V/Q status of lungs
• Physiologic space dead space
41. Side-stream Capnographs
advantages
Easy to connect
No problems with sterilization
Can be used in awake patients
Easy to use when patient is in
unusual positions such as in prone
position
Can be used in collaboration with
simultaneous oxygen
administration via a nasal prong
disadvantages
Delay in recording due to movement
of gases from the ET to the unit
Sampling tube obstruction
Water vapor pressure changes
affect CO2 concentrations
Pressure drop along the sampling
tube affects CO2 measurements
45. Mainstream
• Advantages
No sampling tube
No obstruction
No affect due to pressure drop
No affect due to changes in water
vapor pressure
No pollution
No deformity of capnograms due to
non dispersion of gases
No delay in recording
Suitable for neonates and children
• Disadvantages
weight of the sensor, (the newer
sensors are light weight minimizing
traction on the endotracheal tube)
Long electrical cord, but it is
lightweight.
Sensor windows may clog with
secretions( they can be replaced
easily as they are disposable)
Difficult to use in unusual patient
positioning such as in prone
positions.
46. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
47. Capnographic Waveform
• Normal waveform of one respiratory cycle
• Similar to ECG
– Height shows amount of CO2
– Length depicts time
48. Capnographic Waveform
• Waveforms on screen and printout
may differ in duration
– On-screen capnography waveform is
condensed to provide adequate information
the in 4-second view
– Printouts are in real-time
– Observe RR on device
49. Capnographic Waveform
• Capnograph detects only CO2
from ventilation
• No CO2 present during inspiration
– Baseline is normally zero
A B
C D
E
Baseline
50. Phase I Dead space ventillation
Beginning of exhalation
A B
IBaseline
51. Phase II Ascending Phase
Alveoli
CO2 present and increasing in exhaled air
II
A
B
C
Ascending Phase
Early Exhalation
52. Phase III Alveolar Plateau
CO2 exhalation wave
plateaus
A B
C D
III
Alveolar Plateau
53. Capnogram Phase III
End-Tidal
End of the the wave of exhalation contains the
highest concentration of CO2 - number seen on
monitor
A B
C D
End-tidal
54. Capnogram Phase IV
Descending Phase
• Inhalation begins
• Oxygen fills airway
• CO2 level quickly
drops to zero
Alveoli
55. Capnogram Phase IV
Descending Phase
Inspiratory downstroke returns to baseline
A B
C D
E
IV
Descending Phase
Inhalation
56. Inspiratory segment
• Phase 0:
Inspiration
• Beta Angle - Angle
between phase III
and descending
limb of inspiratory
segment
57. Expiratory segment
• Phase I - Anatomical
dead space
• Phase II - Mixture of
anatomical and
alveolar dead space
• Phase III - Alveolar
plateau
• Alfa angle - Angle
between phase II and
phase III (V/Q status of
lung
60. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
61. Capnography-3 sources of information
• No. – PEtCO2 values
• Shapes of capnogram
• (a-ET)PCO2 differences
62. (a-ET)PCO2 differences
• (a-ET)PCO2 difference is a gradient of
alveolar dead space.
increase decrease
Age
Emphysema
Low cardiac output
states
Hypovolemia
Pulmonary embolism
Pregnancy and
Children
63. Five characteristics of capnogram
should be evaluated
The shape of a capnogram is identical in all
humans with healthy lungs.
Any deviations in shape must be investigated to
determine a physiological or a pathological cause
of the abnormality
• Frequency
• Rhythm
• Height
• Baseline
• Shape
65. • A terminal upswing
at the end of phase
3, known as phase
4, can occur in
pregnant subjects,
obese subjects
and low
compliance states
66. The slope the expiratory plateau is increased as a
normal physiological variation in pregnancy
67. Prolonged inspiratory descending limb
• due to dispersion
gases in the sampling
line or as well as
prolonged response
time of the analyzer.
Seen in children who
have faster
respiratory rates
68. Base line elevated in
• Inadequate fresh gas flow
• Accidental administration of CO2
• Rebreathing
• Insp / exp valve malfunction
• Exhausted CO2 absorber
79. Cardiogenic oscillations.
• Ripple effect,
superimposed on
the plateau and the
descending limb,
resulting from
small gas
movements
produced by
pulsations of the
aorta and heart.
80. Airway obstruction (eg., bronchospasm). Phase II and phase III
are prolonged and alpha angle (angle between phase II and
phase III) is increased
87. • Sampling
problems such air
or oxygen dilution
during nasal or
mask sampling of
carbon dioxide in
spontaneously
breathing patients.
88. Detection of pulmonary air embolism
• A rapid decrease of PETCO2
in the absence of changes in
blood pressure, central
venous pressure and heart
rate indicates an air embolism
without systemic
hemodynamic consequences.
• as the size of air embolism
increases, a reduction in
cardiac output occurs which
further decreases PETCO2
measurement. A reduced
cardiac output by itself can
decrease PETCO2.
90. • History
• Terminology
• Why capnography
• Physics
• Types
• Basic physiology
• Components of capnography
• Clinical application
• Carry home
91. Phases of the Capnogram
Phase I
Expiration
Represents
anatomical
dead space
Phase II
Expiration
Mixture of
anatomical and
alveolar dead
space
Phase III
Expiration
Plateau of
alveolar
expiration
Phase 0
Inspiration
Rapid fall
in CO2
concentration
Phase IV
Exhalation
Compromised
thoracic
compliance
95. Cardiogenic Oscillations
Ripples during Phase II and Phase III
Due to changes in pulmonary blood volume and
ultimately CO2 pressure as a result of cardiac
contractions
96. Curare Cleft
Shallow dips in phase II plateau
Can occur when patient is in a light plane of
anesthesia
Represent patient attempts to breathe independent of mechanical ventilation
98. Rebreathing of Soda Lime
Contamination with CO2
Elevation of Phase II segment and
baseline
Elevation of baseline and Phase II, smaller inspiratory efforts
Progressive elevation of Phase II and baseline
