capnography waveform interpretation ICU anesthesia clinical guide 2024

mkdir -p /home/daytona/workspace/capnography-pptx && ls /home/daytona/workspace/…

~/capnography-pptx/build_capno.js

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── THEME ───────────────────────────────────────────────────────────────────
const C = {
  navy:    "0A1628",   // dominant dark background
  teal:    "0D7377",   // primary accent
  green:   "14A085",   // secondary accent / highlight
  amber:   "F59E0B",   // warning / alert
  white:   "F0F4F8",   // body text
  silver:  "94A3B8",   // muted text
  red:     "E53E3E",   // danger
  bg2:     "0F1F35",   // slightly lighter dark bg
  bg3:     "1A2F4A",   // card backgrounds
};

const pres = new pptxgen();
pres.layout  = "LAYOUT_16x9";
pres.author  = "Orris";
pres.title   = "Capnography: Principles & Clinical Practice";
pres.subject = "ICU / Anesthesia Education";

// ─── HELPERS ─────────────────────────────────────────────────────────────────
function darkSlide(slide) {
  slide.background = { color: C.navy };
}
function cardSlide(slide) {
  slide.background = { color: C.bg2 };
}

function topBar(slide, color = C.teal) {
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.08, fill: { color }, line: { color } });
}
function sectionTag(slide, text, x = 8.4, y = 0.12) {
  slide.addText(text.toUpperCase(), {
    x, y, w: 1.5, h: 0.22, fontSize: 7, bold: true, color: C.teal,
    charSpacing: 2, align: "right", valign: "middle",
  });
}
function slideTitle(slide, title, subtitle = null) {
  slide.addText(title, {
    x: 0.45, y: 0.14, w: 9.1, h: 0.55,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
    margin: 0,
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.45, y: 0.70, w: 9.1, h: 0.3,
      fontSize: 11, color: C.teal, fontFace: "Calibri",
      margin: 0, italic: true,
    });
  }
}
function divider(slide, y = 1.05) {
  slide.addShape(pres.ShapeType.line, {
    x: 0.45, y, w: 9.1, h: 0,
    line: { color: C.teal, width: 1.2 },
  });
}
function bullets(slide, items, x, y, w, h, opts = {}) {
  const base = { fontSize: 12.5, color: C.white, fontFace: "Calibri", ...opts };
  const arr = items.map((item, i) => ({
    text: item,
    options: { bullet: { indent: 14 }, breakLine: i < items.length - 1, ...base },
  }));
  slide.addText(arr, { x, y, w, h, valign: "top" });
}
function card(slide, x, y, w, h, fillColor = C.bg3) {
  slide.addShape(pres.ShapeType.roundRect, {
    x, y, w, h,
    fill: { color: fillColor },
    line: { color: C.teal, width: 0.8 },
    rectRadius: 0.06,
  });
}
function cardTitle(slide, text, x, y, w, color = C.teal) {
  slide.addText(text, {
    x, y, w, h: 0.3,
    fontSize: 10.5, bold: true, color, fontFace: "Calibri",
    margin: 0,
  });
}
function badge(slide, text, x, y, bg = C.teal) {
  slide.addShape(pres.ShapeType.roundRect, {
    x, y, w: 0.55, h: 0.28,
    fill: { color: bg },
    line: { color: bg },
    rectRadius: 0.04,
  });
  slide.addText(text, {
    x, y, w: 0.55, h: 0.28,
    fontSize: 9, bold: true, color: C.white, align: "center", valign: "middle",
    fontFace: "Calibri", margin: 0,
  });
}

// ─── SLIDE 1: TITLE ───────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  darkSlide(s);
  // Left accent bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 5.625, fill: { color: C.teal }, line: { color: C.teal } });
  // Decorative wave rect
  s.addShape(pres.ShapeType.rect, { x: 5.8, y: 0, w: 4.2, h: 5.625, fill: { color: C.bg3 }, line: { color: C.bg3 } });

  s.addText("CAPNOGRAPHY", {
    x: 0.6, y: 1.2, w: 5, h: 0.85,
    fontSize: 38, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 4,
  });
  s.addText("Principles & Clinical Practice", {
    x: 0.6, y: 2.05, w: 5, h: 0.45,
    fontSize: 18, color: C.teal, fontFace: "Calibri", italic: true,
  });
  s.addShape(pres.ShapeType.line, {
    x: 0.6, y: 2.55, w: 3.2, h: 0,
    line: { color: C.amber, width: 2.5 },
  });
  s.addText("For ICU & Anesthesia Clinicians", {
    x: 0.6, y: 2.72, w: 5, h: 0.3,
    fontSize: 11, color: C.silver, fontFace: "Calibri",
  });

  // Right panel content
  s.addText("Key Topics", {
    x: 6.1, y: 0.7, w: 3.6, h: 0.35,
    fontSize: 13, bold: true, color: C.teal, fontFace: "Calibri",
  });
  const topics = [
    "Physics & Technology",
    "Normal Waveform Phases",
    "Abnormal Patterns",
    "Clinical Applications",
    "ETT Confirmation",
    "CPR & ROSC Monitoring",
    "Dead Space & Physiology",
    "Troubleshooting",
    "Special Populations",
  ];
  topics.forEach((t, i) => {
    badge(s, `${i+1}`, 6.1, 1.12 + i * 0.44, C.teal);
    s.addText(t, {
      x: 6.72, y: 1.12 + i * 0.44, w: 2.9, h: 0.28,
      fontSize: 10, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0,
    });
  });
}

// ─── SLIDE 2: WHAT IS CAPNOGRAPHY? ───────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Introduction");
  slideTitle(s, "What is Capnography?");
  divider(s);

  // Definition card
  card(s, 0.4, 1.15, 9.2, 1.0, C.bg3);
  s.addText("Capnography is the continuous, non-invasive measurement and graphical display of CO₂ concentration in respiratory gases, providing real-time breath-by-breath data on ventilation, perfusion, and metabolism.", {
    x: 0.6, y: 1.22, w: 8.8, h: 0.85,
    fontSize: 13, color: C.white, fontFace: "Calibri", valign: "middle",
  });

  // Three pillars
  const pillars = [
    { title: "Capnometry",    desc: "Numeric display only — ETCO₂ value in mmHg or %",        color: C.teal  },
    { title: "Capnography",   desc: "Numeric + waveform (capnogram) — preferred in ICU/OR",   color: C.green },
    { title: "Capnogram",     desc: "The actual CO₂ waveform trace over time",                 color: C.amber },
  ];
  pillars.forEach((p, i) => {
    const x = 0.4 + i * 3.1;
    card(s, x, 2.3, 2.9, 1.55, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y: 2.3, w: 2.9, h: 0.35, fill: { color: p.color }, line: { color: p.color } });
    s.addText(p.title, { x, y: 2.3, w: 2.9, h: 0.35, fontSize: 12, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(p.desc, { x: x + 0.1, y: 2.7, w: 2.7, h: 1.1, fontSize: 11, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Normal ETCO₂: 35–45 mmHg (reflects PaCO₂ with a 2–5 mmHg gradient due to alveolar dead space)", {
    x: 0.4, y: 3.98, w: 9.2, h: 0.3,
    fontSize: 10.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
  s.addText("Sources: Morgan & Mikhail's Clinical Anesthesiology, 7e | Barash Clinical Anesthesia, 9e", {
    x: 0.4, y: 5.25, w: 9.2, h: 0.22,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 3: PHYSICS & TECHNOLOGY ───────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Technology");
  slideTitle(s, "Physics & Technology");
  divider(s);

  // Left: Beer-Lambert
  card(s, 0.4, 1.15, 4.4, 2.5, C.bg3);
  cardTitle(s, "Beer-Lambert Law", 0.55, 1.22, 4.1);
  s.addText([
    { text: "A = ε × c × l", options: { bold: true, fontSize: 15, color: C.amber, breakLine: true } },
    { text: "\nAbsorption of infrared (IR) light is proportional to the concentration of CO₂ in the gas sample. CO₂ absorbs IR at 4.26 µm wavelength. N₂ and O₂ do not absorb IR — measured separately.", options: { fontSize: 11, color: C.white } },
  ], { x: 0.55, y: 1.55, w: 4.1, h: 2.0, valign: "top", fontFace: "Calibri" });

  // Right: two sub-cards
  card(s, 5.05, 1.15, 4.5, 1.18, C.bg3);
  cardTitle(s, "Mainstream (In-line)", 5.2, 1.22, 4.2, C.green);
  bullets(s, [
    "Sensor sits directly at airway adapter",
    "No lag time, no aspiration loss",
    "Heavier — risk of ETT traction",
    "Best for intubated patients",
  ], 5.2, 1.52, 4.2, 0.75, { fontSize: 10.5 });

  card(s, 5.05, 2.45, 4.5, 1.2, C.bg3);
  cardTitle(s, "Sidestream (Diverting)", 5.2, 2.52, 4.2, C.amber);
  bullets(s, [
    "Aspirates gas ~50–250 mL/min to bedside analyzer",
    "Prone to water condensation / obstruction",
    "Works with non-intubated patients (nasal cannula)",
    "Slight lag; may dilute ETCO₂ in small VT (pediatrics)",
  ], 5.2, 2.82, 4.2, 0.78, { fontSize: 10.5 });

  card(s, 0.4, 3.78, 9.15, 0.75, C.bg3);
  cardTitle(s, "Colorimetric Capnometry", 0.55, 3.85, 9.0, C.silver);
  s.addText("Semi-quantitative device using a pH-sensitive indicator that changes color with CO₂ exposure. Used for rapid ETT confirmation — NOT a substitute for continuous waveform capnography.", {
    x: 0.55, y: 4.12, w: 9.0, h: 0.35,
    fontSize: 10.5, color: C.white, fontFace: "Calibri",
  });

  s.addText("Sources: Morgan & Mikhail's Clinical Anesthesiology, 7e | Tintinalli's Emergency Medicine", {
    x: 0.4, y: 5.25, w: 9.2, h: 0.22,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 4: NORMAL CAPNOGRAM ────────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Waveform");
  slideTitle(s, "The Normal Capnogram", "4-Phase respiratory cycle");
  divider(s);

  // Fetch waveform image
  let waveformImg = null;
  try {
    const result = JSON.parse(execSync(
      `node /home/daytona/skills/shared/scripts/fetch_images.js "https://cdn.orris.care/cdss_images/828c73846ab533126561d83ab1202121bde9bde9bec54ca7033cf1a352eb89e7.png"`,
      { timeout: 30000 }
    ).toString());
    if (result[0] && !result[0].error) waveformImg = result[0].base64;
  } catch(e) { /* skip */ }

  if (waveformImg) {
    s.addImage({ data: waveformImg, x: 0.4, y: 1.15, w: 4.4, h: 3.2 });
  } else {
    card(s, 0.4, 1.15, 4.4, 3.2, C.bg3);
    s.addText("[Capnogram waveform diagram]", { x: 0.4, y: 2.5, w: 4.4, h: 0.4, fontSize: 11, color: C.silver, align: "center", fontFace: "Calibri" });
  }

  // Phases
  const phases = [
    { ph: "Phase I",   col: C.teal,   desc: "Baseline — anatomic dead space gas (CO₂ ≈ 0 mmHg)" },
    { ph: "Phase II",  col: C.green,  desc: "Steep upstroke — mixing of dead space & alveolar gas" },
    { ph: "Phase III", col: C.amber,  desc: "Alveolar plateau — plateau of CO₂; ETCO₂ measured at peak" },
    { ph: "Phase 0",   col: C.silver, desc: "Inspiratory downstroke — rapid return to baseline" },
  ];
  phases.forEach((p, i) => {
    card(s, 5.05, 1.15 + i * 0.98, 4.5, 0.88, C.bg3);
    badge(s, p.ph.split(" ")[1], 5.15, 1.22 + i * 0.98, p.col);
    s.addText(p.ph, { x: 5.75, y: 1.22 + i * 0.98, w: 3.7, h: 0.25, fontSize: 10.5, bold: true, color: p.col, fontFace: "Calibri", margin: 0 });
    s.addText(p.desc, { x: 5.75, y: 1.48 + i * 0.98, w: 3.7, h: 0.48, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Normal ETCO₂: 35–45 mmHg | PaCO₂–ETCO₂ gradient: 2–5 mmHg (reflects alveolar dead space)", {
    x: 0.4, y: 5.05, w: 9.2, h: 0.25,
    fontSize: 9.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e, p.227", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 5: CO₂ PHYSIOLOGY ──────────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Physiology");
  slideTitle(s, "CO₂ Physiology & the ETCO₂–PaCO₂ Relationship");
  divider(s);

  card(s, 0.4, 1.15, 9.2, 0.85, C.bg3);
  s.addText("ETCO₂ is determined by 3 factors: CO₂ Production (VCO₂) | Alveolar Ventilation (VA) | Ventilation-Perfusion (V/Q) Matching", {
    x: 0.6, y: 1.22, w: 8.8, h: 0.7,
    fontSize: 12.5, color: C.white, bold: true, fontFace: "Calibri", valign: "middle", align: "center",
  });

  const factors = [
    {
      title: "CO₂ Production ↑",
      items: ["Fever / hyperthermia", "Malignant hyperthermia", "Hypermetabolic states", "Reperfusion after ischemia", "Bicarbonate administration"],
      col: C.amber,
    },
    {
      title: "Alveolar Ventilation ↑",
      items: ["Reduces ETCO₂ (hyperventilation)", "Reduces PaCO₂ in parallel", "Used in controlled ventilation", "Hyperventilation: ETCO₂ <35 mmHg", "Hypoventilation: ETCO₂ >45 mmHg"],
      col: C.teal,
    },
    {
      title: "V/Q Mismatch & Dead Space",
      items: ["Pulmonary embolism ↑ dead space", "Air embolism → sudden ETCO₂ drop", "Decreased cardiac output", "Hypotension / shock states", "PaCO₂–ETCO₂ gradient widens"],
      col: C.red,
    },
  ];
  factors.forEach((f, i) => {
    const x = 0.4 + i * 3.1;
    card(s, x, 2.1, 2.9, 3.0, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y: 2.1, w: 2.9, h: 0.33, fill: { color: f.col }, line: { color: f.col } });
    s.addText(f.title, { x, y: 2.1, w: 2.9, h: 0.33, fontSize: 10.5, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    bullets(s, f.items, x + 0.1, 2.48, 2.7, 2.55, { fontSize: 10.5 });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e | Roberts & Hedges' Clinical Procedures", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 6: ABNORMAL WAVEFORMS ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Waveform");
  slideTitle(s, "Abnormal Capnogram Patterns", "Recognition & clinical significance");
  divider(s);

  const patterns = [
    { label: "Obstructive pattern (COPD/Asthma)", color: C.amber, desc: "Shark fin / slanted plateau — incomplete emptying; no true plateau. PaCO₂–ETCO₂ gradient ↑↑. Suggests air trapping.", icon: "~" },
    { label: "Baseline > 0 (Rebreathing)", color: C.red, desc: "Elevated inspired CO₂. Causes: exhausted CO₂ absorbent, incompetent expiratory valve, inadequate fresh gas flow.", icon: "↑" },
    { label: "Sudden ETCO₂ → 0", color: C.red, desc: "Circuit disconnection, esophageal intubation, cardiac arrest, complete airway obstruction, apnea.", icon: "!" },
    { label: "Gradual ETCO₂ decline", color: C.amber, desc: "Decreasing cardiac output, pulmonary embolism, air embolism, severe hypotension, hyperventilation.", icon: "↓" },
    { label: "Curare cleft (Phase III dip)", color: C.teal, desc: "Spontaneous respiratory effort during controlled ventilation — patient 'biting back' during phase III plateau.", icon: "⌒" },
    { label: "Elevated plateau (Hypoventilation)", color: C.amber, desc: "ETCO₂ >45 mmHg: inadequate ventilator settings, opioid over-sedation, airway obstruction.", icon: "↑" },
  ];

  patterns.forEach((p, i) => {
    const col = i < 3 ? 0 : 1;
    const row = i % 3;
    const x = col === 0 ? 0.4 : 5.05;
    const y = 1.15 + row * 1.38;
    card(s, x, y, 4.5, 1.28, C.bg3);
    badge(s, p.icon, x + 0.1, y + 0.08, p.color);
    s.addText(p.label, { x: x + 0.72, y: y + 0.08, w: 3.7, h: 0.28, fontSize: 10, bold: true, color: p.color, fontFace: "Calibri", margin: 0 });
    s.addText(p.desc, { x: x + 0.1, y: y + 0.42, w: 4.28, h: 0.78, fontSize: 9.5, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e, Figure 6-3 | Tintinalli's Emergency Medicine", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 7: ETT CONFIRMATION ────────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Clinical Use");
  slideTitle(s, "Endotracheal Tube Confirmation & Placement");
  divider(s);

  card(s, 0.4, 1.15, 9.2, 0.78, "1A3A5C");
  s.addText("⚠  Waveform capnography is the GOLD STANDARD for confirming ETT placement — mandatory during ALL anesthetic procedures per ASA standards.", {
    x: 0.6, y: 1.22, w: 8.8, h: 0.65,
    fontSize: 12.5, bold: true, color: C.amber, fontFace: "Calibri", valign: "middle",
  });

  const cols = [
    {
      title: "Tracheal Intubation",
      color: C.green,
      items: [
        "Persistent CO₂ waveform with each breath",
        "ETCO₂ 35–45 mmHg after 3–6 breaths",
        "Waveform confirms tracheal placement",
        "Most reliable confirmation method available",
        "Persists even with epinephrine during CPR",
      ],
    },
    {
      title: "Esophageal Intubation",
      color: C.red,
      items: [
        "Initial transient CO₂ from swallowed air",
        "Washes out within 2–4 breaths → zero",
        "Capnograph rapidly & reliably detects this",
        "Must REMOVE tube and reintubate immediately",
        "Do NOT rely on auscultation alone",
      ],
    },
    {
      title: "Mainstem Bronchus",
      color: C.amber,
      items: [
        "Capnography does NOT reliably detect this",
        "ETCO₂ still present but unilateral ventilation",
        "Auscultation + CXR remain necessary",
        "SpO₂ drop may be first clue",
        "Confirm position: pull back ETT slowly",
      ],
    },
  ];
  cols.forEach((c, i) => {
    const x = 0.4 + i * 3.1;
    card(s, x, 2.05, 2.9, 3.15, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y: 2.05, w: 2.9, h: 0.35, fill: { color: c.color }, line: { color: c.color } });
    s.addText(c.title, { x, y: 2.05, w: 2.9, h: 0.35, fontSize: 11, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    bullets(s, c.items, x + 0.1, 2.45, 2.7, 2.7, { fontSize: 10.5 });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e, p.227 | ASA Monitoring Standards", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 8: CAPNOGRAPHY IN CPR ─────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s, C.red);
  sectionTag(s, "Resuscitation");
  slideTitle(s, "Capnography in Cardiac Arrest & CPR", "AHA 2020 Guidelines: Continuous waveform capnography for ALL intubated patients");
  divider(s);

  // Fetch CPR capnogram image
  let cprImg = null;
  try {
    const result = JSON.parse(execSync(
      `node /home/daytona/skills/shared/scripts/fetch_images.js "https://cdn.orris.care/cdss_images/350f35fead1f8eaf09cb2344b95c939b89f1408dfc5f5732b87a17d63dd7fb30.png"`,
      { timeout: 30000 }
    ).toString());
    if (result[0] && !result[0].error) cprImg = result[0].base64;
  } catch(e) { /* skip */ }

  if (cprImg) {
    s.addImage({ data: cprImg, x: 0.4, y: 1.15, w: 4.0, h: 2.6 });
  }

  const panels = [
    { title: "ETCO₂ at Cardiac Arrest",  col: C.red,   text: "ETCO₂ falls abruptly at the onset of cardiac arrest due to cessation of pulmonary circulation — CO₂ accumulates in tissues but cannot be exhaled." },
    { title: "During CPR",                col: C.amber, text: "ETCO₂ correlates with cardiac output during CPR. Higher ETCO₂ (>10 mmHg) indicates better compression quality. Target ETCO₂ ≥10–20 mmHg." },
    { title: "ROSC Detection",            col: C.green, text: "Sudden rise in ETCO₂ (>35–40 mmHg) during CPR is a sensitive early indicator of ROSC — often before a palpable pulse." },
    { title: "Termination Guide",         col: C.silver, text: "ETCO₂ persistently <10 mmHg after 20+ min of ACLS correlates with poor survival; can support decision to cease resuscitation (context-dependent)." },
  ];
  panels.forEach((p, i) => {
    const x = 4.6;
    const y = 1.15 + i * 1.08;
    card(s, x, y, 5.0, 0.98, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 0.22, h: 0.98, fill: { color: p.col }, line: { color: p.col } });
    s.addText(p.title, { x: x + 0.32, y: y + 0.04, w: 4.6, h: 0.26, fontSize: 10.5, bold: true, color: p.col, fontFace: "Calibri", margin: 0 });
    s.addText(p.text, { x: x + 0.32, y: y + 0.32, w: 4.6, h: 0.62, fontSize: 9.8, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Source: Roberts & Hedges' Clinical Procedures in Emergency Medicine | AHA 2020 ACLS Guidelines", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 9: VENTILATOR MANAGEMENT ─────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Ventilation");
  slideTitle(s, "Capnography in Mechanical Ventilation", "ICU monitoring & ventilator optimization");
  divider(s);

  const items = [
    {
      title: "Confirming Ventilation Adequacy",
      color: C.green,
      points: ["Target ETCO₂ 35–45 mmHg in most patients", "Trend ETCO₂ to guide RR and VT adjustments", "Compare with ABG PaCO₂ — understand the gradient"],
    },
    {
      title: "Detecting Circuit Problems",
      color: C.amber,
      points: ["Sudden ETCO₂ → 0: disconnection or extubation", "Rising baseline CO₂: CO₂ absorbent exhausted", "Incompetent valve: CO₂ in inspired limb"],
    },
    {
      title: "Weaning & Spontaneous Breathing",
      color: C.teal,
      points: ["Rising ETCO₂ during SBT → failing wean", "Curare cleft → return of respiratory drive", "Monitor RR via capnograph during sedation vacation"],
    },
    {
      title: "Protective Lung Ventilation",
      color: C.silver,
      points: ["Permissive hypercapnia: accept ETCO₂ 45–60+", "ARDS: track CO₂ during low VT strategy", "Prone positioning: re-establish ETCO₂ baseline"],
    },
    {
      title: "Malignant Hyperthermia",
      color: C.red,
      points: ["Sudden dramatic ↑ ETCO₂ is earliest sign (before temperature rise)", "Act immediately: stop trigger agent, give dantrolene", "Increase minute ventilation to compensate"],
    },
    {
      title: "Air / Venous Gas Embolism",
      color: C.red,
      points: ["Rapid fall in ETCO₂ — increased dead space + ↓ CO", "Sensitive early indicator in sitting position surgery", "Simultaneously: hypotension, ↑ PAP, 'mill-wheel' murmur"],
    },
  ];

  items.forEach((item, i) => {
    const col = i % 2 === 0 ? 0 : 1;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.4 : 5.05;
    const y = 1.15 + row * 1.42;
    card(s, x, y, 4.5, 1.32, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.5, h: 0.3, fill: { color: item.color }, line: { color: item.color } });
    s.addText(item.title, { x, y, w: 4.5, h: 0.3, fontSize: 10, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    bullets(s, item.points, x + 0.1, y + 0.34, 4.28, 0.94, { fontSize: 10 });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e | Tintinalli's Emergency Medicine", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 10: PROCEDURAL SEDATION ───────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Sedation");
  slideTitle(s, "Capnography During Procedural Sedation & MAC", "Earlier detection than pulse oximetry");
  divider(s);

  card(s, 0.4, 1.15, 9.2, 0.82, "1A3A5C");
  s.addText([
    { text: "Key Evidence: ", options: { bold: true, color: C.amber } },
    { text: "Waugh et al. meta-analysis — respiratory depression 17.6× more likely to be detected with capnography vs. standard monitoring alone. Apnea episodes >20 seconds NOT detected by provider but detected by capnography (Soto et al.).", options: { color: C.white } },
  ], { x: 0.6, y: 1.22, w: 8.8, h: 0.7, fontSize: 11, fontFace: "Calibri", valign: "middle" });

  const sedCards = [
    {
      title: "Why Pulse Ox Lags",
      col: C.amber,
      text: "Supplemental O₂ delays SpO₂ drop by 4–5 minutes even after complete apnea. SpO₂ alone misses early hypoventilation. Capnography detects airway events 45+ seconds before SpO₂ falls.",
    },
    {
      title: "Nasal Sampling Methods",
      col: C.teal,
      text: "Modified nasal cannula with integrated CO₂ port allows continuous ETCO₂ monitoring in non-intubated patients receiving O₂. IV catheter inserted into face mask also works (Figs. 30-1, 30-2).",
    },
    {
      title: "Clinical Thresholds",
      col: C.green,
      text: "Apnea: ETCO₂ drops to 0. Hypoventilation: ETCO₂ >50 mmHg or apneic episodes. Obstruction: obstructive waveform shape without plateau. Act on capnograph change — do not wait for SpO₂ drop.",
    },
    {
      title: "Guideline Recommendations",
      col: C.silver,
      text: "ACEP Level B recommendation for PSA capnography. Growing consensus for routine use in all moderate-deep sedation. Barash (9e): 'capnography should be utilized in every MAC case' — cost is low, benefit is high.",
    },
  ];
  sedCards.forEach((c, i) => {
    const x = i < 2 ? 0.4 + i * 4.65 : 0.4 + (i - 2) * 4.65;
    const y = i < 2 ? 2.1 : 3.6;
    card(s, x, y, 4.45, 1.38, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.45, h: 0.3, fill: { color: c.col }, line: { color: c.col } });
    s.addText(c.title, { x, y, w: 4.45, h: 0.3, fontSize: 10.5, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(c.text, { x: x + 0.1, y: y + 0.34, w: 4.25, h: 1.0, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Source: Barash Clinical Anesthesia, 9e | Roberts & Hedges' Clinical Procedures | Waugh et al. meta-analysis", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 11: DEAD SPACE ─────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Physiology");
  slideTitle(s, "Dead Space & the PaCO₂–ETCO₂ Gradient", "Understanding when the gradient matters most");
  divider(s);

  // Equation display
  card(s, 0.4, 1.15, 9.2, 0.72, C.bg3);
  s.addText([
    { text: "PaCO₂ − ETCO₂ = ", options: { color: C.silver } },
    { text: "Alveolar Dead Space Effect", options: { bold: true, color: C.amber } },
    { text: "   |   Normal: 2–5 mmHg   |   Widened gradient: ↑ dead space or ↓ perfusion", options: { color: C.silver } },
  ], { x: 0.6, y: 1.22, w: 8.8, h: 0.58, fontSize: 12, fontFace: "Calibri", valign: "middle", align: "center" });

  const dsData = [
    { label: "Anatomical Dead Space",  col: C.teal,   text: "Conducting airways (≈2 mL/kg). ETCO₂ phase I reflects this. Increased by tracheostomy, ETT connector dead space." },
    { label: "Alveolar Dead Space",    col: C.amber,  text: "Ventilated but non-perfused alveoli. Normal ≈0. Increases with PE, ↓CO, air embolism, ARDS — widens PaCO₂–ETCO₂ gradient." },
    { label: "Physiological Dead Space", col: C.green, text: "Sum of anatomical + alveolar. Elevated in shock, PE, COPD. Measured by Bohr equation: Vd/Vt = (PaCO₂ − PECO₂) / PaCO₂." },
  ];
  dsData.forEach((d, i) => {
    card(s, 0.4 + i * 3.1, 2.0, 2.9, 1.6, C.bg3);
    s.addShape(pres.ShapeType.rect, { x: 0.4 + i * 3.1, y: 2.0, w: 2.9, h: 0.32, fill: { color: d.col }, line: { color: d.col } });
    s.addText(d.label, { x: 0.4 + i * 3.1, y: 2.0, w: 2.9, h: 0.32, fontSize: 10, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(d.text, { x: 0.5 + i * 3.1, y: 2.36, w: 2.7, h: 1.2, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  // Clinical table
  card(s, 0.4, 3.75, 9.2, 1.42, C.bg3);
  cardTitle(s, "Clinical Causes of Widened PaCO₂–ETCO₂ Gradient", 0.55, 3.82, 9.0, C.teal);
  const causes = [
    ["Pulmonary Embolism", "Air Embolism", "Severe Hypotension", "Cardiac Arrest"],
    ["ARDS / ALI", "COPD (obstructed phase III)", "Prone Positioning", "Reduced CO from any cause"],
  ];
  causes.forEach((row, ri) => {
    row.forEach((cell, ci) => {
      s.addText("• " + cell, {
        x: 0.55 + ci * 2.25, y: 4.12 + ri * 0.42, w: 2.2, h: 0.38,
        fontSize: 10, color: C.white, fontFace: "Calibri",
      });
    });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e | ROSEN's Emergency Medicine", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 12: SPECIAL POPULATIONS ───────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Special Populations");
  slideTitle(s, "Special Populations & Settings");
  divider(s);

  const pops = [
    {
      title: "Pediatrics",
      icon: "P",
      col: C.teal,
      items: [
        "High aspiration rate may dilute ETCO₂ (sidestream) — use low dead-space sampling",
        "Small VT: sidestream aspiration may pull fresh gas → underestimate ETCO₂",
        "Mainstream sensors may be too heavy for small airways",
        "Functional residual capacity lower → faster desaturation; capnography even more critical",
        "Apnea detection in neonates/NICU: nasal capnography highly sensitive",
      ],
    },
    {
      title: "Obstetrics",
      icon: "O",
      col: C.green,
      items: [
        "Pregnancy: baseline ETCO₂ lower (28–32 mmHg) due to progesterone-driven hyperventilation",
        "Rapid sequence induction: capnography immediately post-intubation mandatory",
        "Difficult airway risk higher — cannot rely on auscultation alone",
        "Failed intubation scenario: capnography confirms supraglottic device ventilation",
      ],
    },
    {
      title: "Bariatrics",
      icon: "B",
      col: C.amber,
      items: [
        "Increased risk of hypoventilation under sedation",
        "Pulse oximetry more prone to delay in this population",
        "Sidestream cannula during MAC/moderate sedation essential",
        "ETCO₂ trending helps guide PEEP and VT adjustments",
      ],
    },
    {
      title: "Non-OR Settings",
      icon: "N",
      col: C.silver,
      items: [
        "Endoscopy, MRI, radiology suites: sidestream nasal capnography",
        "ICU transport: continuous waveform confirms ETT position",
        "Emergency department: confirm tube placement, monitor PSA",
        "Prehospital / EMS: ETCO₂ guides CPR quality in field",
      ],
    },
  ];
  pops.forEach((p, i) => {
    const x = i < 2 ? 0.4 + i * 4.65 : 0.4 + (i - 2) * 4.65;
    const y = i < 2 ? 1.15 : 3.32;
    card(s, x, y, 4.45, 2.05, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.45, h: 0.32, fill: { color: p.col }, line: { color: p.col } });
    badge(s, p.icon, x + 0.1, y + 0.02, C.navy);
    s.addText(p.title, { x: x + 0.72, y: y, w: 3.65, h: 0.32, fontSize: 11, bold: true, color: C.navy, valign: "middle", fontFace: "Calibri", margin: 0 });
    bullets(s, p.items, x + 0.1, y + 0.38, 4.25, 1.62, { fontSize: 9.8 });
  });

  s.addText("Source: Barash Clinical Anesthesia, 9e | Roberts & Hedges' Clinical Procedures", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 13: TROUBLESHOOTING ────────────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Troubleshooting");
  slideTitle(s, "Systematic Troubleshooting Guide", "When something looks wrong — is it the patient or the equipment?");
  divider(s);

  card(s, 0.4, 1.15, 9.2, 0.55, C.bg3);
  s.addText("Systematic approach: Check PATIENT first → then EQUIPMENT. Do NOT assume an equipment problem until patient causes are excluded.", {
    x: 0.6, y: 1.2, w: 8.8, h: 0.45, fontSize: 11.5, bold: true, color: C.amber, fontFace: "Calibri", valign: "middle",
  });

  const rows = [
    { finding: "ETCO₂ = 0 (sudden)", patient: "Cardiac arrest, complete airway obstruction, bronchospasm, tension pneumothorax", equip: "Circuit disconnection, kinked ETT, blocked sampling line, sensor failure" },
    { finding: "ETCO₂ trending up", patient: "Hypoventilation, MH, sepsis, fever, CO₂ reabsorption", equip: "Partial obstruction of sampling line, water trap full" },
    { finding: "ETCO₂ trending down", patient: "Hyperventilation, ↓CO, PE, air embolism, hypothermia", equip: "Leak in circuit, sidestream over-aspiration (pediatrics)" },
    { finding: "Elevated inspired CO₂ (baseline >0)", patient: "None — this is almost always equipment", equip: "Exhausted CO₂ absorbent, incompetent expiratory valve, inadequate fresh gas flow" },
    { finding: "Shark-fin waveform", patient: "Bronchospasm, COPD exacerbation, mucus plug, secretions", equip: "Kinked or obstructed ETT, water in sampling line" },
    { finding: "Inconsistent/noisy waveform", patient: "Hiccoughs, patient movement, spontaneous breathing effort", equip: "Water precipitation in tubing, loose sampling connection" },
  ];

  // Table header
  const hdr = ["Finding", "Patient Cause", "Equipment Cause"];
  const colW = [2.6, 3.3, 3.3];
  const colX = [0.4, 3.05, 6.4];
  hdr.forEach((h, i) => {
    s.addShape(pres.ShapeType.rect, { x: colX[i], y: 1.78, w: colW[i], h: 0.28, fill: { color: C.teal }, line: { color: C.teal } });
    s.addText(h, { x: colX[i], y: 1.78, w: colW[i], h: 0.28, fontSize: 9.5, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
  });
  rows.forEach((r, i) => {
    const bg = i % 2 === 0 ? C.bg3 : C.navy;
    const y = 2.1 + i * 0.52;
    const cells = [r.finding, r.patient, r.equip];
    cells.forEach((cell, j) => {
      s.addShape(pres.ShapeType.rect, { x: colX[j], y, w: colW[j], h: 0.5, fill: { color: bg }, line: { color: C.bg3 } });
      s.addText(cell, { x: colX[j] + 0.05, y, w: colW[j] - 0.1, h: 0.5, fontSize: 8.8, color: j === 0 ? C.amber : C.white, fontFace: "Calibri", valign: "middle", bold: j === 0 });
    });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e | Roberts & Hedges' Clinical Procedures", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 14: ETCO₂ AS PROGNOSTIC TOOL ──────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s, C.amber);
  sectionTag(s, "Prognosis");
  slideTitle(s, "ETCO₂ as a Prognostic & Diagnostic Tool");
  divider(s);

  const cards4 = [
    {
      title: "CPR Quality Indicator",
      col: C.green,
      body: "ETCO₂ positively correlates with: cardiac output, coronary perfusion pressure, compression efficacy, ROSC likelihood, and survival. Target >10 mmHg during CPR; aim for >20 mmHg with good technique.",
    },
    {
      title: "Pulmonary Embolism",
      col: C.amber,
      body: "Acute PE increases dead space → ETCO₂ drops. The PaCO₂–ETCO₂ gradient widens. Clinical context: sudden hypotension + ETCO₂ drop → initiate PE workup. Not diagnostic alone but supports suspicion.",
    },
    {
      title: "Malignant Hyperthermia",
      col: C.red,
      body: "Sudden unexplained rise in ETCO₂ is the EARLIEST sign of MH — precedes temperature rise. Immediately: discontinue volatile agent, hyperventilate, give dantrolene 2.5 mg/kg IV (up to 10 mg/kg).",
    },
    {
      title: "Termination of Resuscitation",
      col: C.silver,
      body: "ETCO₂ <10 mmHg after 20 minutes of ACLS is associated with near-zero survival in unwitnessed arrest. Consider as one factor (not sole criterion) in termination decision. AHA 2020 supports this use.",
    },
  ];
  cards4.forEach((c, i) => {
    const x = i < 2 ? 0.4 + i * 4.65 : 0.4 + (i - 2) * 4.65;
    const y = i < 2 ? 1.15 : 3.2;
    card(s, x, y, 4.45, 1.88, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.45, h: 0.32, fill: { color: c.col }, line: { color: c.col } });
    s.addText(c.title, { x, y, w: 4.45, h: 0.32, fontSize: 11, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(c.body, { x: x + 0.1, y: y + 0.38, w: 4.25, h: 1.45, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Source: Roberts & Hedges' p.415 | AHA 2020 ACLS Guidelines | Morgan & Mikhail's Clinical Anesthesiology, 7e", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 15: NON-INTUBATED MONITORING ───────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s);
  sectionTag(s, "Non-Intubated");
  slideTitle(s, "Capnography in Non-Intubated Patients", "Monitoring ventilation without an airway device");
  divider(s);

  card(s, 0.4, 1.15, 9.2, 0.65, C.bg3);
  s.addText("Impedance-based respiratory monitoring detects chest wall movement — NOT airflow. In obstructive apnea or laryngospasm, chest wall still moves, but NO ventilation occurs. Capnography provides DIRECT airway-based respiratory rate.", {
    x: 0.6, y: 1.2, w: 8.8, h: 0.55, fontSize: 11, color: C.amber, fontFace: "Calibri", valign: "middle",
  });

  const methods = [
    { m: "Nasal Cannula O₂/CO₂", d: "Dual-purpose cannula: delivers O₂ + samples CO₂. Most common method for MAC/procedural sedation. Waveform quality good in cooperative patients. Respiratory rate accurate.", c: C.teal },
    { m: "Face Mask Adapter",     d: "IV catheter or sampling port inserted into face mask. Good for patients with mouth breathing or high O₂ requirements. Slightly diluted ETCO₂ but adequate for trend monitoring.", c: C.green },
    { m: "Oral-Nasal Cannula",    d: "Samples both oral and nasal airflow. More accurate in mouth-breathers. Provides true airway CO₂ regardless of route. Preferred for deep sedation cases.", c: C.amber },
    { m: "Tracheostomy Adapter",  d: "Sampling line attached to trach tube connector. Direct airway measurement. Minimal dilution. Standard approach for trach-dependent ICU patients.", c: C.silver },
  ];
  methods.forEach((m, i) => {
    const x = i < 2 ? 0.4 + i * 4.65 : 0.4 + (i - 2) * 4.65;
    const y = i < 2 ? 1.92 : 3.58;
    card(s, x, y, 4.45, 1.52, C.bg3);
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.45, h: 0.3, fill: { color: m.c }, line: { color: m.c } });
    s.addText(m.m, { x, y, w: 4.45, h: 0.3, fontSize: 10.5, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });
    s.addText(m.d, { x: x + 0.1, y: y + 0.35, w: 4.25, h: 1.14, fontSize: 10, color: C.white, fontFace: "Calibri", valign: "top" });
  });

  s.addText("Source: Barash Clinical Anesthesia, 9e, pp.2492–2493 | Roberts & Hedges' Clinical Procedures", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 16: QUICK REFERENCE GUIDE ─────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s, C.green);
  sectionTag(s, "Quick Reference");
  slideTitle(s, "Quick Reference: ETCO₂ Values at a Glance");
  divider(s);

  const valueRows = [
    { range: "35–45 mmHg",  label: "NORMAL",         col: C.green,  meaning: "Adequate ventilation & perfusion" },
    { range: "<35 mmHg",    label: "LOW / HYPER",     col: C.teal,   meaning: "Hyperventilation, PE, ↓CO, hypothermia" },
    { range: ">45 mmHg",    label: "HIGH / HYPO",     col: C.amber,  meaning: "Hypoventilation, MH, fever, obstruction" },
    { range: "= 0",         label: "CRITICAL",        col: C.red,    meaning: "Apnea, cardiac arrest, circuit disconnect, esophageal intubation" },
    { range: ">10 mmHg",    label: "CPR TARGET",      col: C.green,  meaning: "Minimum acceptable ETCO₂ during CPR — suggests adequate compressions" },
    { range: "<10 mmHg",    label: "POOR CPR / POOR Px", col: C.red, meaning: "Poor compression quality or futile resuscitation (>20 min ACLS)" },
    { range: "Sudden rise", label: "ROSC",            col: C.green,  meaning: "Abrupt jump in ETCO₂ during CPR → Return of spontaneous circulation" },
    { range: "28–32 mmHg",  label: "PREGNANCY",       col: C.teal,   meaning: "Normal baseline in pregnancy — progesterone-driven hyperventilation" },
  ];

  valueRows.forEach((r, i) => {
    const y = 1.15 + i * 0.54;
    s.addShape(pres.ShapeType.rect, { x: 0.4, y, w: 1.9, h: 0.46, fill: { color: r.col }, line: { color: r.col } });
    s.addText(r.range, { x: 0.4, y, w: 1.9, h: 0.46, fontSize: 11.5, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });

    s.addShape(pres.ShapeType.rect, { x: 2.35, y, w: 1.9, h: 0.46, fill: { color: C.bg3 }, line: { color: r.col } });
    s.addText(r.label, { x: 2.35, y, w: 1.9, h: 0.46, fontSize: 10, bold: true, color: r.col, align: "center", valign: "middle", fontFace: "Calibri", margin: 0 });

    s.addShape(pres.ShapeType.rect, { x: 4.3, y, w: 5.3, h: 0.46, fill: { color: C.bg3 }, line: { color: C.bg3 } });
    s.addText(r.meaning, { x: 4.4, y, w: 5.1, h: 0.46, fontSize: 10.5, color: C.white, fontFace: "Calibri", valign: "middle" });
  });

  s.addText("Source: Morgan & Mikhail's Clinical Anesthesiology, 7e | AHA 2020 | Barash Clinical Anesthesia, 9e | Roberts & Hedges'", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.2,
    fontSize: 7.5, color: C.silver, italic: true, fontFace: "Calibri",
  });
}

// ─── SLIDE 17: KEY CLINICAL PEARLS ───────────────────────────────────────────
{
  const s = pres.addSlide();
  cardSlide(s);
  topBar(s, C.amber);
  sectionTag(s, "Clinical Pearls");
  slideTitle(s, "10 Clinical Pearls for Practice");
  divider(s);

  const pearls = [
    "Capnography is the gold standard for ETT confirmation — not auscultation, not chest rise.",
    "A transient CO₂ trace (2–4 breaths) after intubation does NOT confirm tracheal placement — always watch for persistence.",
    "In patients on supplemental O₂, SpO₂ may take 4–5 minutes to drop after apnea. Capnography detects apnea immediately.",
    "The PaCO₂–ETCO₂ gradient is normally 2–5 mmHg. Widening suggests dead space (PE, ↓CO, air embolism).",
    "Sudden unexplained rise in ETCO₂ during anesthesia = malignant hyperthermia until proven otherwise.",
    "A sudden drop of ETCO₂ to zero during stable ventilation = circuit disconnection (or cardiac arrest) until proven otherwise.",
    "ETCO₂ during CPR reflects cardiac output — use it as a compression quality metric and early ROSC detector.",
    "In COPD/asthma, a slanted 'shark fin' phase III means no reliable plateau — ETCO₂ may significantly underestimate PaCO₂.",
    "An elevated CO₂ baseline (inspired CO₂ >0) is almost always equipment: check absorbent, valve, and fresh gas flow.",
    "Normal ETCO₂ does NOT rule out pathology — always interpret in clinical context with ABG when uncertain.",
  ];
  pearls.forEach((p, i) => {
    const y = 1.15 + i * 0.42;
    badge(s, `${i + 1}`, 0.4, y, C.amber);
    s.addText(p, { x: 1.0, y, w: 8.6, h: 0.35, fontSize: 10.5, color: C.white, fontFace: "Calibri", valign: "middle" });
  });
}

// ─── SLIDE 18: SUMMARY ────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  darkSlide(s);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 5.625, fill: { color: C.teal }, line: { color: C.teal } });

  s.addText("Summary", { x: 0.6, y: 0.3, w: 9, h: 0.5, fontSize: 11, color: C.teal, bold: true, charSpacing: 3, fontFace: "Calibri" });
  s.addText("Capnography at a Glance", { x: 0.6, y: 0.78, w: 9, h: 0.55, fontSize: 26, bold: true, color: C.white, fontFace: "Calibri" });
  s.addShape(pres.ShapeType.line, { x: 0.6, y: 1.38, w: 3.5, h: 0, line: { color: C.amber, width: 2.5 } });

  const summaryPoints = [
    { icon: "◆", col: C.teal,  text: "Measure CO₂ continuously — it reflects ventilation, perfusion, and metabolism simultaneously." },
    { icon: "◆", col: C.green, text: "ETCO₂ is mandatory in ALL intubated patients: OR, ICU, transport, resuscitation." },
    { icon: "◆", col: C.amber, text: "Waveform analysis is superior to numeric value alone — shape tells the full story." },
    { icon: "◆", col: C.teal,  text: "In non-intubated patients, capnography detects hypoventilation earlier than pulse oximetry." },
    { icon: "◆", col: C.red,   text: "During CPR, ETCO₂ > 10 mmHg = adequate compressions; sudden rise = ROSC." },
    { icon: "◆", col: C.green, text: "Equipment artifacts and patient pathology can produce identical findings — think both." },
  ];

  summaryPoints.forEach((p, i) => {
    s.addText(p.icon, { x: 0.6, y: 1.55 + i * 0.58, w: 0.3, h: 0.42, fontSize: 13, color: p.col, fontFace: "Calibri", valign: "middle", margin: 0 });
    s.addText(p.text, { x: 0.98, y: 1.55 + i * 0.58, w: 8.6, h: 0.45, fontSize: 12, color: C.white, fontFace: "Calibri", valign: "middle" });
  });

  s.addText("Presented by Orris  |  Sources: Morgan & Mikhail 7e | Barash 9e | Roberts & Hedges' | Tintinalli's | AHA 2020", {
    x: 0.6, y: 5.28, w: 9.0, h: 0.22, fontSize: 7.5, color: C.silver, fontFace: "Calibri",
  });
}

// ─── WRITE FILE ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/capnography-pptx/Capnography_ICU_Anesthesia.pptx" })
  .then(() => console.log("DONE: Capnography_ICU_Anesthesia.pptx"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

cd /home/daytona/workspace/capnography-pptx && node build_capno.js 2>&1

ls -lh /home/daytona/workspace/capnography-pptx/Capnography_ICU_Anesthesia.pptx