Anaesthesia for copd

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"COPD" AND "anesthesia" AND "perioperative"

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Miller's Anesthesia has the most relevant content. Let me read the key sections:

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Excellent — Barash's Clinical Anesthesia has a dedicated "Chronic Obstructive Pulmonary Disease" section. Let me read it along with Morgan & Mikhail's intraoperative section:

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Let me get the key intraoperative management section for COPD from Morgan & Mikhail:

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I now have comprehensive data. Let me compile the complete answer:

Anaesthesia for COPD

Pathophysiology Relevant to Anaesthesia

COPD encompasses chronic bronchitis and emphysema. Key physiological derangements the anaesthetist must understand:

Feature	Chronic Bronchitis	Emphysema
Cough	Frequent, productive	Minimal
Hematocrit	Elevated	Normal
PaCO₂	Often elevated (>40 mmHg)	Usually normal/<40
Chest X-ray	Increased lung markings	Hyperinflation
Elastic recoil	Normal	Decreased
Airway resistance	Increased	Normal–slightly increased
Cor pulmonale	Early	Late

Emphysema: loss of elastic recoil → expiratory airflow limitation → air trapping → dynamic hyperinflation → elevated intrinsic PEEP (iPEEP). V/Q mismatch and reduced diffusion capacity are universal. In advanced disease, chronic CO₂ retention produces compensated respiratory acidosis; hypoxic ventilatory drive may be blunted — oxygen therapy must be targeted to SpO₂ ~90% to avoid suppressing this drive.

Preoperative Assessment

History

Dyspnea grading: FEV₁ <50% predicted → dyspnea on exertion; FEV₁ <25% (<1 L in men) → dyspnea at minimal activity, often with CO₂ retention and pulmonary hypertension
Productive cough: volume, colour, and culture of sputum; treat active infection with antibiotics pre-op
Exercise tolerance: inability to climb stairs or walk on level ground signals markedly reduced reserve
Wheeze, recent exacerbations, recent hospitalisations

Investigations

Spirometry (PFTs): FEV₁/FVC <0.7 confirms obstruction; FEV₁ % predicted grades severity (GOLD 1–4). However, PFT findings are NOT predictors of perioperative pulmonary complications and should not be used to deny surgery
ABG: establish baseline; PaCO₂ >45 mmHg = chronic CO₂ retention → higher postoperative morbidity; PaO₂ helps gauge severity of hypoxaemia
Chest X-ray: hyperinflation, bullae (critical — bullae + N₂O = risk of pneumothorax), increased lung markings
ECG and ECHO: for cor pulmonale, right ventricular dysfunction, pulmonary hypertension
ARISCAT score can stratify perioperative pulmonary risk (low <26, intermediate 26–44, high ≥45, with complication rates of 1.6%, 13.3%, and 42.1% respectively)

Risk Factors for Postoperative Pulmonary Complications

Patient: COPD, advanced age, ASA class ≥2, smoking history, obesity, low functional capacity, pre-existing hypoxaemia, pulmonary hypertension, cor pulmonale, anaemia, poor nutritional status
Procedure: thoracic > upper abdominal > aortic > neurosurgical; emergency surgery; duration >3 hours; general anaesthesia

Optimisation Before Elective Surgery

Smoking cessation ≥6–8 weeks before surgery — reduces secretions and carboxyhaemoglobin; even 24h cessation improves O₂-carrying capacity
Continue long-acting bronchodilators, anticholinergics (ipratropium, tiotropium), inhaled corticosteroids — on the day of surgery
Treat any active exacerbation aggressively before proceeding
Antibiotics for active sputum infection
Short course corticosteroids (e.g. prednisolone 40 mg/day × 2 days) for significant COPD/asthma
Chest physiotherapy, incentive spirometry, breathing exercises, postural drainage
Pulmonary rehabilitation in high-risk patients (prehabilitation — promising but evidence certainty remains low)
Discuss with patient: possible need for postoperative ICU admission and ventilation in high-risk cases (FEV₁ <50% predicted)

Choice of Anaesthesia

Regional vs General

Regional anaesthesia is generally preferred where feasible — avoids airway manipulation, reduces postoperative opioid requirement, reduces risk of respiratory depression
However: high spinal or epidural blocks decrease lung volumes, restrict accessory respiratory muscles, produce ineffective cough → dyspnea and retained secretions
Interscalene blocks are relatively contraindicated due to risk of hemidiaphragmatic paralysis
Position concerns (lithotomy, lateral decubitus) may worsen dyspnoea in awake patients

If General Anaesthesia Is Required

Preoxygenation is essential — COPD patients desaturate rapidly at induction
LMA vs ETT: avoid endotracheal intubation where possible (airway stimulation provokes bronchospasm); use LMA when appropriate
Induction agents: propofol or ketamine preferred; ketamine has bronchodilatory properties
Volatile agents (sevoflurane, desflurane, isoflurane) are bronchodilators — preferable to TIVA in bronchospasm-prone patients; however, in severe COPD, increased dead space makes end-tidal volatile concentration unreliable
Avoid N₂O: contraindicated if bullae (pneumothorax risk) or pulmonary hypertension; also worsens V/Q mismatch
Opioids: use with caution; respiratory depression risk; short-acting preferred (fentanyl/remifentanil)
Neuromuscular blockers: use the minimum necessary; ensure complete reversal (residual block is a major risk factor for postoperative pulmonary complications); prefer sugammadex for reversal of rocuronium/vecuronium

Intraoperative Ventilation Strategy

The central challenge: expiratory flow limitation → air trapping → dynamic hyperinflation → intrinsic PEEP (iPEEP).

Ventilator Settings

Parameter	Target
Tidal volume	6–8 mL/kg IBW
Respiratory rate	Slow (8–12 breaths/min)
I:E ratio	Prolonged expiration (1:3 or 1:4)
PEEP	Low extrinsic PEEP (3–5 cmH₂O) to counterbalance iPEEP
Peak airway pressure	<30 cmH₂O
FiO₂	Titrate to SpO₂ 92–96%

Permissive Hypercapnia

Allow PaCO₂ to rise if needed to avoid dangerous airway pressures — PaCO₂ up to 70 mmHg may be tolerated short-term with adequate cardiovascular reserve
Avoid rapid normalisation of CO₂ in chronic retainers (will cause post-hyperventilation alkalosis)
Monitor arterial CO₂ directly (not just ETCO₂) — the arterial-to-end-tidal CO₂ gradient is widened due to increased dead space in COPD

iPEEP Management

Slow respiratory rate + prolonged expiratory time
Reduce tidal volume
Treat bronchospasm aggressively (nebulised salbutamol, ipratropium, IV hydrocortisone)
Apply low-level extrinsic PEEP (stents small airways open)

Intraoperative Complications

Complication	Recognition	Management
Bronchospasm	↑ peak airway pressure, wheeze, desaturation	Deepen anaesthesia (volatile), IV salbutamol, ipratropium, IV hydrocortisone
Dynamic hyperinflation / iPEEP	↑ airway pressure, haemodynamic instability, hypercapnia	Slow RR, extend expiration, disconnect & allow passive exhalation
Pneumothorax (esp. bullae)	Hypoxia, ↑ airway pressure, ↓ tidal volumes, haemodynamic collapse	Immediate needle decompression; avoid N₂O
Right heart failure / cor pulmonale	Hypotension, ↑ CVP, ECG changes	Treat hypercapnia/acidosis, inotropes (dobutamine), vasopressors
Hypoxaemia	SpO₂ ↓	ABG; address V/Q mismatch; avoid excessive O₂ in chronic retainers

Postoperative Management

Extubation criteria: adequate pain control, full reversal of NMB, minimal/no bronchospasm, secretions manageable, no significant hypercapnia, SpO₂ acceptable on moderate FiO₂
Avoid early extubation in high-risk cases; plan for HDU/ICU postoperatively
Regional analgesia / epidural postoperatively reduces the need for systemic opioids → fewer respiratory complications
O₂ therapy: target SpO₂ 88–92% in confirmed CO₂ retainers (not high-flow); avoid hyperoxia suppressing hypoxic drive
Chest physiotherapy, incentive spirometry, early mobilisation
NIV/CPAP: useful for postoperative atelectasis and mild-to-moderate respiratory failure
Monitor for delayed pulmonary complications: pneumonia, atelectasis, respiratory failure, exacerbation

Key Points Summary

COPD is a major independent risk factor for postoperative pulmonary complications
Preoperative optimisation is mandatory; only limited improvement may occur in a short preoperative window (unlike asthma)
Regional anaesthesia is preferred but has its own respiratory caveats
If GA: bronchodilating volatiles preferred; avoid N₂O in bullae/pulmonary hypertension
Ventilate with slow rate and prolonged expiration; accept permissive hypercapnia; watch for iPEEP
Pneumothorax must be excluded early when unexplained haemodynamic collapse occurs
Postoperative epidural/regional analgesia and targeted O₂ therapy are important

Sources:

Morgan & Mikhail's Clinical Anesthesiology, 7e — Chapter 24 (COPD pathophysiology and anaesthetic considerations)
Miller's Anesthesia, 10e — Chapter 28 (postoperative pulmonary complications, preoperative risk stratification)
Barash, Cullen & Stoelting's Clinical Anesthesia, 9e — Chapter on thoracic anaesthesia and COPD assessment
Miller's Anesthesia, 10e — Chapter 52 (vascular surgery: pulmonary assessment including COPD)

Make it ppt

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ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace not found"

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mkdir -p /home/daytona/workspace/copd-anaesthesia-ppt

Writing File

~/copd-anaesthesia-ppt/generate.js

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// ─── SLIDE 1: TITLE ─────────────────────────────────────────────────────────
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titleSlide(s1, "Anaesthesia for COPD", "Preoperative Assessment  ·  Intraoperative Management  ·  Postoperative Care");

// ─── SLIDE 2: SECTION — Pathophysiology ─────────────────────────────────────
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sectionHeader(s2, "Pathophysiology", "Understanding the respiratory derangements that drive anaesthetic decision-making");

// ─── SLIDE 3: COPD Overview ──────────────────────────────────────────────────
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contentSlide(s3, "COPD — Overview & Pathophysiology", [
  "COPD = Chronic Bronchitis + Emphysema (most patients have both)",
  "Chronic Bronchitis: productive cough ≥3 months/year for ≥2 consecutive years; ↑ airway resistance, mucus hypersecretion",
  "Emphysema: irreversible alveolar destruction → loss of elastic recoil → expiratory airflow limitation",
  "Air trapping → Dynamic Hyperinflation → ↑ RV, FRC, TLC and RV/TLC ratio",
  "V/Q mismatch + ↓ diffusion capacity → hypoxaemia",
  "Chronic CO₂ retention → compensated respiratory acidosis; blunted hypercapnic drive",
  "Advanced disease: pulmonary hypertension → right ventricular dysfunction → Cor Pulmonale",
]);

// ─── SLIDE 4: Pink Puffer vs Blue Bloater ────────────────────────────────────
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tableSlide(s4, "Emphysema vs Chronic Bronchitis",
  ["Feature", "Chronic Bronchitis\n(\"Blue Bloater\")", "Emphysema\n(\"Pink Puffer\")"],
  [
    ["Cough", "Frequent, productive", "With exertion"],
    ["Sputum", "Copious", "Scant"],
    ["Hematocrit", "Elevated", "Normal"],
    ["PaCO₂", "Often elevated (>40 mmHg)", "Usually normal / <40"],
    ["Chest X-ray", "↑ lung markings", "Hyperinflation, bullae"],
    ["Elastic recoil", "Normal", "Decreased"],
    ["Airway resistance", "Increased", "Normal–slightly increased"],
    ["Cor pulmonale", "Early", "Late"],
  ],
  [2.5, 3.45, 3.45]
);

// ─── SLIDE 5: SECTION — Preoperative Assessment ──────────────────────────────
let s5 = pres.addSlide();
sectionHeader(s5, "Preoperative Assessment", "Optimise before elective surgery — only limited improvement is possible in a short window");

// ─── SLIDE 6: History & Clinical Assessment ──────────────────────────────────
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twoColSlide(s6, "Preoperative Assessment — History & Examination",
  "Key History Points", [
    "Dyspnoea grade: exertional vs minimal activity",
    "Productive cough — sputum colour, volume",
    "Recent exacerbations / hospitalisations",
    "Exercise tolerance (stairs / flat walking)",
    "Wheeze, current medications",
    "Smoking history (pack-years)",
    "Symptoms of cor pulmonale (oedema, exertional syncope)",
  ],
  "Examination Findings", [
    "Barrel chest, hyperinflated",
    "Pursed-lip breathing (emphysema)",
    "Prolonged expiration, wheeze",
    "Accessory muscle use",
    "Cyanosis, elevated JVP",
    "Peripheral oedema (cor pulmonale)",
    "Clubbing (lung cancer co-morbidity)",
  ]
);

// ─── SLIDE 7: Investigations ─────────────────────────────────────────────────
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contentSlide(s7, "Investigations", [
  "Spirometry (PFTs): FEV₁/FVC <0.7 confirms obstruction; FEV₁ % predicted grades severity (GOLD 1–4)",
  "⚠️ PFT results are NOT predictors of perioperative complications and should NOT be used to deny surgery",
  "ABG: establish baseline; PaCO₂ >45 mmHg = chronic CO₂ retention → higher postoperative morbidity",
  "Chest X-ray: hyperinflation, bullae (critical — bullae + N₂O = pneumothorax risk), increased lung markings",
  "ECG: P pulmonale, right axis deviation, RV hypertrophy",
  "ECHO: assess pulmonary hypertension, RV function, LVEF",
  "FBC: polycythaemia (chronic hypoxaemia); Sputum culture if infected",
  "ARISCAT Score: Low <26 (1.6%), Intermediate 26–44 (13.3%), High ≥45 (42.1%) risk of pulmonary complications",
], { fontSize: 15 });

// ─── SLIDE 8: Preoperative Optimisation ──────────────────────────────────────
let s8 = pres.addSlide();
contentSlide(s8, "Preoperative Optimisation", [
  "🚭  Smoking cessation ≥6–8 weeks before surgery (↓ secretions, ↓ carboxyHb). Even 24h → ↑ O₂-carrying capacity",
  "💊  Continue ALL bronchodilators (SABAs, LABAs, anticholinergics, ICS) on the day of surgery",
  "🦠  Treat active respiratory infection with antibiotics; culture sputum if purulent",
  "💉  Short course corticosteroids (prednisolone 40 mg/day × 2 days) for significant COPD/asthma",
  "🫁  Chest physiotherapy, incentive spirometry, breathing exercises, postural drainage",
  "🏃  Pulmonary rehabilitation (prehabilitation) in high-risk patients — improves functional reserve",
  "⚕️  Patients with FEV₁ <50% predicted: warn of possible postoperative HDU/ICU admission & ventilation",
  "❌  Treat any active COPD exacerbation aggressively before proceeding with elective surgery",
], { fontSize: 15 });

// ─── SLIDE 9: SECTION — Choice of Anaesthesia ────────────────────────────────
let s9 = pres.addSlide();
sectionHeader(s9, "Choice of Anaesthesia", "Regional vs General — benefits and caveats for the COPD patient");

// ─── SLIDE 10: Regional vs General ───────────────────────────────────────────
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twoColSlide(s10, "Regional vs General Anaesthesia",
  "Regional Anaesthesia — Preferred Where Feasible", [
    "Avoids airway manipulation (↓ bronchospasm risk)",
    "Reduces postoperative opioid requirements",
    "↓ respiratory depression risk",
    "Epidural/spinal: good for lower limb, urological, some abdominal surgery",
    "BUT: high spinal/epidural → ↓ lung volumes, restricted accessory muscles, ineffective cough",
    "Interscalene block: relatively contraindicated (hemidiaphragm paralysis risk)",
    "Awake patients: positional dyspnoea in lithotomy/lateral positions",
  ],
  "General Anaesthesia — When Required", [
    "Mandatory preoxygenation — rapid desaturation on induction",
    "Volatile agents (sevo/iso) preferred — bronchodilatory",
    "LMA preferred over ETT where feasible (less airway stimulation)",
    "Ketamine useful: bronchodilatory properties",
    "Avoid N₂O: bullae → pneumothorax; worsens V/Q; pulmonary HTN",
    "ETCO₂ unreliable — widened a-ET CO₂ gradient (↑ dead space)",
    "Neuromuscular blockade: full reversal essential (sugammadex preferred)",
  ]
);

// ─── SLIDE 11: SECTION — Intraoperative Management ───────────────────────────
let s11 = pres.addSlide();
sectionHeader(s11, "Intraoperative Management", "Ventilation strategy  ·  Dynamic hyperinflation  ·  Monitoring");

// ─── SLIDE 12: Ventilation Strategy ──────────────────────────────────────────
let s12 = pres.addSlide();
tableSlide(s12, "Ventilator Settings for COPD (Positive Pressure Ventilation)",
  ["Parameter", "Target", "Rationale"],
  [
    ["Tidal Volume", "6–8 mL/kg IBW", "Prevent volutrauma; accommodate hyperinflation"],
    ["Respiratory Rate", "8–12 breaths/min (slow)", "Allow full expiration; reduce air trapping"],
    ["I:E Ratio", "1:3 or 1:4 (prolonged expiration)", "↑ expiratory time to allow lung emptying"],
    ["PEEP (extrinsic)", "Low: 3–5 cmH₂O", "Counterbalance iPEEP; stent airways open"],
    ["Peak Airway Pressure", "<30 cmH₂O", "Prevent barotrauma"],
    ["FiO₂", "Target SpO₂ 92–96%", "Avoid hyperoxia suppressing hypoxic drive"],
    ["PaCO₂", "Permissive hypercapnia (up to 70 mmHg)", "Prioritise lung-protective strategy over normocapnia"],
  ],
  [2.5, 3.3, 3.6]
);

// ─── SLIDE 13: Dynamic Hyperinflation / iPEEP ─────────────────────────────────
let s13 = pres.addSlide();
contentSlide(s13, "Dynamic Hyperinflation & Intrinsic PEEP (iPEEP)", [
  "Mechanism: expiratory flow limitation → incomplete lung emptying before next breath → air trapping → iPEEP",
  "Consequences: lung injury, haemodynamic instability, hypercapnia, acidosis",
  "Recognition: persistently elevated plateau/peak pressures, haemodynamic deterioration, hypercapnia",
  "Management (4 key interventions):",
  { text: "① ↓ Respiratory rate + ↑ expiratory time (lower I:E ratio)", options: { bullet:false, indentLevel:1, color:C.tealDk, bold:true, fontSize:16, fontFace:"Calibri", breakLine:true, paraSpaceBefore:2 } },
  { text: "② ↓ Tidal volume to reduce air delivered per breath", options: { bullet:false, indentLevel:1, color:C.tealDk, bold:true, fontSize:16, fontFace:"Calibri", breakLine:true, paraSpaceBefore:2 } },
  { text: "③ Apply low extrinsic PEEP to stent small airways open", options: { bullet:false, indentLevel:1, color:C.tealDk, bold:true, fontSize:16, fontFace:"Calibri", breakLine:true, paraSpaceBefore:2 } },
  { text: "④ Treat bronchospasm aggressively — nebulised salbutamol, ipratropium, IV hydrocortisone", options: { bullet:false, indentLevel:1, color:C.tealDk, bold:true, fontSize:16, fontFace:"Calibri", breakLine:true, paraSpaceBefore:2 } },
  "Disconnect circuit and allow passive exhalation if haemodynamic collapse occurs",
]);

// ─── SLIDE 14: Intraoperative Complications ───────────────────────────────────
let s14 = pres.addSlide();
tableSlide(s14, "Intraoperative Complications — Recognition & Management",
  ["Complication", "Recognition", "Management"],
  [
    ["Bronchospasm", "↑ peak pressures, wheeze, SpO₂↓", "Deepen volatile, nebulised salbutamol, ipratropium, IV hydrocortisone"],
    ["Dynamic Hyperinflation / iPEEP", "↑ airway pressures, haemodynamic collapse, hypercapnia", "↓ RR, extend expiration, disconnect circuit for passive exhale"],
    ["Pneumothorax (bullae rupture)", "Hypoxia, ↑ pressures, ↓ TV, cardiovascular collapse", "Immediate needle decompression; avoid N₂O entirely"],
    ["Cor pulmonale / RV failure", "Hypotension, ↑ CVP, ECG: RV strain", "Treat hypercapnia/acidosis; dobutamine; vasopressors"],
    ["Hypoxaemia", "SpO₂↓, widened A-a gradient", "ABG; address V/Q mismatch; adjust FiO₂; PEEP titration"],
    ["Hypotension", "BP↓ intraoperatively", "Exclude pneumothorax, iPEEP; fluid; vasopressors; inotropes"],
  ],
  [2.4, 3.2, 3.8]
);

// ─── SLIDE 15: SECTION — Postoperative Care ───────────────────────────────────
let s15 = pres.addSlide();
sectionHeader(s15, "Postoperative Care", "Extubation criteria  ·  Oxygen therapy  ·  Analgesia  ·  Monitoring");

// ─── SLIDE 16: Extubation & Postoperative Management ────────────────────────
let s16 = pres.addSlide();
twoColSlide(s16, "Postoperative Management",
  "Extubation Criteria", [
    "Adequate pain control (multimodal/regional)",
    "Full reversal of neuromuscular blockade (TOF ratio ≥0.9)",
    "Absence of significant bronchospasm / secretions",
    "No significant hypercapnia",
    "SpO₂ acceptable on moderate FiO₂",
    "Awake, cooperative, protective airway reflexes present",
    "Plan ICU/HDU admission for high-risk patients (FEV₁ <50%)",
  ],
  "Postoperative Interventions", [
    "O₂ therapy: target SpO₂ 88–92% in CO₂ retainers (avoid hyperoxia suppressing hypoxic drive)",
    "Regional/epidural analgesia: ↓ systemic opioids → ↓ respiratory depression",
    "Chest physiotherapy, incentive spirometry, early mobilisation",
    "NIV/CPAP: for postoperative atelectasis, mild-moderate respiratory failure",
    "Continue bronchodilators (inhaled + nebulised as needed)",
    "Monitor for: pneumonia, atelectasis, respiratory failure, COPD exacerbation",
    "ABG postoperatively if CO₂ retainer at baseline",
  ]
);

// ─── SLIDE 17: Key Summary ────────────────────────────────────────────────────
let s17 = pres.addSlide();
slide = s17;
slide.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:5.625, fill:{ color: C.navy }, line:{ color: C.navy } });
slide.addShape(pres.shapes.RECTANGLE, { x:0, y:0, w:10, h:0.08, fill:{ color: C.amber }, line:{ color: C.amber } });
slide.addShape(pres.shapes.RECTANGLE, { x:0, y:5.545, w:10, h:0.08, fill:{ color: C.amber }, line:{ color: C.amber } });

slide.addText("Key Summary", {
  x:0.5, y:0.12, w:9, h:0.7,
  fontSize:26, bold:true, color: C.teal, fontFace:"Calibri", align:"center"
});

const summaryPoints = [
  { icon:"🫁", text:"COPD = air trapping + V/Q mismatch + ↓ elastic recoil → dynamic hyperinflation risk under PPV" },
  { icon:"⚕️", text:"Optimise pre-op: continue bronchodilators, treat exacerbation, smoking cessation ≥6–8 wks" },
  { icon:"📊", text:"PFTs diagnose severity but do NOT predict perioperative risk — do not deny surgery on PFTs alone" },
  { icon:"🩺", text:"Regional anaesthesia preferred where feasible; avoid interscalene block (hemidiaphragm risk)" },
  { icon:"💉", text:"If GA: volatile agents (bronchodilatory), avoid N₂O (bullae/pulmonary HTN), ensure full NMB reversal" },
  { icon:"🌬️", text:"Ventilate: slow rate, prolonged expiration (1:3–1:4), low tidal volume, permissive hypercapnia" },
  { icon:"⚠️", text:"Unexplained haemodynamic collapse → exclude pneumothorax, dynamic hyperinflation, RV failure" },
  { icon:"🏥", text:"Post-op: SpO₂ 88–92% in CO₂ retainers; regional analgesia; plan ICU if FEV₁ <50% predicted" },
];

const summaryItems = summaryPoints.map((p, i) => [
  { text: p.icon + "  " + p.text, options: { bullet:false, color:C.offWht, fontSize:14, fontFace:"Calibri", breakLine: i < summaryPoints.length-1, paraSpaceBefore:5 } }
]).flat();

slide.addText(summaryItems, {
  x:0.4, y:0.88, w:9.2, h:4.55,
  valign:"top", margin:6
});

// ─── WRITE ────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/copd-anaesthesia-ppt/Anaesthesia_for_COPD.pptx" })
  .then(() => console.log("✅ Saved: Anaesthesia_for_COPD.pptx"))
  .catch(e => { console.error("❌ Error:", e); process.exit(1); });

Failed to upload files: 400: /home/daytona/workspace/copd-anaesthesia-ppt/generate.js: rename: rename /home/daytona/workspace/copd-anaesthesia-ppt/generate.js.daytona-upload-1447350952 /home/daytona/workspace/copd-anaesthesia-ppt/generate.js: function not implemented

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