Anaesthesia for COPD

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pres.title = "Anaesthesia for COPD";
pres.author = "Orris Medical";

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

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

// ─── SLIDE 3: COPD Overview ──────────────────────────────────────────────────
let s3 = pres.addSlide();
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 ────────────────────────────────────
let s4 = pres.addSlide();
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 ──────────────────────────────────
let s6 = pres.addSlide();
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 ─────────────────────────────────────────────────
let s7 = pres.addSlide();
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 ───────────────────────────────────────────
let s10 = pres.addSlide();
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 ────────────────────────────────────────────────────
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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" },
];

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// ─── 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); });