capnography ICU anesthesia waveform interpretation clinical uses 2024

https://resources.wfsahq.org/wp-content/uploads/ATOTW534.pdf

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

~/capnography-pptx/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "Orris Medical";
pres.title = "Capnography: Advanced Clinical Applications";

// ─── PALETTE ────────────────────────────────────────────────────────────────
const DARK   = "0A1628";   // dominant deep navy
const MID    = "122B4F";   // supporting navy
const ACCENT = "00C9A7";   // teal accent
const GOLD   = "F4A261";   // warm alert/highlight
const WHITE  = "FFFFFF";
const LGRAY  = "D0E4F7";   // light blue-gray
const RED    = "E63946";
const GREEN  = "2DC653";
const YELLOW = "FFD166";

// ─── HELPER FUNCTIONS ───────────────────────────────────────────────────────
function titleSlide(pres) {
  const slide = pres.addSlide();
  // Full dark background
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  // Accent bar left
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  // Decorative circle
  slide.addShape(pres.ShapeType.ellipse, { x: 7.2, y: -0.8, w: 4.5, h: 4.5, fill: { color: MID }, line: { color: MID } });
  slide.addShape(pres.ShapeType.ellipse, { x: 7.8, y: -0.3, w: 3.3, h: 3.3, fill: { color: ACCENT }, line: { color: ACCENT }, transparency: 80 });

  // CO2 symbol large watermark
  slide.addText("CO₂", { x: 6.8, y: 0.6, w: 3, h: 2, fontSize: 96, color: ACCENT, bold: true, align: "center", transparency: 70 });

  slide.addText("CAPNOGRAPHY", {
    x: 0.5, y: 1.1, w: 7, h: 0.9,
    fontSize: 44, bold: true, color: ACCENT, charSpacing: 8, margin: 0
  });
  slide.addText("Advanced Clinical Applications for ICU & Anesthesia", {
    x: 0.5, y: 2.05, w: 7.5, h: 0.6,
    fontSize: 18, color: LGRAY, italic: true, margin: 0
  });
  // Divider line
  slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 2.8, w: 4, h: 0.04, fill: { color: ACCENT } });
  slide.addText("Principles • Waveforms • Pathophysiology • Clinical Decision-Making", {
    x: 0.5, y: 2.95, w: 8, h: 0.45,
    fontSize: 13, color: LGRAY, margin: 0
  });
  slide.addText("Barash Clinical Anesthesia 9e  |  WFSA ATOTW 534  |  AHA Guidelines 2020", {
    x: 0.5, y: 5.0, w: 9, h: 0.4,
    fontSize: 10, color: "6B8CAE", italic: true, margin: 0
  });
  return slide;
}

function sectionDivider(pres, number, title, subtitle) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: MID } });
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  slide.addShape(pres.ShapeType.rect, { x: 0, y: 2.3, w: 10, h: 0.05, fill: { color: ACCENT }, transparency: 60 });
  slide.addText(number, {
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    fontSize: 72, bold: true, color: ACCENT, align: "center", margin: 0, transparency: 30
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  slide.addText(title, {
    x: 0.5, y: 2.0, w: 9, h: 0.9,
    fontSize: 36, bold: true, color: WHITE, margin: 0
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  slide.addText(subtitle, {
    x: 0.5, y: 3.0, w: 9, h: 0.7,
    fontSize: 16, color: LGRAY, italic: true, margin: 0
  });
  return slide;
}

function contentSlide(pres, title, bullets, options = {}) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });

  slide.addText(title, {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const bulletItems = bullets.map((b, i) => {
    if (typeof b === "string") {
      return [
        { text: "▸  ", options: { color: ACCENT, bold: true, fontSize: 13 } },
        { text: b, options: { color: LGRAY, fontSize: 13, breakLine: i < bullets.length - 1 } }
      ];
    } else {
      // { text, sub } format
      return [
        { text: "▸  ", options: { color: ACCENT, bold: true, fontSize: 13 } },
        { text: b.text, options: { color: WHITE, fontSize: 13, bold: true, breakLine: true } },
        { text: "    " + b.sub, options: { color: "8BAAC8", fontSize: 11.5, breakLine: i < bullets.length - 1 } }
      ];
    }
  }).flat();

  slide.addText(bulletItems, {
    x: 0.4, y: 1.1, w: options.w || 9.2, h: 4.3,
    valign: "top", lineSpacingMultiple: 1.35, margin: [0, 0, 0, 8]
  });

  if (options.note) {
    slide.addShape(pres.ShapeType.rect, { x: 0.4, y: 4.9, w: 9.2, h: 0.5, fill: { color: "0D2240" }, rounding: true });
    slide.addText("⚑  " + options.note, {
      x: 0.5, y: 4.92, w: 9, h: 0.42,
      fontSize: 10, color: GOLD, italic: true, valign: "middle", margin: 0
    });
  }
  return slide;
}

function twoColSlide(pres, title, col1Title, col1Items, col2Title, col2Items, col1Color = ACCENT, col2Color = GOLD) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText(title, { x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0 });

  // Col 1
  slide.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.1, w: 4.4, h: 4.2, fill: { color: "0D2240" }, rounding: true });
  slide.addText(col1Title, { x: 0.5, y: 1.15, w: 4.2, h: 0.45, fontSize: 14, bold: true, color: col1Color, margin: 0 });
  const c1 = col1Items.map((t, i) => [
    { text: "•  ", options: { color: col1Color, bold: true, fontSize: 12 } },
    { text: t, options: { color: LGRAY, fontSize: 12, breakLine: i < col1Items.length - 1 } }
  ]).flat();
  slide.addText(c1, { x: 0.5, y: 1.65, w: 4.1, h: 3.4, valign: "top", lineSpacingMultiple: 1.35, margin: 0 });

  // Col 2
  slide.addShape(pres.ShapeType.rect, { x: 5.2, y: 1.1, w: 4.4, h: 4.2, fill: { color: "0D2240" }, rounding: true });
  slide.addText(col2Title, { x: 5.3, y: 1.15, w: 4.2, h: 0.45, fontSize: 14, bold: true, color: col2Color, margin: 0 });
  const c2 = col2Items.map((t, i) => [
    { text: "•  ", options: { color: col2Color, bold: true, fontSize: 12 } },
    { text: t, options: { color: LGRAY, fontSize: 12, breakLine: i < col2Items.length - 1 } }
  ]).flat();
  slide.addText(c2, { x: 5.3, y: 1.65, w: 4.1, h: 3.4, valign: "top", lineSpacingMultiple: 1.35, margin: 0 });

  return slide;
}

function waveformSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("The Normal Capnogram: Four Phases", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  // Y-axis label
  slide.addText("PaCO₂\n(mmHg)", { x: 0.22, y: 1.5, w: 0.9, h: 1.0, fontSize: 9, color: LGRAY, align: "center", margin: 0 });

  // Waveform canvas background
  slide.addShape(pres.ShapeType.rect, { x: 1.0, y: 1.1, w: 6.2, h: 3.4, fill: { color: "061120" }, rounding: false });

  // Grid lines (horizontal)
  for (let i = 0; i < 5; i++) {
    const y = 1.1 + i * 0.68;
    slide.addShape(pres.ShapeType.line, { x: 1.0, y, w: 6.2, h: 0, line: { color: "1A3D5C", width: 0.5 } });
  }
  // Y-axis values
  ["50","40","30","20","10","0"].forEach((v, i) => {
    slide.addText(v, { x: 0.5, y: 1.0 + i * 0.56, w: 0.45, h: 0.3, fontSize: 9, color: "6B8CAE", align: "right", margin: 0 });
  });

  // Capnogram waveform drawn with lines — one full breath cycle + partial second
  // Phase I (baseline) → Phase II (steep rise) → Phase III (plateau) → Phase IV (drop inspiration)
  const waveColor = ACCENT;
  const lw = 3;

  // Breath 1
  // Phase I: baseline 0
  slide.addShape(pres.ShapeType.line, { x: 1.1, y: 4.3, w: 0.5, h: 0, line: { color: waveColor, width: lw } });
  // Phase II: steep rise to ~40mmHg
  slide.addShape(pres.ShapeType.line, { x: 1.6, y: 4.3, w: 0.25, h: -2.0, line: { color: waveColor, width: lw } });
  // Phase III: alveolar plateau (slight slope up)
  slide.addShape(pres.ShapeType.line, { x: 1.85, y: 2.3, w: 1.2, h: -0.15, line: { color: waveColor, width: lw } });
  // D point — ETCO2 peak
  slide.addShape(pres.ShapeType.ellipse, { x: 3.0, y: 2.1, w: 0.12, h: 0.12, fill: { color: GOLD }, line: { color: GOLD } });
  // Phase IV (0): steep drop back to 0
  slide.addShape(pres.ShapeType.line, { x: 3.05, y: 2.15, w: 0.25, h: 2.15, line: { color: waveColor, width: lw } });
  // Next Phase I
  slide.addShape(pres.ShapeType.line, { x: 3.3, y: 4.3, w: 0.6, h: 0, line: { color: waveColor, width: lw } });
  // Breath 2
  slide.addShape(pres.ShapeType.line, { x: 3.9, y: 4.3, w: 0.25, h: -2.0, line: { color: waveColor, width: lw } });
  slide.addShape(pres.ShapeType.line, { x: 4.15, y: 2.3, w: 1.2, h: -0.15, line: { color: waveColor, width: lw } });
  slide.addShape(pres.ShapeType.ellipse, { x: 5.3, y: 2.1, w: 0.12, h: 0.12, fill: { color: GOLD }, line: { color: GOLD } });
  slide.addShape(pres.ShapeType.line, { x: 5.35, y: 2.15, w: 0.25, h: 2.15, line: { color: waveColor, width: lw } });
  slide.addShape(pres.ShapeType.line, { x: 5.6, y: 4.3, w: 0.6, h: 0, line: { color: waveColor, width: lw } });
  // Partial breath 3 rise only
  slide.addShape(pres.ShapeType.line, { x: 6.2, y: 4.3, w: 0.25, h: -2.0, line: { color: waveColor, width: lw } });
  slide.addShape(pres.ShapeType.line, { x: 6.45, y: 2.3, w: 0.6, h: -0.15, line: { color: waveColor, width: lw } });

  // Phase labels under waveform
  const phases = [
    { label: "Phase I\nInspiratory\nBaseline", x: 1.05 },
    { label: "Phase II\nExpiratory\nUpstroke", x: 1.5 },
    { label: "Phase III\nAlveolar\nPlateau", x: 2.1 },
    { label: "Phase IV\nInspiratory\nDownstroke", x: 3.0 },
  ];
  phases.forEach(p => {
    slide.addText(p.label, { x: p.x, y: 4.55, w: 0.85, h: 0.75, fontSize: 8.5, color: "8BAAC8", align: "center", margin: 0 });
  });

  // ETCO2 label
  slide.addText("ETCO₂\n35–45 mmHg", { x: 3.1, y: 1.75, w: 1.3, h: 0.55, fontSize: 9.5, color: GOLD, bold: true, margin: 0 });

  // Right panel — phase details
  slide.addShape(pres.ShapeType.rect, { x: 7.4, y: 1.1, w: 2.25, h: 4.2, fill: { color: "0D2240" }, rounding: true });
  slide.addText("Phase Details", { x: 7.5, y: 1.15, w: 2.1, h: 0.38, fontSize: 12, bold: true, color: ACCENT, margin: 0 });
  const phaseDetails = [
    { text: "I — Baseline", options: { bold: true, color: ACCENT, fontSize: 10.5 } },
    { text: "\nInspired gas, CO₂ = 0 mmHg\n", options: { color: LGRAY, fontSize: 9.5 } },
    { text: "II — Upstroke", options: { bold: true, color: YELLOW, fontSize: 10.5 } },
    { text: "\nDead space + alveolar gas mixing\n", options: { color: LGRAY, fontSize: 9.5 } },
    { text: "III — Plateau", options: { bold: true, color: GREEN, fontSize: 10.5 } },
    { text: "\nAlveolar gas; slope reflects V/Q\nPeak = ETCO₂\n", options: { color: LGRAY, fontSize: 9.5 } },
    { text: "IV — Downstroke", options: { bold: true, color: RED, fontSize: 10.5 } },
    { text: "\nFresh gas inhalation; rapid drop to 0", options: { color: LGRAY, fontSize: 9.5 } },
  ];
  slide.addText(phaseDetails, { x: 7.5, y: 1.6, w: 2.0, h: 3.5, valign: "top", lineSpacingMultiple: 1.2, margin: 0 });
  return slide;
}

function abnormalWaveformsSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("Abnormal Waveform Patterns & Clinical Significance", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const patterns = [
    {
      name: "Shark-Fin / Obstructive",
      color: RED,
      desc: "Slurred upstroke + rounded plateau peak; Phase II-III merge into a sloping ramp. Indicates airflow obstruction — bronchospasm, COPD, asthma, kinked ETT.",
      x: 0.3, y: 1.1
    },
    {
      name: "Curare Cleft",
      color: GOLD,
      desc: "Notch in plateau (Phase III) caused by incomplete neuromuscular blockade — diaphragmatic contraction during expiration. Indicates residual paralysis.",
      x: 0.3, y: 2.5
    },
    {
      name: "Rebreathing (Elevated Baseline)",
      color: YELLOW,
      desc: "Baseline CO₂ > 0. Causes: exhausted CO₂ absorber, faulty circuit valve, low FGF, or calibration error.",
      x: 0.3, y: 3.9
    },
    {
      name: "Sudden Loss of Waveform",
      color: RED,
      desc: "Esophageal intubation, circuit disconnect, ventilator failure, cardiac arrest (no pulmonary blood flow). FIRST confirm tube placement.",
      x: 5.2, y: 1.1
    },
    {
      name: "Sustained Low ETCO₂",
      color: ACCENT,
      desc: "Hyperventilation, hypothermia, PE (dead space ↑), low cardiac output. Gradient PaCO₂ - ETCO₂ > 5 mmHg suggests V/Q mismatch.",
      x: 5.2, y: 2.5
    },
    {
      name: "Sustained High ETCO₂",
      color: GOLD,
      desc: "Hypoventilation, malignant hyperthermia, sepsis (↑ metabolic CO₂), exogenous CO₂ (laparoscopy), NaHCO₃ infusion.",
      x: 5.2, y: 3.9
    }
  ];

  patterns.forEach(p => {
    slide.addShape(pres.ShapeType.rect, { x: p.x, y: p.y, w: 4.6, h: 1.25, fill: { color: "0A1E38" }, rounding: true, line: { color: p.color, width: 1.5 } });
    slide.addText(p.name, { x: p.x + 0.15, y: p.y + 0.07, w: 4.3, h: 0.32, fontSize: 11.5, bold: true, color: p.color, margin: 0 });
    slide.addText(p.desc, { x: p.x + 0.15, y: p.y + 0.42, w: 4.3, h: 0.78, fontSize: 9.8, color: LGRAY, margin: 0 });
  });

  return slide;
}

function etco2table(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("ETCO₂ Changes: Systematic Differential Diagnosis", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const rows = [
    ["", "ETCO₂ Change", "Mechanism", "Clinical Causes"],
    ["↑ High", "> 45 mmHg", "↑ CO₂ production or ↓ ventilation", "Hypoventilation, MH, sepsis, laparoscopy, NaHCO₃, tourniquet release"],
    ["↓ Low", "< 35 mmHg", "↓ CO₂ production or ↑ dead space", "Hyperventilation, hypothermia, PE, low CO, hemorrhage, cardiac arrest"],
    ["→ Zero", "0 mmHg", "No CO₂ measured", "Esophageal intubation, circuit disconnect, cardiac arrest, apnea"],
    ["↑ Gradient", "PaCO₂ - ETCO₂ > 5", "V/Q mismatch / dead space", "PE, ARDS, low CO states, COPD, prone position (variable)"],
  ];

  const colW = [0.9, 1.5, 2.8, 4.0];
  const rowH = 0.72;
  const startX = 0.35;
  const startY = 1.1;
  const rowColors = [MID, "08192E", "0A1E38", "08192E", "0A1E38"];
  const textColors = [ACCENT, RED, ACCENT, YELLOW, GOLD];

  rows.forEach((row, ri) => {
    let xCursor = startX;
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      slide.addShape(pres.ShapeType.rect, {
        x: xCursor, y: startY + ri * rowH, w: colW[ci], h: rowH,
        fill: { color: isHeader ? "0D2240" : rowColors[ri] },
        line: { color: "1A3D5C", width: 0.5 }
      });
      slide.addText(cell, {
        x: xCursor + 0.06, y: startY + ri * rowH + 0.04,
        w: colW[ci] - 0.12, h: rowH - 0.08,
        fontSize: isHeader ? 11 : (ci === 0 ? 14 : 10.5),
        bold: isHeader || ci === 0,
        color: isHeader ? ACCENT : (ci === 0 ? textColors[ri] : LGRAY),
        valign: "middle", margin: 0
      });
      xCursor += colW[ci];
    });
  });
  return slide;
}

function rolesSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("Clinical Applications by Setting", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const cards = [
    { icon: "🔬", title: "Intubation Confirmation", color: GREEN, text: "Gold standard for ETT placement (AHA Class IA). Continuous waveform > colorimetric. Must confirm with each manual bag ventilation.", x: 0.3, y: 1.1 },
    { icon: "❤", title: "CPR Quality & ROSC", color: RED, text: "ETCO₂ < 10 mmHg during CPR = poor prognosis. Abrupt rise to ≥ 35-40 mmHg signals ROSC. Also guides CPR chest compression depth/rate.", x: 3.55, y: 1.1 },
    { icon: "🫁", title: "Mechanical Ventilation", color: ACCENT, text: "Monitor adequacy of ventilation. Adjust TV/RR in ARDS lung-protective strategy. Detect air leak, obstruction, asynchrony.", x: 6.8, y: 1.1 },
    { icon: "💉", title: "Procedural Sedation / MAC", color: GOLD, text: "Detects respiratory depression 4+ min before SpO₂ drop. Mandated for moderate/deep sedation (ASA 2018). Especially critical with supplemental O₂.", x: 0.3, y: 3.15 },
    { icon: "🧪", title: "Malignant Hyperthermia", color: YELLOW, text: "Sudden unexplained rise in ETCO₂ is the earliest sign. Triggers cessation of volatile agents and dantrolene administration.", x: 3.55, y: 3.15 },
    { icon: "🚑", title: "ICU Monitoring", color: LGRAY, text: "Confirm airway at insertion and continuously. Detect circuit disconnection. ETCO₂ trend replaces frequent ABG in stable ventilated patients.", x: 6.8, y: 3.15 },
  ];

  cards.forEach(card => {
    slide.addShape(pres.ShapeType.rect, { x: card.x, y: card.y, w: 3.0, h: 1.9, fill: { color: "0D2240" }, rounding: true, line: { color: card.color, width: 1.5 } });
    slide.addText(card.icon + " " + card.title, { x: card.x + 0.12, y: card.y + 0.1, w: 2.8, h: 0.42, fontSize: 11, bold: true, color: card.color, margin: 0 });
    slide.addText(card.text, { x: card.x + 0.12, y: card.y + 0.55, w: 2.8, h: 1.25, fontSize: 9.5, color: LGRAY, margin: 0 });
  });

  return slide;
}

function technologySlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("Technology: Measurement Methods & Equipment", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  // Three main tech method cards
  const methods = [
    {
      title: "Mainstream",
      color: ACCENT,
      items: [
        "Sensor in-line with airway circuit",
        "No aspiration — real-time waveform",
        "Larger sensor head adds dead space",
        "Condensation can impair accuracy",
        "Better for small patients (neonates)"
      ]
    },
    {
      title: "Sidestream",
      color: GOLD,
      items: [
        "Aspirates 50-200 mL/min via T-piece",
        "Most common in OR & ICU",
        "Lightweight proximal connector",
        "Slight signal delay (2-3 sec)",
        "Water trap required; may underestimate ETCO₂ in neonates"
      ]
    },
    {
      title: "Microstream",
      color: YELLOW,
      items: [
        "Modified sidestream; very low flow (~50 mL/min)",
        "CO₂-specific laser spectroscopy",
        "Minimal N₂O/O₂ collision broadening",
        "Suitable for nasal/oral cannula in non-intubated",
        "Widely used in procedural sedation"
      ]
    }
  ];

  methods.forEach((m, i) => {
    const x = 0.3 + i * 3.2;
    slide.addShape(pres.ShapeType.rect, { x, y: 1.1, w: 3.0, h: 3.2, fill: { color: "0D2240" }, rounding: true, line: { color: m.color, width: 1.5 } });
    slide.addText(m.title, { x: x + 0.15, y: 1.15, w: 2.7, h: 0.42, fontSize: 14, bold: true, color: m.color, margin: 0 });
    const bullets = m.items.map((t, j) => [
      { text: "•  ", options: { color: m.color, bold: true, fontSize: 11 } },
      { text: t, options: { color: LGRAY, fontSize: 11, breakLine: j < m.items.length - 1 } }
    ]).flat();
    slide.addText(bullets, { x: x + 0.15, y: 1.65, w: 2.7, h: 2.5, valign: "top", lineSpacingMultiple: 1.3, margin: 0 });
  });

  // Bottom note on IR spectroscopy
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 4.4, w: 9.4, h: 0.92, fill: { color: "0A1E38" }, rounding: true });
  slide.addText([
    { text: "Principle: ", options: { bold: true, color: ACCENT, fontSize: 11 } },
    { text: "CO₂ absorbs infrared light at 4.26 μm. The Beer-Lambert law governs absorption proportional to CO₂ concentration. Modern analysers apply collision-broadening correction factors for O₂ and N₂O.", options: { color: LGRAY, fontSize: 11 } },
    { text: "  |  Capnometry vs Capnography: ", options: { bold: true, color: GOLD, fontSize: 11 } },
    { text: "Capnometry = numeric ETCO₂ value only. Capnography = waveform + numeric — clinically superior.", options: { color: LGRAY, fontSize: 11 } },
  ], { x: 0.5, y: 4.43, w: 9.0, h: 0.88, valign: "middle", margin: 0 });

  return slide;
}

function cprSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: RED } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: RED } });
  slide.addText("Capnography in Cardiac Arrest & CPR", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  // ETCO2 during CPR visual
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.1, w: 4.5, h: 4.15, fill: { color: "0A1628" }, rounding: true });
  slide.addText("ETCO₂ During CPR", { x: 0.45, y: 1.15, w: 4.2, h: 0.4, fontSize: 13, bold: true, color: RED, margin: 0 });

  // Visual bar chart representing ETCO2 levels
  const bars = [
    { label: "Normal\nperfusion", val: 38, color: GREEN },
    { label: "CPR\n(poor)", val: 8, color: RED },
    { label: "CPR\n(good)", val: 18, color: GOLD },
    { label: "ROSC", val: 40, color: GREEN },
  ];
  const barW = 0.65;
  const maxH = 2.0;
  const maxVal = 50;
  bars.forEach((b, i) => {
    const bh = (b.val / maxVal) * maxH;
    const bx = 0.5 + i * 1.05;
    const by = 3.9 - bh;
    slide.addShape(pres.ShapeType.rect, { x: bx, y: by, w: barW, h: bh, fill: { color: b.color }, rounding: true });
    slide.addText(b.val + "", { x: bx, y: by - 0.3, w: barW, h: 0.28, fontSize: 10, bold: true, color: b.color, align: "center", margin: 0 });
    slide.addText(b.label, { x: bx - 0.05, y: 4.0, w: barW + 0.1, h: 0.65, fontSize: 8.5, color: LGRAY, align: "center", margin: 0 });
  });
  // Threshold line
  slide.addShape(pres.ShapeType.line, { x: 0.45, y: 3.1, w: 4.0, h: 0, line: { color: GOLD, width: 1, dashType: "dash" } });
  slide.addText("10 mmHg\nthreshold", { x: 3.95, y: 2.95, w: 0.85, h: 0.5, fontSize: 8, color: GOLD, margin: 0 });

  // Key points right panel
  slide.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.1, w: 4.55, h: 4.15, fill: { color: "0D2240" }, rounding: true });
  slide.addText("Key Clinical Points  (AHA 2020)", { x: 5.25, y: 1.15, w: 4.2, h: 0.4, fontSize: 12, bold: true, color: RED, margin: 0 });
  const cprPoints = [
    { text: "ETCO₂ reflects cardiac output", sub: "CO₂ reaches lungs only if blood is moving — ETCO₂ ≈ surrogate for pulmonary blood flow during CPR" },
    { text: "< 10 mmHg after 20 min = poor outcome", sub: "Used as one factor (not sole criterion) in termination-of-resuscitation decisions" },
    { text: "CPR quality optimization", sub: "Rising ETCO₂ suggests improved compressions; target ETCO₂ ≥ 10 mmHg" },
    { text: "ROSC detection", sub: "Sudden sustained rise to ≥ 35–40 mmHg is highly specific for ROSC — reduces unnecessary interruptions for pulse checks" },
    { text: "Avoid pseudo-ROSC", sub: "NaHCO₃ bolus causes transient ETCO₂ spike — do not confuse with ROSC" },
  ];
  const cprBullets = cprPoints.map((p, i) => [
    { text: "▸  ", options: { color: RED, bold: true, fontSize: 11 } },
    { text: p.text + "\n", options: { color: WHITE, fontSize: 11, bold: true } },
    { text: "    " + p.sub + (i < cprPoints.length - 1 ? "\n" : ""), options: { color: "8BAAC8", fontSize: 10 } }
  ]).flat();
  slide.addText(cprBullets, { x: 5.25, y: 1.65, w: 4.25, h: 3.45, valign: "top", lineSpacingMultiple: 1.2, margin: 0 });

  return slide;
}

function physSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("Physiology: CO₂ Transport & the PaCO₂ – ETCO₂ Gradient", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  // Left column: CO2 transport diagram (text-based)
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.1, w: 4.5, h: 4.15, fill: { color: "0D2240" }, rounding: true });
  slide.addText("CO₂ Transport in Blood", { x: 0.45, y: 1.15, w: 4.2, h: 0.38, fontSize: 13, bold: true, color: ACCENT, margin: 0 });

  const transport = [
    { pct: "70%", label: "Bicarbonate (HCO₃⁻)", color: ACCENT },
    { pct: "23%", label: "Carbamino-Hb", color: GOLD },
    { pct: "7%",  label: "Dissolved CO₂", color: LGRAY },
  ];
  transport.forEach((t, i) => {
    const bw = parseFloat(t.pct) / 100 * 3.8;
    slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 1.65 + i * 0.6, w: bw, h: 0.4, fill: { color: t.color }, rounding: true });
    slide.addText(t.pct + " — " + t.label, { x: 0.55, y: 1.67 + i * 0.6, w: 4.0, h: 0.36, fontSize: 11, color: DARK, bold: true, valign: "middle", margin: 0 });
  });

  const gradPoints = [
    "Normal PaCO₂ – ETCO₂ gradient: 2–5 mmHg",
    "Widened gradient (> 5 mmHg) indicates ↑ dead space ventilation",
    "Dead space causes: PE, low CO, ARDS, hyperinflation",
    "Normal ETCO₂ does NOT rule out abnormal PaCO₂ — always correlate with ABG in critically ill patients",
    "Alveolar equation: PaCO₂ ≈ VCO₂ / (VA × k)",
    "Decreased VA or increased dead space → ↑ PaCO₂ without proportional ↑ ETCO₂"
  ];
  slide.addText("PaCO₂ – ETCO₂ Gradient", { x: 0.45, y: 3.5, w: 4.0, h: 0.38, fontSize: 12, bold: true, color: GOLD, margin: 0 });
  const gradItems = gradPoints.map((g, i) => [
    { text: "• ", options: { color: GOLD, bold: true, fontSize: 10.5 } },
    { text: g, options: { color: LGRAY, fontSize: 10.5, breakLine: i < gradPoints.length - 1 } }
  ]).flat();
  slide.addText(gradItems, { x: 0.45, y: 3.95, w: 4.2, h: 1.15, valign: "top", lineSpacingMultiple: 1.3, margin: 0 });

  // Right column: Determinants of ETCO2
  slide.addShape(pres.ShapeType.rect, { x: 5.1, y: 1.1, w: 4.55, h: 4.15, fill: { color: "0A1E38" }, rounding: true });
  slide.addText("Determinants of ETCO₂", { x: 5.25, y: 1.15, w: 4.2, h: 0.38, fontSize: 13, bold: true, color: ACCENT, margin: 0 });

  const determinants = [
    { factor: "CO₂ Production (VCO₂)", items: ["Metabolic rate, fever, shivering", "Malignant hyperthermia, sepsis", "Tourniquet release, reperfusion"] },
    { factor: "Alveolar Ventilation (VA)", items: ["RR and tidal volume settings", "Dead space fraction (Vd/Vt)", "ETT position, circuit leaks"] },
    { factor: "Pulmonary Blood Flow (Q)", items: ["Cardiac output", "Pulmonary embolism", "Cardiac arrest"] },
  ];
  let yOff = 1.6;
  determinants.forEach(d => {
    slide.addText(d.factor, { x: 5.25, y: yOff, w: 4.2, h: 0.32, fontSize: 11, bold: true, color: GOLD, margin: 0 });
    yOff += 0.32;
    d.items.forEach(it => {
      slide.addText("  · " + it, { x: 5.25, y: yOff, w: 4.2, h: 0.28, fontSize: 10, color: LGRAY, margin: 0 });
      yOff += 0.28;
    });
    yOff += 0.08;
  });

  return slide;
}

function nonIntubatedSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addText("Capnography in the Non-Intubated Patient", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const items = [
    {
      title: "Key Principle",
      color: ACCENT,
      text: "In non-intubated patients, sidestream sample is diluted with ambient/supplemental O₂. The absolute ETCO₂ value is less reliable than the trend and waveform pattern. Focus on respiratory rate, waveform morphology, and changes from baseline."
    },
    {
      title: "Detection Advantage",
      color: GREEN,
      text: "Capnography detects apnea or hypoventilation 4+ minutes before SpO₂ drops — critical when supplemental O₂ masks respiratory depression. Pulse oximetry alone is inadequate for ventilatory monitoring during sedation."
    },
    {
      title: "Devices Used",
      color: GOLD,
      text: "Nasal cannula with oral sampling port (most common). Nasal-oral mask for mouth-breathers. Microstream technology preferred due to low flow requirements and CO₂ specificity."
    },
    {
      title: "Procedural Sedation (ASA/ACEP Mandate)",
      color: YELLOW,
      text: "Continuous waveform capnography mandated for all moderate/deep sedation cases (ASA 2018, ACEP). Multiple RCTs show earlier detection of respiratory compromise vs. standard monitoring alone."
    },
    {
      title: "PACU & Post-op Monitoring",
      color: LGRAY,
      text: "Mask capnography detects apnea events after intrathecal opioids (e.g., morphine after C-section). Undetected by 2-hourly nursing checks in one study of 80 patients — 198 apnea alerts captured by capnography."
    },
    {
      title: "ICU / NIV",
      color: ACCENT,
      text: "Useful during NIV to monitor adequacy of ventilation without invasive airway. Also valuable during transport of non-intubated trauma patients — more stable than SpO₂ alone."
    },
  ];

  items.forEach((item, i) => {
    const col = i % 2 === 0 ? 0.3 : 5.2;
    const row = Math.floor(i / 2);
    const y = 1.1 + row * 1.45;
    slide.addShape(pres.ShapeType.rect, { x: col, y, w: 4.65, h: 1.3, fill: { color: "0D2240" }, rounding: true, line: { color: item.color, width: 1.3 } });
    slide.addText(item.title, { x: col + 0.13, y: y + 0.08, w: 4.4, h: 0.32, fontSize: 11, bold: true, color: item.color, margin: 0 });
    slide.addText(item.text, { x: col + 0.13, y: y + 0.43, w: 4.4, h: 0.82, fontSize: 9.2, color: LGRAY, margin: 0 });
  });

  return slide;
}

function pitfallsSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.0, fill: { color: MID } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0.95, w: 10, h: 0.06, fill: { color: RED } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: RED } });
  slide.addText("Pitfalls, Limitations & Troubleshooting", {
    x: 0.4, y: 0.12, w: 9.2, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const rows = [
    ["Pitfall / Source of Error", "Cause", "Solution / Caveat"],
    ["Low ETCO₂ ≠ low PaCO₂", "Widened dead-space gradient (PE, low CO)", "Confirm with ABG; calculate Vd/Vt"],
    ["Normal ETCO₂ ≠ normal ventilation", "ETCO₂ can appear normal in compensated V/Q mismatch", "Clinical assessment + ABG mandatory in unstable pts"],
    ["False low in non-intubated", "Dilution by ambient O₂ / air", "Use trends not absolute values; microstream preferred"],
    ["Elevated baseline / rebreathing", "Exhausted CO₂ absorber, faulty valve", "Replace absorber; check valves; increase FGF"],
    ["Signal dropout", "Moisture in sample line, blocked cannula", "Water trap, frequent line changes"],
    ["NaHCO₃ pseudo-ROSC", "Exogenous CO₂ from bicarbonate bolus", "Correlate with pulse check after bicarb"],
    ["TIVA / Xenon", "IR spectroscopy cannot detect xenon", "Capnography only measures CO₂; no xenon data"],
    ["Prone positioning", "ETCO₂ may change with position — not always pathological", "Establish new baseline after repositioning"],
  ];

  const cw = [2.6, 3.5, 3.4];
  const rh = 0.47;
  const sx = 0.28, sy = 1.08;
  rows.forEach((row, ri) => {
    let xc = sx;
    row.forEach((cell, ci) => {
      slide.addShape(pres.ShapeType.rect, {
        x: xc, y: sy + ri * rh, w: cw[ci], h: rh,
        fill: { color: ri === 0 ? "0D2240" : (ri % 2 === 0 ? "08192E" : "0A1E38") },
        line: { color: "1A3D5C", width: 0.5 }
      });
      slide.addText(cell, {
        x: xc + 0.07, y: sy + ri * rh + 0.03, w: cw[ci] - 0.14, h: rh - 0.06,
        fontSize: ri === 0 ? 10.5 : 9.8, bold: ri === 0,
        color: ri === 0 ? ACCENT : (ci === 0 ? GOLD : LGRAY),
        valign: "middle", margin: 0
      });
      xc += cw[ci];
    });
  });
  return slide;
}

function summarySlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.ellipse, { x: 7.5, y: 3.5, w: 4.5, h: 4.5, fill: { color: MID }, line: { color: MID } });

  slide.addText("Key Takeaways", {
    x: 0.4, y: 0.3, w: 9, h: 0.7, fontSize: 32, bold: true, color: ACCENT, margin: 0
  });
  slide.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.05, w: 3.5, h: 0.04, fill: { color: ACCENT } });

  const points = [
    "Capnography is the standard of care for ventilation monitoring in ALL anesthetized and deeply sedated patients",
    "The four-phase waveform encodes airway anatomy, gas exchange, and cardiac output simultaneously",
    "ETCO₂ changes should be interpreted alongside waveform morphology and the PaCO₂ gradient",
    "In CPR: ETCO₂ < 10 mmHg predicts poor outcome; sudden rise ≥ 35 mmHg signals ROSC",
    "Malignant hyperthermia: unexplained rising ETCO₂ is the earliest trigger — act immediately",
    "Non-intubated monitoring: detect hypoventilation 4+ min before pulse oximetry — never rely on SpO₂ alone during sedation",
    "Always correlate with clinical examination and ABG in critically ill patients — no monitor replaces bedside assessment",
  ];

  const items = points.map((p, i) => [
    { text: String(i + 1) + ".  ", options: { color: ACCENT, bold: true, fontSize: 12.5 } },
    { text: p, options: { color: LGRAY, fontSize: 12.5, breakLine: i < points.length - 1 } }
  ]).flat();

  slide.addText(items, {
    x: 0.4, y: 1.2, w: 7.3, h: 4.1,
    valign: "top", lineSpacingMultiple: 1.4, margin: 0
  });

  slide.addText("CO₂", {
    x: 7.5, y: 3.6, w: 2.4, h: 1.5, fontSize: 72, bold: true, color: ACCENT, align: "center", transparency: 50
  });
  slide.addText("Sources: Barash Clinical Anesthesia 9e | WFSA ATOTW 534 (2024) | AHA 2020 Guidelines | Medscape Capnography Review", {
    x: 0.4, y: 5.25, w: 9.2, h: 0.3, fontSize: 8, color: "4A6580", italic: true, margin: 0
  });

  return slide;
}

// ─── BUILD PRESENTATION ─────────────────────────────────────────────────────

// Slide 1: Title
titleSlide(pres);

// Slide 2: Agenda
contentSlide(pres, "Presentation Agenda", [
  { text: "1.  Physiology & Physics", sub: "CO₂ production/transport, Beer-Lambert law, IR spectroscopy" },
  { text: "2.  Technology", sub: "Mainstream vs. sidestream vs. microstream; capnometry vs. capnography" },
  { text: "3.  The Normal Capnogram", sub: "Four phases, alpha/beta angles, ETCO₂ reference ranges" },
  { text: "4.  Abnormal Waveforms & Differential Diagnosis", sub: "Pattern recognition: obstructive, rebreathing, curare cleft, flat-line" },
  { text: "5.  ETCO₂ Changes — Systematic Approach", sub: "High, low, zero — causes and clinical interpretation" },
  { text: "6.  Clinical Applications", sub: "Intubation, CPR, MH, ICU ventilation, procedural sedation" },
  { text: "7.  Non-Intubated Monitoring", sub: "Sedation safety, NIV, PACU, transport" },
  { text: "8.  Pitfalls, Limitations & Troubleshooting", sub: "Common errors and how to avoid them" },
]);

// Slide 3: Physiology overview
sectionDivider(pres, "01", "Physiology & Physics", "Understanding what CO₂ tells us about the patient's physiology");

physSlide(pres);

// Slide 5: Technology
sectionDivider(pres, "02", "Technology & Equipment", "From infrared spectroscopy to bedside monitoring");

technologySlide(pres);

// Slide 7: Normal waveform
sectionDivider(pres, "03", "The Normal Capnogram", "Four phases, reference values, and clinical correlates");

waveformSlide(pres);

// Additional normal waveform details
contentSlide(pres, "Normal Capnogram: Clinical Reference Values & Interpretation", [
  { text: "Normal ETCO₂ range: 35–45 mmHg", sub: "Reflects alveolar PCO₂ at end-expiration; best approximates PaCO₂ in healthy patients" },
  { text: "Normal PaCO₂ – ETCO₂ gradient: 2–5 mmHg", sub: "Widened gradient (> 5 mmHg) indicates increased alveolar dead space" },
  { text: "Alpha angle (< 90°)", sub: "Between Phase II and III — sharpness reflects homogenous lung emptying; obtuse = inhomogeneous V/Q (obstructive disease)" },
  { text: "Beta angle (≈ 90°)", sub: "Between Phase III and Phase IV — rounded beta angle suggests CO₂ rebreathing" },
  { text: "Respiratory rate visible on trend", sub: "Apnea shows as flat line; breath stacking shows progressive baseline elevation" },
  { text: "Phase III slope (S III)", sub: "Normally slightly upward; steep rise = severe V/Q mismatch (COPD, asthma exacerbation)" },
], { note: "ETCO₂ should always be interpreted with waveform morphology — numeric value alone is insufficient" });

// Slide 10: Abnormal waveforms
sectionDivider(pres, "04", "Abnormal Waveform Patterns", "Pattern recognition as a diagnostic tool");

abnormalWaveformsSlide(pres);

// Slide 12: ETCO2 differential
sectionDivider(pres, "05", "ETCO₂ Changes: Systematic Approach", "High, low, zero — causes and clinical response");

etco2table(pres);

// Slide 14: Clinical applications
sectionDivider(pres, "06", "Clinical Applications", "Anesthesia, ICU, Emergency Medicine");

rolesSlide(pres);

// ETT confirmation + MH detail
twoColSlide(pres,
  "Intubation Confirmation & Malignant Hyperthermia",
  "ETT Confirmation (AHA Class IA)",
  [
    "Continuous waveform capnography is the gold standard",
    "Colorimetric CO₂ detectors acceptable only if waveform unavailable",
    "Absence of waveform after intubation = esophageal intubation until proven otherwise",
    "Confirm after each patient repositioning, transport, and manual ventilation",
    "Six consecutive ETCO₂ waveforms recommended before securing ETT",
    "Supraglottic airways: capnography also confirms adequate ventilation"
  ],
  "Malignant Hyperthermia Early Warning",
  [
    "Unexplained ETCO₂ rise is the EARLIEST sign of MH (before hyperthermia develops)",
    "Mechanism: massively ↑ cellular metabolism → ↑ CO₂ production overwhelms ventilation",
    "Action: increase minute ventilation → stop volatile agents → dantrolene IV",
    "ETCO₂ may exceed 100 mmHg in severe MH",
    "Also monitor temperature, rigidity, CK, ABG (severe metabolic acidosis)",
    "MH hotline: 1-800-MH-HYPER (North America)"
  ],
  GREEN, RED
);

// Slide 16: CPR
sectionDivider(pres, "07", "Cardiac Arrest & CPR", "ETCO₂ as a hemodynamic surrogate");

cprSlide(pres);

// Slide 18: Non-intubated
sectionDivider(pres, "08", "Non-Intubated Monitoring", "Procedural sedation, PACU, ICU, transport");

nonIntubatedSlide(pres);

// Slide 20: Pitfalls
sectionDivider(pres, "09", "Pitfalls & Limitations", "When capnography can mislead");

pitfallsSlide(pres);

// Slide 22: Summary
summarySlide(pres);

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

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

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

libreoffice --headless --convert-to pdf /home/daytona/workspace/capnography-pptx…

mkdir -p /home/daytona/workspace/capnography-pptx/output && libreoffice --headle…

chmod 777 /home/daytona/workspace/capnography-pptx/output && cp /home/daytona/wo…

cp /home/daytona/workspace/capnography-pptx/Capnography_Advanced.pptx /tmp/cap.p…

cp /tmp/cap.pdf /home/daytona/workspace/capnography-pptx/Capnography_Advanced.pd…

ls -lh /home/daytona/workspace/capnography-pptx/ && echo "---" && file /home/day…