6a5a6ed541594d5075e87079-mp3

0:00

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

The guidelines say is you're supposed to use multimodal risk,

0:01

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

and we do have a reveal -echo scoring now that's available that we can use that to maybe

0:06

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

quantify the severity of the echo.

0:08

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Although we all can just look at it and say,

0:10

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

RV's sick on this patient.

0:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But I mean,

0:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you should never use one pillar and say,

0:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

well, because the patient's low risk,

0:16

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

we buy a reveal -like two.

0:17

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

we're not going to escalate therapy while the patient's got a severe RB with a basal diameter of 6.

0:21

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That doesn't make sense.

0:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But correct me if I'm wrong,

0:24

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

isn't the general,

0:25

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

and this is my personal sort of thing,

0:27

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

I feel like the general consensus is always like,

0:29

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

use risk and kind of only,

0:31

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

and I know people don't say that,

0:33

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

but I feel like it's almost implicit.

0:34

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Like, use the risk score and kind of not anything else.

0:37

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

But, I mean, obviously that's not the case,

0:39

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

but I don't know if that's like,

0:40

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

just based on sort of like a,

0:43

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

a Gestalt of mine,

0:44

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

which is probably incorrect,

0:45

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

but I, you know,

0:46

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

that's sort of the push.

0:47

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

And I can tell you a quick anecdote about that is when we went up for recreation last

0:51

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

year, literally I got wrapped on Knuckles because I didn't put reveal scores in every single one of my notes,

0:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like properly.

0:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Wow.

0:57

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

You put reveal Echo scores and they didn't like it?

1:00

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

No, I,

1:01

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

well, I didn't put it all the time because I was like,

1:03

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

there's some people I'm like,

1:04

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

okay, this is not,

1:05

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

this is kind of pointless to like kind of write the reveal scores.

1:08

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So that was one of my things.

1:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Oh, I see what you're saying.

1:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah, yeah,

1:10

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

yeah. I mean,

1:13

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

we do it.

1:14

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

obviously for patient care reasons,

1:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but it's also a good measure to track,

1:17

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

especially if you're doing research and things because it quantifies severity.

1:22

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But,

1:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, ERS 2022,

1:25

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

ProSymposium both say that we should be using multimodal

1:29

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

risk assessment,

1:31

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

not just a risk calculation score.

1:33

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

And they kind of left

1:37

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

it a little bit vague.

1:38

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

It is vague.

1:39

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

It is vague.

1:41

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Because it's clinical style,

1:42

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

right? It's clinical style,

1:43

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

yeah. Is there anything that you kind of used a little bit differently than

1:47

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Echos that might,

1:48

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

or anything that kind of comes to mind that you're like,

1:50

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

okay, this is kind of what I was trained on?

1:52

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, I also,

1:53

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I think a lot of what we look at is static

1:57

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

data, right?

1:58

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

We're looking at patients at rest,

1:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

which is not necessarily the best predictor for how they do out in the world.

2:04

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So heart rate recovery is another piece that I think is really valuable for a six -minute walk.

2:07

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Your patient's going up to 130 heart rate,

2:10

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

and they're only coming down 127 after a minute.

2:13

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's a sick RV.

2:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I don't care what else the risk says.

2:17

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

Yeah, and that was this patient.

2:18

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

He was talking about,

2:19

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you know,

2:20

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

she was going into palpitation.

2:21

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And then she had an episode of AFIT,

2:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

and like, okay, now we have a problem.

2:24

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I don't care if she scores five.

2:29

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Because current criteria has revealed skin of 9 and 10 to list somebody.

2:32

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

It was like,

2:33

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

by the time she gets to 9 and 10,

2:35

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

she'll be dead.

2:35

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah. And then .

2:37

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

But I think that's an example.

2:38

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

She's a good example,

2:39

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

though, of what are you looking at?

2:41

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

Because when she got to us,

2:42

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

she had been undertreated,

2:43

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and she was mixed CTD.

2:45

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And so she had very aggressive disease.

2:47

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And so then it's like,

2:48

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

well, if that person was,

2:50

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

I don't know her initial journey

2:54

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

of what they were using as far as

2:56

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

choosing her medications,

2:57

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

but like maybe she was low risk.

3:00

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And so they only put her on dual anti or dual

3:04

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

therapy at first.

3:06

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And she got to us with triple,

3:08

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

but it was a very weird regimen,

3:10

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

as I'm sure you guys all see all the time.

3:11

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So then it's like,

3:13

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

well, I think she got to us too late,

3:15

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and we probably could have helped her more.

3:17

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

But maybe she was low risk the whole time,

3:20

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and that's why they chose that.

3:22

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And they should have been looking at other factors.

3:24

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Right.

3:24

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

And they didn't follow up on a regular basis.

3:28

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Maybe. I don't know.

3:28

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But that makes sense.

3:30

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Kind of a little bit tangential,

3:31

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

but for our critical care colleagues,

3:33

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

you know, so when you see acute RV dysfunction,

3:36

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

in pH patients specifically or not?

3:38

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

I mean, obviously there's no risk calculator for acute inpatient ICU for RIPPs as well.

3:42

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Is there something that you look for that specifically concerns you that this patient is having

3:46

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

worsening acute RV failure in the setting of ARDS or in the setting of severe pH as

3:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

well? You can start with the hemodynamics.

3:51

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's the easiest one.

3:52

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

And tachycardia is definitely number one.

3:55

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Okay.

3:55

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Like resting tachycardia.

3:57

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Rest tachycardia.

4:02

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

As everybody said,

4:03

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

basically it's the increase in heart rate on ambulation and recovery

4:07

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

phase.

4:08

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

So let's say that patient get up and go to the bathroom.

4:11

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Heart rate was 150 or 30 point difference or 40 point difference.

4:15

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

That's a huge difference.

4:16

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

That's a huge thing that we need to address.

4:18

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Why is it doing that?

4:20

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Is it actually too much diuresis or is it a disease

4:25

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

RV?

4:25

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Two, blood pressure changes,

4:27

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

especially with ambulation.

4:29

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Okay.

4:31

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

and end of the walk.

4:33

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

If the RV is unable to support this patient and

4:38

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

there's leg pain and dizziness by the end of it,

4:41

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

or even standing up,

4:42

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

that's a diseased RV.

4:44

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Echo findings,

4:45

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I feel like the internal diameter,

4:48

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

that's RV ID,

4:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

basically.

4:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Anything above five and a half,

4:53

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

close to six.

4:54

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

It's a very diseased RV,

4:57

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

especially in an ICU setting.

5:00

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

We don't look a lot at the BNP.

5:02

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

I've been fooled many times with the BNP.

5:06

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

I've seen normal BNPs in severe RV.

5:09

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

TAPSI,

5:10

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

I really don't care what the TAPSI score is when it comes to ECHO.

5:16

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

changes, especially if the TR -JET is not very accurately calculated.

5:20

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

There's a lot of inter -variability between cardiologists and

5:24

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

you have to pick up the phone and call them and say,

5:26

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

can you please take another look at the echocardiogram?

5:29

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Because if you just rely on the echo numbers

5:33

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

and you look at the patient,

5:35

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

there's a huge discrepancy.

5:36

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

It's just a bad echo.

5:40

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

So consistency with an echo with a

5:44

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

cardiologist is also important when it comes to the ICU,

5:46

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

knowing that that person reads the same echo daily

5:51

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

or interpatient variability,

5:53

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I guess.

5:54

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And I guess sort of a partial follow -up for that is

5:58

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

when you're trying to wean patients off ECMO with acute RV

6:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

dysfunction, I'm assuming you do TEs or TTEs on a regular basis.

6:07

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Is there a specific parameter that looks better?

6:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, because you may not always get a normal artery function before you decannulate,

6:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

right? So what is like,

6:13

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, is it other clinical factors or is it?

6:16

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

I mean, following the coupling is a great way.

6:18

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And so we don't just look at TAP -C in isolation.

6:21

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

We look at the upload with TAP -C and see how those numbers,

6:24

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

that ratio changes over time.

6:25

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

A lot of times for our ECMO folks.

6:27

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

There's now the new mind ray,

6:30

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

which sounds like to do a quick strain index for patients.

6:34

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Really? Like just RV logical and free ones?

6:36

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

Yeah, it's pretty crazy.

6:37

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So you don't even have to go in and measure it.

6:39

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

It literally does all of it for you.

6:41

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So the technology is getting it.

6:42

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's cool.

6:43

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Yeah, that is really cool.

6:45

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Like on the echo?

6:46

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

On the echo.

6:47

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So like on the point of care.

6:48

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

As long as you can visualize the,

6:51

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

basically you can see the RV,

6:52

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

it can map it,

6:54

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

you select yes,

6:55

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and then it will do a strain index for you and pop your number.

6:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Awesome.

6:59

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Now,

7:00

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

these patients you're talking about are newly diagnosed PH,

7:03

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

who are not on therapy,

7:04

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

lended on ECMO,

7:05

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

that we're trying to recover.

7:06

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I think that would be the ideal patient,

7:08

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but I sort of was a little bit vague,

7:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

because it could be patients with secondary artery dysfunction,

7:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

too, due to whatever other reason.

7:14

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But I was just curious,

7:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

because I don't do ECMO on a regular basis,

7:18

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

so I was just curious.

7:19

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

in patients with like acute rv dysfunction like kind of weaning them because especially newly diagnosed

7:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

the rv is never going to be like completely normal i mean it probably won't be for the year yeah if anything so

7:27

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

i was just curious like if there are specific parameters because i mean you can't necessarily go by you

7:31

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

know tapsy or you know but you know looking rv free while longitudinal strain makes sense you know first of

7:35

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

all you probably have a swan end so that's an effect your taps scores uh two the

7:40

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

weaning of uh of ecmo on on a ph patient

7:44

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

is really challenging

7:46

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Having just a two or three minute weaning or a clam trial isn't

7:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

really significant.

7:52

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

So in these

7:56

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

patients, I usually give them a 24 -hour weaning

8:01

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

down to the least possible flow,

8:03

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

possibly about 2,

8:04

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

2 .2 liters,

8:05

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

and see how they do overnight before

8:10

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

doing a clam trial.

8:12

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Got it.

8:12

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

I think the overarching experience is that it's pH patient group 1

8:17

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

blended on ECMO.

8:18

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Yeah. Okay,

8:20

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

so that's what I was going with.

8:23

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Our success rate to...

8:26

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

liberate them from ECMO,

8:28

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

from VA,

8:29

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

which is always going to be VA,

8:30

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

it's extremely low.

8:31

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I can't imagine that's easy,

8:32

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

if at all possible.

8:33

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

The only place it would be possible was a new diagnosis,

8:36

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

it was never on therapy,

8:37

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

crashed,

8:38

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

you put them on therapy and you expect them to get it.

8:40

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

But somebody was on it already?

8:42

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

On Remodulin?

8:43

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

I mean, we have got calls about people on 100 of Remodulin already,

8:47

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

and they're trying to liberate it.

8:49

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

It's like, no, that's not liberating.

8:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

No, it's not possible.

8:51

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Let's just...

8:52

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

That's a great point.

8:53

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

You made like newly diagnosed versus like already on maximal therapy.

8:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, they're that's two completely different clinical outcomes,

8:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

right?

8:59

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

We have been unsuccessful even the newly diagnosed to be honest.

9:02

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

We have lost them unfortunately,

9:05

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

but it's I think the easiest thing is generally the last patient we said to you guys was a brand

9:09

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

new guy Generally speaking

9:14

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

putting up group one pH on ECMO is not

9:18

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

very common.

9:19

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah,

9:20

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

unless you have a

9:21

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

way for a bridge to transplant.

9:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Right.

9:23

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

And then there comes also the question of is the RV so

9:28

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

failed that we need a PROTECT instead of just a

9:32

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

conventional peripheral VA.

9:33

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Okay.

9:34

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So PROTECT meaning like a PA?

9:36

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

A PA catheter with basically an RV support.

9:39

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

And at the same time,

9:41

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

some argue that

9:44

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

with the high pressures in the pulmonary vasculature and pushing

9:48

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

all the blood towards that.

9:50

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Pulmonary hemorrhage.

9:50

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Exactly, exactly.

9:51

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

And so it's a really rare

9:56

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

phenomenon for VA ECMO.

9:58

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

And if it happens,

9:59

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

it's usually...

10:00

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Sounds like a sphincter tightening moment right there.

10:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I

10:06

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

think we sort of talked about most of this stuff,

10:07

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

socioeconomic realities,

10:08

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

meth, meth, and more meth.

10:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But I mean,

10:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

and there's more slides down the road about socioeconomic realities and we'll go over that.

10:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So this is,

10:16

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

oh my God,

10:17

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

this is so much fun.

10:18

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Looking at cardiopulmonary exercise testing and pH.

10:20

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I did an exercise count today.

10:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

We have a bike at St.

10:24

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Joe's.

10:26

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

We have a bike and you can put it on the cath lab table.

10:28

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

This bike works in Phoenix right now.

10:30

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

So you do your right now gets at Joe's right?

10:32

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah.

10:32

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Plus most of them.

10:33

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

So yeah,

10:34

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

we can split the cost on this new bike that I want to get.

10:37

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Well, there's,

10:37

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

have you used the bike that's sitting on the,

10:39

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like you can attach it to the cath lab table.

10:40

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

No, but that's just out.

10:41

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

It's dated.

10:42

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Okay.

10:43

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

I'll show you a different one.

10:45

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

But everybody else's is broken in Phoenix except for Dr.

10:47

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Swarov's right now.

10:48

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

So at least we have something.

10:52

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

So we do still do non -invasives,

10:54

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

but we aren't doing any invasives in Phoenix.

10:55

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

We just use our team in Tucson.

10:57

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Yeah, honor health.

10:58

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah, Dr.

10:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Richard.

10:59

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Yeah,

11:00

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

France is, like,

11:01

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

on the frickin' top of that.

11:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But anyway,

11:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

the data shows,

11:03

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

obviously, what CPEC detects.

11:05

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Obviously, you know,

11:05

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

dead space ventilation is the number one,

11:07

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you know, the earliest sign of worsening pulmonary vascular disease.

11:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

VCO2 slope.

11:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And then,

11:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you know, if you're starting to get to,

11:13

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you know,

11:14

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

earlier anaerobic thresholds or,

11:16

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you know, decreased O2 pulse,

11:17

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

you're in real trouble at that point.

11:20

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Am I right about all of that?

11:21

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Absolutely.

11:21

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I think this is an underutilized tool.

11:24

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I think in tracking patients,

11:25

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

and especially when we were having this conversation about risk being not the best tool,

11:29

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

this will detect a patient who's in decline way before their risk starts

11:33

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

to increase,

11:34

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

especially,

11:34

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

like you said, dead space ventilation,

11:35

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

the VCO2 ratio is a big one.

11:37

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Makes complete sense.

11:38

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And I mean, I think that's kind of where we're looking at is kind of looking at ventilatory efficiency as a response

11:43

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

factor and kind of normalization of that.

11:46

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I've used CPET to diagnose pH patients.

11:48

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I've never used it to follow pH patients.

11:50

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's probably my bad.

11:51

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

Do you do it every time?

11:52

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

No,

11:53

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

no, no. All pH patients?

11:54

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

No, no,

11:55

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

no. I'm saying CPET,

11:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

not exercise cath,

11:57

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but specifically CPET.

11:58

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I've done it once or twice a couple of times in my practice,

12:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

too, especially for those...

12:04

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

The ones actually that I'm worried about the most are the ones that have a known risk factor.

12:07

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So scleroderma patients are the ones that come to mind where I do exercise right hard cats a lot pretty

12:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

often.

12:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

But,

12:13

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

well,

12:14

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

let's go to the next slide here,

12:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

looking at prostacyclins.

12:18

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Well, we'll come back to that.

12:19

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So looking at CPET and exercise catheterizations,

12:21

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I don't know,

12:23

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

what are your thoughts about that?

12:23

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Should we be exercising everybody?

12:24

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean, I did one this morning.

12:26

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I found FF,

12:27

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but like...

12:29

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

So when you say exercise everybody,

12:30

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

what do you mean?

12:31

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So let me back up a little bit.

12:33

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I'm sorry about that.

12:34

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I wasn't very specific.

12:35

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So I'm talking about the people with a known risk

12:39

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

factor for pH,

12:40

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

okay, methamphetamine,

12:41

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

scleroderm, or whatever,

12:42

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

where you aren't convinced based on echo and non -invasive data

12:46

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

to date because you haven't had a hard cat that they may not have resting pH,

12:49

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but you're convinced that they probably...

12:51

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

CTET is another one where I feel like I've seen that.

12:52

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So...

12:54

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

what are your thresholds for doing an exercise cath early on?

12:57

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I know, obviously,

12:57

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Franz does them on pretty much everybody.

12:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And then what is your,

13:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like,

13:03

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

have you ever, and I've never done this,

13:04

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

is follow -up exercise heart catheterization and follow -up CPETS after

13:08

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

therapy to assess response?

13:10

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

So I think that any patient who you have a high suspicion for

13:14

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

PAH, who with a traditional workup,

13:16

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

you're not getting the answers you need,

13:18

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

should be exercise in general.

13:20

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I don't think that you necessarily need to follow those patients with exercise right

13:24

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

heart casts per se.

13:26

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

But I would say that if you're worried about a patient who,

13:30

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

again, is one of these,

13:30

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I mean,

13:31

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

the phenotype that comes to my mind is like this young patient with CTD

13:35

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

-related PAH.

13:36

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

risk scores are low,

13:38

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

but you just know something's off,

13:39

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

right? Like the heart rate's not normal.

13:40

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

The patient's exercise tolerance is normal for an 80 -year -old,

13:43

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

but not for this young person who should be able to do a lot more.

13:46

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I would seriously exercise that person because like what Boven said,

13:49

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

this may be a patient that's heading towards transplant and you just don't even know it because the risk and

13:53

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

everything else is going to tell you to sit on your haunches and not escalate therapy.

13:57

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Are you guys also using like wearable data in clinics saying,

13:59

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

hey, you've got your watch,

14:01

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

bring in your heart rate.

14:01

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yes.

14:02

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Bring in your number so we can keep your lip sign on.

14:03

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

Absolutely.

14:04

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Absolutely.

14:04

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

What is your heart rate doing?

14:05

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

What's your peak heart rate?

14:06

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

What's your R ring saying?

14:08

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Yeah.

14:09

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I mean,

14:10

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

not even technically speaking,

14:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but regular speaking.

14:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Like a six -minute walk distance is a freaking exercise test every single time that we do it,

14:15

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but it's just not as.

14:16

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

They blow it out of the park,

14:17

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

right? Right.

14:17

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Exactly.

14:18

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Every time.

14:19

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

And also sometimes it depends on the technician and

14:23

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

stuff. We don't do a lot of seat bed.

14:25

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

to be honest.

14:25

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Okay.

14:26

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

Undiagnosed,

14:27

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

undifferentiated cases,

14:29

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

we will do it.

14:32

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and exercise right hard kids,

14:33

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

we do a lot of them,

14:34

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

honestly.

14:34

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

We do a lot of exercise.

14:36

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

But we send them out.

14:37

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

We send them out because I know a guy who has the right equipment

14:41

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

and the right way to do it.

14:43

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Okay.

14:43

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

But if we can do them at Joe's,

14:45

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

that would be like...

14:46

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

If you guys tell me how many patients you're sending out,

14:48

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I could get an S -bar to get S -bar.

14:50

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Yeah,

14:51

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

trust me.

14:52

S… Speaker 4 (6a5a6ed541594d5075e87079-mp3)

We're all business.

14:54

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Also,

14:55

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

what about altitude?

14:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah.

14:57

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

So National Jewish,

14:58

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

I was talking to one of the NPs that used to work there for about 12 years,

15:01

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

and they're starting to do these right hard casts

15:05

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

and testing the altitude.

15:06

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Do we have a way to do that,

15:07

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

or is that something that we feel like would be beneficial?

15:10

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

Would it change our,

15:11

S… Speaker 5 (6a5a6ed541594d5075e87079-mp3)

like...

15:11

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah, I mean,

15:12

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

unless we set up a clinic in Flagstaff.

15:14

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Yeah.

15:14

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

With hypoxic gas mixture.

15:16

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

But your equations and everything are going to be all messed up.

15:19

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

There's probably a way you can program the metabolic cart for lower oxygen tension.

15:24

S… Speaker 3 (6a5a6ed541594d5075e87079-mp3)

I think that's above my pay grade.

15:26

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Okay, yeah.

15:26

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

But the only data you're going to get is objective data,

15:30

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

really. Right.

15:30

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

And most studies of pH are mostly subjective.

15:33

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

Well,

15:34

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

that's the other thing.

15:34

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

30 -minute walk,

15:35

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

all that kind of stuff,

15:36

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

right? Subjective.

15:36

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And that's to your point,

15:38

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like, even once you have this data,

15:39

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

what are you going to do with it,

15:40

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

right?

15:40

S… Speaker 2 (6a5a6ed541594d5075e87079-mp3)

Yeah, exactly.

15:41

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And so to your point,

15:42

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like, you know, we have all this fun data,

15:44

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

and it's fun to look at,

15:45

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

but, like, you know, I mean,

15:46

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

yeah, you've got a mean PA,

15:47

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

what is it, mean PA pressure over cardiac output slope of three,

15:49

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

right?

15:50

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's, am I correct?

15:51

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

That's still the current way of doing it.

15:55

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

After that,

15:55

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

like, okay,

15:56

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

all you can get approved is probably selenofil or tadalatil.

15:59

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

I've never gotten anything more than that approved for exercise pH.

16:02

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

And so then you have to kind of wait around until they get worsening pH.

16:05

S… Speaker 1 (6a5a6ed541594d5075e87079-mp3)

So, you know,

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