MS Respiratory System

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A complete yet brief lecture about the Respiratory system. This Lecture focuses on the Anatomy and Physiology, Diagnostic Exams, Lab Values, Respiratory Diseases and Nursing Managements.
  1. Brief Review of System
  2. Upper Respiratory Tract
  3. Lower Respiratory Tract
  4. Lung Volumes & Capacities
    • Lung volumes – amount of air exchanged during ventilation
      • Tidal volume (TV) – amount of air that moves in & out of the lungs during normal breathing (500mL)
      • Inspiratory reserve volume (IRV) – maximum amount of inhaled air in excess of the normal TV (3000mL)
      • Expiratory reserve volume (ERV) – maximum amount of exhaled air in excess of the normal TV (1100mL)
      • Residual volume (RV) – amount of air remaining in the lungs after forced expiration; increases with age (1200mL)
    • Lung capacities – 2 or more lung volumes
      • Vital capacity (VC) = TV+IRV+ERV (amount of air than can be exhaled from maximal inspiration) 4600mL
      • Inspiratory capacity = TV+IRV (maximum amount of inhaled air at the beginning of normal expiration & distending the lungs to its maximum) 3500mL
      • Functional residual capacity = RV+ERV (amount of air remaining in lungs after normal expiration) 2300mL
      • Total lung capacity = sum of all lung volumes; total amount of air that the lungs can hold
    • average pair of human lungs can hold about 8L of air, but only a small amount of this capacity is used during normal breathing
  6. Factors Affecting Lung Volume
    • Larger volumes
      • males
      • taller people
      • non-smokers
      • athletes
      • people living at high altitudes (the body's diffusing capacity increases in order to be able to process more air)
    • Smaller volumes
      • Females
      • shorter people
      • Smokers
      • non-athletes
      • people living at low altitudes (atmosphere is less dense at higher altitude, therefore, the same volume of air contains fewer molecules of all gases
  7. Effects of Aging
    • Progressive loss of elastic recoil of lungs – due to elastin & collagen fiber changes
    • Increased respiratory muscle workload – due to calcification of soft tissues in chest wall
    • Total lung capacity remains constant
    • Increased residual lung volume – result of changes in aging
  8. Physical Assessment
    • Inspection:
        • Symmetry of Chest Expansion
        • Size of chest (barrel chest, pigeon chest, deformities, flail segment/paradoxical movement)
        • Signs of Increased Respiratory Effort
        • Changes in Skin Color (including nail beds)
        • Clubbing of fingernails
        • Include listening to patient’s speech
    • Palpation
      • Trachea – slightly movable & quickly returns to midline after displacement
      • Tactile fremitus –transmission of vibration of air movement through chest wall during phonation (99 method)
      • Thoracic excursion
    • Percussion:
      • Resonant – low-pitched hollow (normal lung sound)
      • Hyperresonant – louder & lower-pitched; presence of increased amount of air (emphysema, pneumothorax)
      • Dull- thudlike
      • Tympanic – hollow (tension-pneumothorax)
      • Flat – soft high-pitched
    • Auscultation:
      • Bronchial, bronchovesicular, vesicular
      • Adventitious Breath sounds:
        • Stridor - High pitched crowing sound, usually heard on inspiration, indication of a tight upper airway
        • Wheezing - Whistling sound, usually heard on expiration, indication of narrowing of lower airways (bronchospasm, edema, foreign material)
        • Ronchi - Rattling sound, caused by mucus in larger airways
        • Rales - Fine crackling sound, indication of fluid in the alveoli
  9. Diagnostics
    • Chest X-ray (Chest radiography; Serial chest x-ray)
      • Visualization of the chest, lungs, heart, large arteries, ribs, and diaphragm while standing in front of the machine
      • Two views are usually taken:
        • Antero-posterior view - x-rays pass through the chest from the back
        • Lateral view - x-rays pass through the chest from one side to the other
      • Nursing Interventions:
        • Instruct client to hold his breath while x-ray is taken
        • Inform client that test is performed in the radiology department (in hospitals, mobile x-rays may be used) & the film plate may feel cold
        • Instruct client to wear a hospital gown and remove all jewelries
  10. B. Pulmonary Function Tests (PFT)
    • a group of tests measuring lung function
    • Measure of diffusion capacity
      • client breathes in a harmless gas for a very short time (one breath)
      • the concentration of the gas in the air exhaled is measured
      • the difference in the amount of gas inhaled and exhaled can help estimate how quickly gas can travel from the lungs into the blood
    • Body plethysmograph - most accurate
      • Client sits in a sealed, clear box that looks like a telephone booth while breathing in and out into a mouthpiece
      • Changes in pressure inside the box help determine the lung volume
  11. Cont…(PFT)
    • Spirometry test – measures airflow; client will breathe through a tight fitting mouthpiece and will have nose clips
    • Nursing Interventions: Instruct client to:
      • breathe into a mouthpiece that is connected to an instrument (spirometer)
      • eat a light meal before the test
      • not to smoke for 4 - 6 hours before the test
      • stop using bronchodilators or inhaler medications 6-8hrs prior
      • Inform client that temporary shortness of breath or light-headedness may be felt
  12. C. Peak Expiratory Flow Rate (PEFR)
    • measures how fast a person can exhale
    • it is one of many tests that measure how well the airways work
    • requires a peak expiratory flow (PEF) monitor, a small handheld device with a mouthpiece at one end and a scale with a moveable indicator (usually a small plastic arrow)
    • commonly used to diagnose and monitor lung diseases such as asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD), & emphysema
    • Home monitoring helps determine whether treatments are working or detect when your condition is getting worse . This allows anticipation on when breathing will bec ome worse and to take medications or to call hea lth care providers before symptoms become too seve re
    • A decrease in peak flow indicates blocked or narrowed airways
    • A significant fall in peak flow can signal the onset of a lung disease esp. when accompanied by persistent coughing, SOB, or wheezing
    • PEFR measurements are not as accurate as the spirometry
    • Nursing Interventions:
      • Inform client that repeated efforts may cause lightheadedness
      • Loosen any tight clothing that might restrict breathing
      • Sit up straight or stand while performing the tests
      • Instruct client on proper procedure to do this test:
      • Breathe in as deeply as possible.
      • Blow into the instrument's mouthpiece as hard and fast as possible.
      • Do this 3 times, and record the highest flow rate
  13. D. Throat Culture
    • Also known as throat swab culture
    • a laboratory test to isolate and identify organisms that may cause infection in the throat; when throat infection is suspected, particularly strep throat
    • back of the throat is swabbed with a sterile cotton swab near the tonsils
    • Nursing Interventions:
      • Instruct client not to use antiseptic mouthwashes before the test
      • Inform client that he may experience a gagging sensati on when the back of the throat is swabbed
      • Instru ct to resist gagging and closing the mouth during procedure (test only takes a few seconds)
  14. E. Bronchoscopy (Fiber Optic Bronchoscopy)
    • views the airways and diagnose lung disease
    • may also be used during the treatment of some lung conditions
    • flexible bronchoscope is usually used (less than ½ in wide and about 2ft long)
    • scope is passed through the mouth or nose, and then into the lungs
    • rigid bronchoscope requires general anesthesia
    • flexible bronchoscope uses local anesthesia (spray if via mouth and throat; numbing jelly if via nose)
    • IV meds may be given to help relax the client
  15. Cont…(Bronchoscopy)
    • Nursing Interventions:
      • Inform client that spraying of local anesthesia will cause coughing at first, which will stop as the anesthetic begins to work
      • Inform client that as the anesthesia wears off, the throat may be scratchy for several days
      • Instruct client on NPO 6-12hrs prior (withhold ASA or Ibuprofen if client takes it on a regular basis or as ordered)
      • Place client on NPO 1-2hrs after the procedure or until (+) for gag reflex
  16. F. Sputum Culture
    • Sputum - secretion produced in the lungs and the bronchi; what comes up with deep coughing
      • This mucus-like secretion may become infected, bloodstained, or contain abnormal cells that may lead to a diagnosis
    • Nursing Interventions:
      • Drinking a lot of water and other fluids the night before collection may help
      • Perform back tapping or chest clapping on client to aid in loosening the sputum
      • Instruct client on proper specimen collection
        • Collect morning specimen
        • Gargle with water only before specimen collection cough deeply and spit sputum in a sterile cup
      • Send specimen to lab ASAP
  17. G. Oximetry
    • measures oxygen concentration (%) in the blood
    • used in the evaluation of various medical conditions affecting heart & lung functions
    • most commonly used = pulse oximeters because they respond only to pulsations, such as those in pulsating capillaries of the area tested
    • pulse oximeter works by passing a beam of red and infrared light through a pulsating capillary bed
    • ratio of red to infrared blood light transmitted gives a measure of the oxygen saturation in the blood
    • Principle: oxygenated blood is bright red while the deoxygenated blood is blue-purple
    • Other types:
      • intracardiac oximetry - blood that is within the heart or on whole blood that has been removed from the body
      • More recently, using a similar technology to oxymetry, carbon dioxide levels can be measured at the skin as well
  19. Pulmonary Tuberculosis
    • contagious bacterial infection that mainly involves the lungs, but may spread to other organs
    • Cause: Mycobacterium tuberculosis
    • Mode of transmission: inhalation of air droplets from a cough or sneeze of an infected person
    • primary stage of the infection is usually asymptomatic
  20. Pathophysiology
    • High-risk individuals
      • Elderly
      • Infants
      • Immunosuppressed (AIDS, chemotherapy, or antirejection medicines given after a organ transplant)
      • Are in frequent contact with people who have the disease
      • Live in crowded or unsanitary living conditions
      • Have poor nutrition
      • The appearance of drug-resistant strains of TB
    • S/Sx
      • Limited to minor cough
      • Fever and night sweats
      • Fatigue
      • Unintentional weight loss
      • Excessive sweating, especially at night
      • Coughing up blood
      • Phlegm-producing cough
      • Wheezing
      • Chest pain
      • Breathing difficulty
  22. Cont…(PTB)
    • Dx:
      • Chest x-ray – seen on upper lobes (due to higher O 2 concentration)
      • Sputum cultures (Acid-Fast Stain) – confirmatory test
      • Tuberculin skin test (Mantoux Test) – ID purified protein derivative (PPD)
        • 48-72hrs interpretation
        • (+) = 15mm induration (5mm for immunosuppressed clients)
      • Bronchoscopy
      • Thoracentesis (very rare occasions)
      • Chest CT Scan
    • Complications:
      • Miliary TB - widespread dissemination of Mycobacterium tuberculosis from hematogenous spread
      • Pleural Effusion – collection of fluid in the pleural cavity
      • Empyema – purulent drainage It results from an untreated pleural-space infection Empyema
  23. Cont…
    • Tx: Multi-drug therapy = to prevent development of resistance ( RIPES )
    • R ifampicin – inhibits RNA synthesis of the bacilli
    • I soniazid – remarkably potent to the bacilli; prophylaxis; given with Vit. B 6
    • P yrazinamide (PZA) – inhibits cell growth
    • E thambutol – inhibits cell growth
    • S treptomycin – 1 st drug found to be effective against PTB; given by injection
    • Nursing Management:
    • Give meds before meals
    • Maintenance therapy = after 6months
    • Client not communicable after 2wks
    • Rifampicin’s SE: reddish/orange body secretions (urine)
    • PZA prone to hyperuricemia so ↑ oral fluids
    • Ethambutol - A/E: optic neuritis so √ vision/visual changes
      • C/I: pedia – cannot report any visual disturbances
    • Streptomycin – A/E: ototoxic (√ tinnitus)
      • nephrotoxic = √ oliguria
      • neurotoxic = seizure precautions
  24. Asthma
    • Chronic inflammatory airway disease
    • Exposure to allergens (dust, smoke,
    • animal dander, pollen, volatile organic
    • compounds, food, meds, etc)
    • Cold air, exercise, & emotional upset
    • can produce bronchospasm
    • Pathophysiology:
      • allergens -> immune response (mast cells, eosinophils, T lymphocytes) -> mucus production -> bronchospasm -> inflammation -> excessive mucus production -> narrowing of airways -> bronchoconstriction -> asthma attack
    • Manifestations: (asthma attacks differ from 1
    • person to another)
      • Episodic wheezing
      • Feelings of chest tightness
      • Cough may be accompanied by wheezing
      • Prolonged expiration
      • Increased RR
      • Severe attacks = severe dyspnea (use of accessory muscles)
        • Distant breath sounds (due to air trapping)
        • Loud wheezing
        • Fatigue develops
        • Moist skin
        • Anxiety/panic attack
        • Client is able to speak 1-2 words before taking a breath
    • Complication: respiratory failure (onset marked by inaudible breath sounds, diminished wheezing, coughing becomes ineffective
  25. Cont…
    • Dx: careful Hx & physical assessment
      • Spirometry
      • Inhalation challenge test – measures the level of airway responsiveness (histamine, or exposure to non-pharmacologic agent)
    • Tx/ Nursing Management: goal = prevention of attack episodes
      • Pharmacologic
        • Quick-relief – not for daily use; relaxes bronchial muscles (albuterol, terbutaline via MDI or nebulizer)
        • Long-term meds – taken on daily basis; anti-inflammatory (cromolyn via MDI), corticosteroids (budesonide via MDI), bronchodilators (theophylline)
    • Mgt:
      • B ronchodilators
      • R est & relaxation techniques
      • O 2 = low flow (1-2Lpm)
      • N ebulize
      • C hest physiotherapy & controlled breathing (IPPB)
      • H igh-fowler’s/ orthopneic
      • I mmunotherapy
      • A void allergens
      • L iberal fluid intake
    • Meds:
      • A minophylline
      • S teroids
      • T heophylline – relaxes bronchial muscles
      • H istamine antagonist
      • M ucolytics – acetylcysteine (Fluimucil)
      • A ntibiotics
  26. Chronic Obstructive Pulmonary Disease (COPD)
    • clinical syndrome of chronic dyspnea as a result of expiratory airflow obstruction due to chronic bronchitis or emphysema (often both)
    • Causes: long-term smoking (leading cause) & Alpha1-antitrypsin deficiency (only known inherited form of the disease)
    • Risk factors:
      • Exposure to certain gases or fumes in the workplace
      • Exposure to heavy amounts of second hand smoke and pollution
      • Frequent use of cooking gas without proper ventilation
      • Low socioeconomic status
      • Male
      • Living in heavily industrialized urban areas
      • Recurrent respiratory illnesses
      • Family history of chronic bronchitis and emphysema (e.g., alpha1-antitrypsin deficiency)
      • Emotional stress and repressed emotions have also been shown to contribute
  27. Chronic Bronchitis (“Blue Bloaters”)
    • chronic cough, resulting from excessive tracheobronchial mucus production and impaired mucus elimination, on most days for 3 months of a year, for 2 consecutive years
    • Some people, even those with severe COPD, have few or no symptoms
    • Pathophysiology:
      • hallmarked by hyperplasia (increased number) and hypertrophy (increased size) of the goblet cells (mucous gland) of the airway -> increase mucus secretion -> airway obstruction -> cyanosis
      • infiltration of the airway walls with inflammatory cells (neutrophils) -> scarring -> airway wall thickening -> narrowing of the small airway -> metaplasia (abnormal change in the tissue) & fibrosis (further thickening and scarring) of lower airway -> limitation of airflow -> cyanosis
  28. Chronic Bronchitis Illustration
  29. Emphysema (Pink Puffers)
    • enlarged air spaces distal to the terminal bronchioles with destruction of the alveolar walls; there is also a loss of elastic recoil in the lung
    • Pathophysiology:
      • exact mechanism for the development of emphysema is not understood, although it is known to be linked with smoking and age
      • enlarged air sacs (alveoli) of the lungs -> reduces lung surface area -> ↓ lung elasticity -> small bronchioles collapse -> dead air space formation (blebs) -> air trapping -> dyspnea
  30. Emphysema Illustrations
  31. Emphysema vs. Chronic Bronchitis
    • Characteristic Pink Puffers Blue Bloaters
    • Definition - alveolar wall - inflammation of bronchi ->
    • destruction leads ↑ mucus prod uction (goblet
    • to air spaces (blebs) cells) & chronic cough
    • Smoking Hx - usual - usual
    • Age of onset - 40-50y/o - 30-40y/o; mid-age disability
    • Clinical Features
    • Color - acyanotic - cyanosis w/ edema
    • Barrel Chest - dramatic - may be present
    • Weight loss - severe (advanced) - infrequent (often overweight)
    • SOB - compensatory - predominant early symptom
    • pursed-lip breathing
    • Sputum - may be absent - copious sputum production
    • Lung x-ray - overinflated lucent - “dirty lungs”
    • Heart involvement - none, late cor pulmonale - cor pulmonale (RV)
    • ABGs - mild-mod hypoxemia - (+)hypoxemia
    • Dx: physical assessment
      • Chest x-ray or Chest CT Scan = confirmatory
      • PFTs, TST
      • Lab: Arterial Blood Gas (ABG)
    • Below Above
    • Acidosis pH = 7.35 – 7.45 Alkalosis
    • Acidosis HCO 3 = 22 – 26mEq/L Alkalosis
    • Alkalosis PCO 2 = 35 – 45mmHg Acidosis
    • R espiratory Compensation
    • A lternate arrows pH compensatory system
    • M etabolic uncompensated abnormal no change
    • S ame arrows partially abnormal change
    • Fully normal change
    • Management: STOP SMOKING
      • Improve oxygenation
        • Monitor respiratory patterns & assess breath sounds
        • Low flow O 2 (1-3Lpm)
        • High fowler’s position
        • Energy conservation techniques
      • Decrease CO 2 retention (airway clearance)
        • facilitate coughing
        • pursed-lip breathing technique
        • Maintain adequate hydration & room humidity
      • Meds: bronchodilators - to increase airflow and reduce dyspnea
        • sometimes theophylline - requires frequent blood monitoring for toxicity
        • inhaled steroids
        • Antibiotics - during flare-ups of symptoms
        • Alpha1-antitrypsin replacement therapy
  32. Pleurisy
    • inflammation of the lining of the lungs that ca uses pain when you take a breath or cough
    • normally smooth lining of the lungs (the pleura) become rough, they rub together with each breath, and may produce a rough, grating sound called a "friction rub."
    • Causes:
      • may develop when you have lung inflammation due to infections such as pneumonia or tuberculosis
      • Asbestos-related disease
      • Certain cancers
      • Chest trauma
      • Pulmonary embolus - blockage of an artery in the lungs by fat, air, blood clot, or tumor cells
      • Respiratory tract infections
    • S/Sx: main symptom = chest pain
      • Some people feel the pain in the shoulder
      • Deep breathing, coughing, and chest movement makes the pain worse
      • fluid may collect inside the chest cavity & may cause the following:
        • Coughing
        • Cyanosis
        • Shortness of breath, tachypnea
    • Dx: Complete Blood Count (CBC)
    • Activity intolerance (fatigue) RBC = 4.5M – 5.4M Risk for injury (CVA/Thrombosis)
    • Risk for infection WBC = 5K – 10K Actual infection
    • Risk for injury (bleeding) Platelets = Risk for injury (CVA- 150k – 450k clot formation)
    • Fluid volume deficit Hematocrit = Fluid volume excess
    • (dehydration) 35 – 45%
      • Thoracentesis - procedure to remove fluid from the space between the lining of the outside of the lungs (pleura) and the wall of the chest; local anesthesia
      • Pleural Biopsy - procedure to remove a sample of the tissue lining the lungs and the inside of the chest wall to check for disease or infection
      • Ultrasound of the chest or Chest x-ray
      • Sputum exam
    • Tx: depends on what is causing the pleurisy
      • Bacterial infections = antibiotics (some bacterial infections require a surgical procedure to drain all the infected fluid)
      • acetaminophen or anti-inflammatory drugs such as ibuprofen (for pain control)
      • Thoracentesis
    • Complications: Collapsed lung due to thoracentesis
      • Complications from the original illness
    • Nursing Management:
      • Health teachings (infection, work environment, splinting ribcage with pillow)
      • Position client on affected side
      • Thoracentesis: Instruct client not to cough, breathe de eply, or move during the test to lung puncture
        • Instruct to report SOB &/or chest pain during procedure
        • Apply pressure on puncture site & monitor for bleeding
  33. Tracheostomy
    • Tracheostomy – used for severe lung disorder , neurological problem, or infection makes it impossible to breathe,
    • to keep the windpipe open and supply air
    • a small opening (stoma) through the skin on the throat
    • a breathing tube is directly inserted into the windpipe (trachea).
    • The trache tube is sometimes sewn to the skin around the stoma
    • It can also be held in place with trache ties
    • Some trache tubes have an inflatable cuff near the outer end to keep it from coming out and to prevent air leaks
    • trache tube parts
      • Obturator - used to pass the trache into the windpipe
      • outer cannula (tube) - has a plastic "trache plate" that lies against the skin of the neck and holds the trache in place
      • Inner cannula that fits inside the outer one and locks into place
    • Obturator and clamp should always be at bedside
  34. Tracheostomy Care
    • clean the inner cannula on a daily basis
    • Observe proper precautions & handwashing before & after care
    • Whenever the tube threatens to become clogged with mucus, suction it clear
    • Materials:
      • kidney basin
      • a small brush (like a toothbrush) or twisted OS
      • H 2 O 2 &/or sterile NSS
      • 4x4 gauze pad
      • scissors
    • Procedures:
      • Place a “trache bib” under the trache plate with a gauze pad (upright “U”)
      • Unlock the inner cannula and remove it by pulling it gently out and down
      • Put a clean wet inner cannula (if reserve is available) as replacement & lock in place
      • Clean the dirty cannula by soaking it in H 2 O 2
      • Scrub it with the small brush when bubbling stops
      • Rinse well the inner cannula by pouring the sterile NSS
      • Return in place & lock if client has no reserve
  35. Endotracheal (ET) Tube
    • most common artificial airway used for short-term airway management or mechanical ventilation
    • may be inserted either orally or nasally
    • has a cuff that is inflated with air to hold the tube in place in the trachea
    • amount of air in the cuff should be checked every 8hrs to ensure that the cuff is not exerting too much pressure on the trachea walls
    • client with ET tube must be closely monitored:
      • to ensure that the tube remains patent
      • that skin breakdown does not occur from the tube (either the oral or nasal cavity)
      • infection is prevented
  36. Intubation Illustrations 2 Intubation 3 ET tube Placement 4 Securing the ET tube 1 ET tubes
  37. Securing Apparatuses for ET Tube ETAD Thomas Tube Holder
  38. Nursing Management
    • RNs prepare all needed materials needed for in tubation &/or assist in placement by securing p at ient’s position (head tilted on supine)
    • Sterile suction kit, a bottle of sterile NSS, sterile gloves, a clean bite block if necessary, and tape already torn into appropriately-sized pieces, laryngoscope
    • Documentation (note also tube distance at client’s lips)
    • All waste should be properly disposed
    • Complete airway check every 8hrs & prn
    • The insertion point (in cm) of the ET tube should be confirmed to be the same as prior to the procedure, unless the purpose of the procedure was to change the depth of the tube (via X-ray)
  39. Cont…
    • Primary portion of ET tube management is suctioning every 2hrs or prn
    • Client should be hyperoxygenated prior to suctioning
    • Color and amount of any sputum return should be noted
    • Oral cavity should also be suctioned
    • Thorough oral care every 8hrs and prn
    • If client has a bite block, it must be removed and cleaned or replaced every 8hrs
    • tube should be repositioned so as not to continuously exert pressure in the same area
    • If the tube is taped to the client's face, tape must be removed and replaced on the opposite side of the face at least once per day and prn
  40. Devices for Oxygen Administration
    • nasal cannula (NC) - thin tube with two small nozzles that protrude into the nostrils
      • It can only provide oxygen at low flow rates, 2-6 litres per minute (LPM), delivering a concentration of 28-44%.
    • simple face mask - basic mask used for non-life-threatening conditions but which may progress in time
      • Often set to deliver oxygen between 2-10 LPM
      • The final oxygen concentration delivered by this device is dependent upon the amount of room air that mixes with the oxygen
    • non-rebreather mask- utilized for those requiring high-flow oxygen, but do not require breathing assistance
      • It has an attached reservoir bag where oxygen fills in between breaths, and a valve that largely prevents the inhalation of room or exhaled air.
  41. Cont…
    • bag-valve-mask (Ambubag) - use d in CPR or if client is in critical condition
      • An oxygen reservoir bag is attached to a central cylindrical bag, attached to a valved mask
      • administers almost 100% concentration oxygen at 8-15 Lpm
      • The central bag is squeezed manually to deliver a "breath"
    • anaesthetic machine - used for general anesthesia
      • allows a variable amount of oxygen to be delivered, along with other gases including air, nitrous oxide and inhalational anaesthetics

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