Download of Respiratory Waveforms Plethysmography : Accuracy

Evaluation of Respiratory Inductive
Plethysmography : Accuracy for Analysis
of Respiratory Waveforms
Pierre-Yves Carry, Pierre Baconnier, Andre Eberhard, Pierre Cotte
and Gila Benchetrit
Chest 1997;111;910-915
DOI 10.1378/chest.111.4.910
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ISSN:0012-3692
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Respiratory Inductive
Plethysmography*
Evaluation of
Accuracy for Analysis of Respiratory Waveforms
Pierre-Yves Carry, MD, PhD; Pierre Baconnier,
Pierre Cotte; and Gila Benchetrit, MD, PhD
PhD; Andre Eberhard, PhD;
Objective: To assess the accuracy of respiratory inductive plethysmography (RIP) waveforms to
those obtained with whole body plethysmograph (BP) as this device gives a plethysmographic
signal and a pneumotachograph (PNT).
Design: Randomized controlled trial.
Setting: Physiologic laboratory in a university hospital.
Participants: Eleven subjects from the laboratory staff.
study was achieved during four consecutive periods in subjects breathing
through different added resistive loads. Using the least square method
spontaneously
calibration, two RIP waveforms, VRiP.BP(t) and VRiP.PNT(t), were simultaneously calculated with
coefficients obtained from BP and from PNT volume waveforms, respectively VBP(t) and VPNT(t).
For each recording, to compare volume waveforms, we calculated their differences in term of
distances, Drip-bp and Drip-pnt, between the normalized RIP volume signal (respectively,
VRiP.BP[t] and VRiP.PNT[t]) and its normalized reference (respectively, VBP[t] and VPNT[t]). We also
calculated the distance Dpnt-bp between the two normalized references VBP(t) and VPNT(t).
Results: No significant effect of load or time on the distance occurred. Including all the
appears significantly lower than both the mean
recordings, the mean distance Drip-bp (3.4± 1.1%)
distance Drip-pnt (4,5±1.3%; p<0.04) and the mean distance Dpnt-bp (4.6±0.9%; p<0.008). For
each period or load level, Drip-bp appears to be lower than Drip-pnt and Dpnt-bp.
Conclusion: The RIP seems reasonably accurate for analysis of respiratory waveform while
(CHEST 1997; 111:910-15)
subjects subsequently breathe against resistive loads.
Interventions: This
and
Key words: body plethysmography; respiratory inductive plethysmography; volume waveform
Abbreviations: ABD=abdomen; AN OVA=analysis of variance; BP=body plethysmograph; Dpnt-bp=distance be¬
tween PNT waveform and body plethysmograph waveform; Drip-bp=distance between RIP waveform calibrated with
between RIP waveform calibrated with
body plethysmographandand body plethysmograph waveform; Drip-pnt=distance
waveform; FetC02=fractional end-tidal C02; Pbody=pressure measured
pneumotachograph
pneumotachograph
a pressure transducer; PNT=pneumotachograph; RC=rib cage; RIP=respiratoiy inductive plethysmograph;
by
R4.7=resistive ventilatory load of 4.7 cm H20/L/s; R7.5=resistive ventilatory load of 7.5 cm H20/L/s; V=flow at mouth;
VBP(t)= waveform from body plethysmographic signal; VBP(t)= normalized waveform from body plethysmographic
pneumotachograph signal; VPNT(t)=normalized waveform from pneumotachograph
signal; VPNT(t) waveform from
VRiP.BP(t)=waveform from RIP signal calibrated with body plethysmograph; VRip.BP(t)=normalized waveform
signal;
from RIP signal calibrated with body plethysmograph; VRiP.PNT(t) ^waveform from RIP signal calibrated with
VRiP.PNT(t)=normalized waveform from RIP signal calibrated with pneumotachograph; VT=tidal
pneumotachograph;
volume
=
T^\ ifferent circumstances in anesthesia and intencare can modify respiratory drive.1 Re¬
Renchetrit
et al,2 using a quantitative analysis
cently,
of respiratory waveforms, demonstrated that primary
variables (frequency, mean inspiratory flow rate, and
fractional inspiratory time) commonly used for mon¬
itoring of breathing pattern are not sensitive enough
to detect respiratory personality differences. One
-*-^ sive
Grenoble, PRETA-TIMC/
Supported by the University Hospital of Lyon (Dr. Carry).
*From the Faculte de Medecine de
I MAG, La
Tranche, France.
Manuscript received January 23, 1996; revision accepted October 2.
910
might expect that the monitoring of respiratory
pattern via such a waveform analysis could help in
detecting respiratory drive changes in anesthesia and
intensive care.
The quantitative analysis of respiratory waveforms
developed by Renchetrit et al2 (harmonic or Fourier
analysis) relies on the precise measurement of air¬
flow profile. In the intubated patient, this analysis of
breathing pattern is easy to perform by attaching a
spirometer or a pneumotachograph (PNT) to the
patient's endotracheal tube. During recovery from
anesthesia or during weaning from mechanical venClinical
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1997 by the American College of Chest Physicians
Investigations
tilation, problems
arise because these devices, re¬
direct
connection
to the patient's airway,
quiring
demonstrate a low tolerance.3 In addition, the use of
alterations in the
mouthpiece produces spurious
breathing
pattern, causing tidal volume (Vt) to
increase and respiratory frequency to decrease.47
Other devices, such as body plethysmograph (RP),
the measurements of respired volumes, are
allowing
not convenient for clinical monitoring, particularly
a
during a prolonged period or during sleep. Conse¬
quently, devices have been developed to measure
ventilation directly.
Respiratory inductive plethysmography (RIP) is
the most widely accepted method for quantitative
and qualitative noninvasive respiratory measure¬
ments.810 When correctly calibrated, the RIP allows
the measurement of volume and time components of
the breathing cycle as well as the relative participa¬
tion of thorax and abdomen to this cycle.
To our knowledge, the study of Stromberg et al11
is the only one that investigates the reliability of the
time course profile of RIP as compared to that of the
PNT. While studying the influence of RIP accuracy
on the respiratory phase chosen for the calibration,
these authors observed that RIP underestimated
lung volume at the start of inspiration and overesti¬
mated lung volume at the end of inspiration. They
observed a similar tendency during expiration.
As RIP is supposed to give a plethysmographic
waveform,12 we undertook the present work to assess
the accuracy of RIP waveform by comparing it with
from
RP.
the volume waveform obtained
the whole
We also carried out the same comparison with the
PNT as this device is commonly used for breathing
pattern analysis.2 The waveforms of the RIP volume
calibrated, respectively, with a RP and a PNT were
of the volume ob¬
compared with the waveforms
RP and with PNT. This
study was achieved in subjects breathing spontane¬
added resistive loads to simulate
ously and through
diseases.
tained, respectively, with
respiratory
Materials
and
Methods
Subjects
Eleven healthy subjects (eight male, three female) without
histoiy of respiratory disease, recruited from the laboratory staff,
volunteered for RIP validation against BP and PNT. The protocol
was approved by the local ethics committee and all subjects gave
informed consent. The characteristics of these subjects are
presented in Table 1.
Apparatus
Measurements were made with the subjects seated in a
690-L barometric whole BP. This device (Pulmostar SMB;
Table
Subject/Sex/Age,
1.Subject Characteristics*
Weight,
vr
l/M/27
2/M/46
3/M/23
4/M/38
5/M/28
6/F/24
7/F/25
8/F/33
9/M/37
10/M/45
ll/M/47
*Ve=minute ventilation;
68
90
77
92
65
54
55
57
68
75
72
Ve,
F,
FetC02
L/min
/min
%
11.7
12.2
12.5
12.7
8.7
10
14
14
18
10
19
11
11
8
8
13
5.0
4.5
12.0
9.1
7.9
7.1
9.0
12.1
4.4
4.5
5.1
4.6
3.9
5.5
4.6
5.5
4.0
F=respiratory frequency.
Geneva, Switzerland), with high-frequency response, allowed
the measurements of rapid volume changes.13 A pressure
transducer measured the pressure (Pbody) of gas compressed
in BP by pulmonary volume changes, giving after calibration
(see below) a first volume waveform VBP(t). During protocol,
absence of gas leaks in the BP was checked by measuring the
stability of Pbody during a voluntary apnea. Stability of BP
temperature during each recording was checked by the aver¬
age stability of Pbody signal (no drift). A heated PNT (Fleisch;
Lausanne, Switzerland) inserted in the front wall of the BP
measured the flow at mouth (V). The zero flow of this channel
was carefully set at the beginning of each protocol but was not
readjusted afterward. The volume waveform from PNT,
VPNT(t), was obtained by numerical integration of flow. After
zero setting, BP and PNT were calibrated with a 1-L syringe
before each procedure.14 The coefficient of calibration for
each signal was determined from five syringe maneuvers.
The rib cage (RC) and abdominal (ABD) displacements were
measured using a direct current-coupled RIP. This device con¬
sists of two belts, to which wavy coated wires are attached, that
encircle the RC and the ABD. A garment incorporating the two
coils was developed in our laboratory. It consists of a sleeveless
jacket, made of a special fabric with texture allowing horizontal
wiredrawing only.15
During each experiment, the subject had his or her back
applied to a wall inside the BP and was instructed to avoid any
to prevent interference of changes in spinal
changes in position
attitude with RIP calibration. This calibration is based on the
assumption that the respiratory system behaves with two degrees
of freedom motion16 such that the change in lung volume (Vrip)
is the sum of the volume changes of the rib cage (Vrc) and
abdominal (Vabd) compartments. Vrc and Vabd are expressed
in terms of RC and ABD signals by the volume-motion coeffi¬
cients a and b: VRiP=a-RC+b-ABD.
The a and b coefficients are obtained by the least squares
calibration procedure.17 Two RIP waveforms (VRiP.BP[t] and
VRiP.PNT[t]) are simultaneously calculated with coefficients ob¬
tained respectively from BP volume waveform (VBPft]) and from
PNT volume waveform (VPNT[t]). The a and b coefficients were
calculated from the data recordings from each situation, thus
allowing comparisons based on the same source data.
All signals (Pbody, V, ABD, and RC) were recorded on a
computer (Macintosh Ilci) equipped with a 12-bit analogue-todigital converter (MacAdios; G.W. Instruments; Boston) and
each signal sampled at 32 Hz (softwares are written in Think
Pascal; Symantec SARL, Surenes, France).
CHEST / 111 / 4 / APRIL, 1997
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1997 by the American College of Chest Physicians
911
Experimental Protocol
The study was conducted while the subjects, seated in the BP with
the RIP body jacket, wore noseclips and breathed through the
mouthpiece connected to the PNT (palms on the cheeks) (Fig 1).
To analyze the effects of load level on RIP volume waveforms,
the subjects breathed successively through different load levels.
The resistance of the BP-mouthpiece-PNT system was 2.0 cm
H20/L/s; the first and last measurements were obtained when
subjects breathed through this equipment (control load level,
R2.0). The addition of two different resistive ventilatory loads,
respectively, 2.7 and 5.5 cm H20/L/s, to the outer part of PNT
provided two other levels of measurements (R4.7 and R7.5).
Linearity of these different resistances was checked by plotting
pressure at mouth vs V during tidal breathing. Additional deadspace induced by added resistances was negligible.
After a 15-min temperature stabilization period, the instruments
were calibrated. Each subject underwent four consecutive periods of
92-s recordings: control (PI); first added resistive load (P2); second
resistive load (P3); control (P4). The subjects were allowed to choose
their own breathing pattern. The order of R4.7 and R7.5 were at
random. Each subject underwent then one of the following load
sequences: (R2.0 R4.7 R7.5 R2.0) or (R2.0 R7.5 R4.7 R2.0).
For each period, recordings were undertaken once fractional endtidal C02 (FetC02) was in steady state. FetC02 was measured by
a capnograph (Engstrom Eliza; Bromma, Sweden) through a side
port of the mouthpiece (this side port was closed during recording
periods).
Data Analysis
The primary signals V, Pbody, ABD, and RC were simulta¬
neously sampled and recorded on the microprocessor system
during periods of 92 s (which corresponds to 2,944 points at 32
Hz sampling frequency for each signal).
The accuracy of the two RIP volume waveforms (VRiP.BP[t]
and VRiP.PNTft]) during the four different periods was estimated
in the following way. We compared the closeness of VRiP.BP(t)
and Vrip.pnt(0 with the corresponding reference waveform,
respectively, VBP(t) and VpNT(t). To compare the waveforms of
these four signals, we had to eliminate any discrepancy due to
baseline or to amplitude difference. These conditions were
realized by normalizing each signal waveform (ie, mean value of
each waveform at zero, and SD at 1) (Fig 2).
For each recording, we calculated the mean square difference
A2 between each normalized RIP waveform (VRiP.Bp[t] or
VRiP.PNT[t]) and its normalized reference (VBP[t] or VPNT[t]) on
the whole
recordings (2,944 points):
ARiP-BP2=(l/N)*X[YRiP-BP(i)-VBP(i)]2 (i=l to N),
ARIP-PNT2=(l/N)*XKRIP-PNT(i)~VPNT(i)]2 (i=l to N)
(N 2,944).
=
To have a comparison between the reference signals, we also
calculated the mean square difference between the normalized
signals VBp(t) and VPNT(t):
APNT-BP2=(l/N)*^][VPNT(i)-VBP(i)]2 (i=l to N)
(N=2,944).
As waveforms are normalized, 95% of the values lie between
.2 and +2, then a near maximum value for A2 is equal to 16 (a
situation in which each sample pair is 2 SDs apart). The square
root of A^ being equivalent of an euclidean distance, we called D
this distance between each waveform and its reference, expressed
in
percentage of this maximum, respectively:
Drip-bp=100
/vy\yv Pbody
^^/WVTVrc
Figure 1. The system used in the present study, showing the
at the mouth from PNT; (2) Pbody from whole
following:RC(1)andflowABD
BP; (3)
signals from RIP.
912
16
and
Drip-pnt=100
Arip-pnt
16
We also calculated the distance Dpnt-bp between PNT and BP
waveforms:
Dpnt-bp 100
Apnt-bp2
=
16
Statistics
The effects of load level and time
on
distances were
analyzed
using analysis of variance (ANOVA). The paired t tests were used
compare the global mean values of distances. The level of
statistical significance was taken as p<0.05.
to
PSL <vw Flow
t5p.
Arip-bp2
Results
ANOVA shows that the load level has
effect on the
no
signifi¬
distances (Drip-bp, Drippnt, or Dpnt-bp) (Fig 3). However, mean distances
were similar whatever the period: ANOVA did not
evidence any statistical difference (Fig 4).
The mean values of the three distances for each
subject are gathered in Table 2. Including all the
recordings, the statistical analysis exhibits that the
mean distance Drip-bp (3.4±1.1%) appears signifi¬
cantly lower than both the mean distance Drip-pnt
(4.5±1.3%; p<0.04) and the mean distance
Dpnt-bp (4.6±0.9%; p<0.008). No statistical differ¬
ence appears between Drip-pnt and Dpnt-bp
cant
mean
(p=0.63).
Clinical
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Investigations
VRIP.PNT(t)
VRIP.BP(t)
VpNT(t)
VBP(t)
B
1.5 SD
VRIP.BP(t)
YBP(t)
-1.5 SD
(A) The four waveforms Vbp(0, VPNT(t), VRiP.BP(t), and VRiP.PNT(t) for one breath during
recording
period in a representative subject; (B) normalized curves VBP(t) and VRiP.BP(t) waveforms
from this breath showing that they almost overlap each other; (C) part of VBP(t) and VRlP.BP(t)
waveforms has been enlarged and the distance for one sample (VRiP.BP[i] Vbp[i]) is illustrated (see
text for commentary).
Figure 2.
a
Discussion
The purpose of the present study was to test the
that the RIP volume waveform is as
hypothesis
accurate as that obtained from RP and from PNT. To
confirm this hypothesis, we analyzed the stability of
the different signals during the recording period and
?
demonstrated that the measurements from the RIP,
RP, and PNT were comparable.
Following the initial work of Konno and Mead,16
several investigators proposed RIP as a method to
RC-ARD motions. In clinical situations, the
analyse
RIP generally is used for continuous noninvasive
monitoring.18 These different utilizations of RIP
R2.0
R7.5
D PNT-BP
Dpnt-bp
Drip-bp
Figure 3. Mean distances
Drip-bp, Drip-pnt, and Dpnt-bp
for all subjects while breathing against the three different load
levels (R2.0, R4.7, and R7.5) (see "Experimental Protocol"
section for more details). Results are expressed in percent;
vertical bars indicate SD.
D RIP-BP
D RIP-PNT
Drip-pnt
Figure 4. Mean distances Drip-bp, Drip-pnt, and Dpnt-bp
for all
subjects during
the successive
periods (PI control,
=
P2=resistive load R4.7 or R7.5 [random], P3 resistive load R7.5
or R4.7 [random], P4=control) (see "Experimental Protocol"
=
section
for
more
details). Results
vertical bars indicate SD.
are
expressed
in
percent;
CHEST/111 IM APRIL, 1997
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1997 by the American College of Chest Physicians
913
Table 2.Mean Values of Distance for Each
Subjects
9+
10
11 +
Mean
Drip-bp
Drip-pnt
4.6
2.8
2.6
4.5
4.6
3.8
5.0 ± 1.0
7.0 ± 0.4
2.6 ± 0.7
5.6 ± 2.0
4.2 ± 1.8
5.8 ± 2.2
3.7 ± 1.2
5.0 ± 1.3
4.1 ± 1.5
3.0 ± 0.4
3.4 ± 0,5
4.5 ± 1.3*
±
±
±
±
±
±
2.7 ±
2.2 ±
4.7 ±
1.0
0.6
0.2
0.7
1.6
1.5
0.3
0.1
0.8
1.8 ±0.1
2.5 ± 0.3
3.4 ± 1.1
Subject*
Dpnt-bp
4.0
6.8
3.4
4.3
5.3
5.3
±
±
±
±
±
±
4.4 ±
5.1
4.6
4.4
3.5
4.6
±
±
±
±
±
0.9
0.7
0.2
1.4
1.7
2.4
0.7
1.2
0.4
0.3
0.8
0.9n
*Data include all the situations and all subjects. Plus sign indicates
subjects for whom R7.5 was imposed before R4.7. Drip-bp distance
between BP and RIP calibrated with BP; Drip-pnt, distance
between PNT with RIP calibrated with PNT; Dpnt-bp distance
between BP and PNT. Results are expressed in percent ± SD.
+p<0.05 vs Drip-bp.
'Not significant vs Drip-pnt.
assume (1) a minimum drift of the RIP signal and (2)
the stability of calibration during the time of record¬
ing. Such assumptions must also be testified for
other comparative methods. Using current RIP tech¬
transducers placed on different-shaped
nology with
Watson
et al19 confirmed the baseline sta¬
models,
RIP.
Two
studies demonstrated that the RIP
of
bility
calibration was well maintained in normal sub¬
jects.20-21 Hudgel et al,22 using inductance vest in
COPD patients, showed that calibration changed
after 240 min.
minimally
Refore measurements, the RIP must be cali¬
brated. As noted by Sartene et al,23 the choice of the
calibration method depends on experimental or clin¬
ical conditions. Among the different methods,161724
Chadha et al17 proposed the least squares method as
the most accurate during long-term trial when
in body posture and/or Vt cannot be con¬
change
trolled. Tobin et al25 confirmed that the least squares
method provides the most reliable measurements
However, the changes of
breathings.
during loaded
after
and patient movements
calibration
position
could possibly have an adverse effect on satisfactory
measurements.11-26 In our study, each subject seated
in the RP was instructed to avoid any changes in
position and to breathe through the mouthpiece,
on the cheeks during recording to prevent
palms
excessive interference of movements.7
When the waveform signal was obtained from RP,
the drift is essentially associated with the variations
of temperature and humidity in the box. Retween
each recording, the subjects breathed without con¬
nection with the mouthpiece. In these conditions, no
drift of plethysmographic signal was observed during
914
the recording periods. To obtain the correct V offset
during steady-state period, we hypothesized that the
end-expiratory volume is the same at the beginning
and at the end of each level of recording as proposed
Peslin et al.27
byThe
comparison of the waveforms of the different
needs
the stability of the transducers and elec¬
signals
tronics used. In addition, if one needs to quantify the
RC-ARD motion changes with RIP, one has to dem¬
onstrate the reliability of the time course of the signal.
The frequency responses of measurement devices must
also be compatible. The pressure-compensated vol¬
ume-displacement RP has a frequency response com¬
with that of the PNT.28 Roynton et al29 dem¬
patible
onstrated in dogs that the sum of the RC and ARD
band signals underestimated determined volume
above 8 Hz. A frequency spectral analysis of the
change
three signals demonstrated that frequency spectra were
very similar up to 10 Hz, except for RIP which exhibits
higher cardiogenic oscillations (between 1 and 1.5 Hz).
This can only be responsible for a parallel increase of
Drip-bp and Drip-pnt relative to Dpnt-bp and can¬
not explain the observed difference between Drip-bp
and Drip-pnt. We then think that the lower degree of
damping of cardiogenic oscillations found in RIP does
not influence the results of the present study. In our
study, we demonstrated the closeness of RIP waveform
VRiP.BP(t) and VRlP.PNT(t) with the corresponding
reference waveform, respectively, VBP(t) and VPNT(t).
Our results suggest that the RIP frequency response is
comparable to that of the PNT and RP. Finally, paired
t tests applied to Vt obtained from the four different
volume measurement methods exhibit no statistical
difference between methods. This confirms the accu¬
rate calibrations of the three devices.
Currently, the RC and ARD coefficients were
obtained from RIP calibrated with flow signal or
volume signal.7'2326 The qualitative comparison of
simultaneous volume waveforms from RIP and spi¬
rometer, in normal subjects breathing through low
levels of resistances, exhibited no difference.21 We
calibrated RIP against PNT as currently performed.
Simultaneously, RIP was also calibrated against RP
as these two measurement methods are based on the
same physical property, volume displacement. In our
study, the comparison of waveforms exhibits that the
RIP signal is closer to the RP signal than to the PNT
signal. This confirms that RIP is a good plethysmo¬
graph that is possibly suitable for use during pulmo¬
nary rehabilitation.14
Comparing the mean distances Drip-bp and
Drip-pnt, we demonstrated no difference whatever
the periods or added resistances used. Stromberg et
al,11 comparing RIP and PNT measurements,
showed that the RIP underestimated volume profile
at the start of inspiration or expiration and overestiClinical
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1997 by the American College of Chest Physicians
Investigations
mated it at the end of inspiration or expiration. They
attributed these phase differences to the fact that the
movements of the RC and the ARD are not linearly
related to the lung volume. This discrepancy may be
by the physical approach. The phase
interpreted
differences observed between volume displacement
(measured by RIP) and air displacement (measured
PNT) may be attributed to gas compression which
by
is similarly observed when volume displacement
(measured by RP) and air displacement at mouth are
used to assess airway resistances.25'30
The comparison between different signals was
carried out in subjects breathing against different
resistive loads. These resistive loads were lower than
the values inducing respiratory muscle fatigue pro¬
posed
by Tobin et al.25 However, the resistive levels
obtained by added resistances were chosen to be
the values of airway resistances
comparable with
in some human diseases.9 The
state
during steady
values of resistances were calculated with RP using a
reference method to measure resistances.31
In conclusion, the results of this study indicate that
the RIP seems reasonably accurate for analysis of
respiratory waveform while subjects subsequently
breathe against resistive loads. This confirms that
RIP can be considered as a good plethysmograph. If
this were to be also true in clinical situations, one
would then get a precise and noninvasive tool of
chest wall motion monitoring.
ACKNOWLEDGMENTS: We gratefully acknowledge the coop¬
eration of the staff of PRETA laboratory and V. Banssillon, MD,
Professor of Anaesthesiology and Intensive Care.
ventilation from body surface
11
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915
Evaluation of Respiratory Inductive Plethysmography : Accuracy for
Analysis of Respiratory Waveforms
Pierre-Yves Carry, Pierre Baconnier, Andre Eberhard, Pierre Cotte and
Gila Benchetrit
Chest 1997;111; 910-915
DOI 10.1378/chest.111.4.910
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