Puritan Bennett 840 Ventilator Pocket Guide
Contents
1. Figure 5 Installing the expiratory filter and collector vial 840 Ventilator Pocket Guide 9 r gt Cap the collector vial drain port if you are not using the drain bag see Figure 6 t If you are using the drain bag install clamp on tubing Uncap collector vial drain port and install tubing to collector vial drain port Connect other end of tubing to drain bag If the ventilator is mounted on the cart place the drain bag in the cart drawer see Figure 6 The drain bag is designed to lie flat and is not designed to be suspended Place drain bag in cart drawer Tubing Collector vial drain port must be capped if not using drain bag Figure 6 Using the collector vial with or without drain bag 10 840 Ventilator Pocket Guide WARNING I Puritan Bennett recommends that you use one of the patient circuits identified by Puritan Bennett see the 840 Ventilator Operator s and Technical Reference Manual for patient circuit testing speci fications Using a circuit with a higher resistance does not prevent ventilation but can cause an SST fault or compromise the patient s ability to breathe through the circuit NOTE To ensure optimum compliance compensation Puritan Bennett recommends that you use low compliance patient circuits For pediatric patients the compliance compensation volume limit is four times the set tidal volume in addition to the set tidal volume NOTE To ensure optimum ventila2. Hum 60 uone euxo JO puo y JE ounssoud oui pue neoje d ay jo puo ay 3e ounssoud NIII IYI UdIMI9q 22u2319jIp AL UOH HU2A euou Sup po1 adxo jou st stu I gjqeuonsanb pue eurrurui 31 paA OAUI SAO pue soumn oA so1nssoud ou aeui SIS BBNS SIY J WAOFIAPM MOTI o1enbs ay Jo puo y a JMOJS 3501 aInssaid au sueaur J JUIUIDINSPJIW a qeuonsand ASA M JUIUIDINSPIW a qeuonsand AKA M poAvydsip 31 Y IUPISISIY IO s on eA andur PIouserp qns xxx O juauraJnseaui 9 qeuonsoan XXX I D e ueiduro 29s no WJM 19 840 Ventilator Pocket Guide The top of the upper screen shows monitored data data outside the normal range flashes Once normal ventila tion is in progress ventilator settings are displayed across the top of the lower screen Figure 8 shows how infor mation is displayed on the GUI Patient data Upper Screen Soo ed Alarm and status gt ae Unius information indicators alarms patient data Miscellaneous patient data including graphics and alarm log Primary settings Lower screen Batch settings ventilator ventilator setup alarm settings settings breath timing miscellaneous settings Off screen keys Figure 8 840 Ventilator graphic user interface GUI 20 840 Ventilator Pocket Guide Alarm settings Most alarm settings are initially set based on the patient s IBW You should review all alarm settings r gt Touch
3. Guide 53 The 840 Ventilator is also designed to enter emergency states ventilator inoperative and safety valve open SVO under some circumstances A ventilator inoperative condi tion always includes the SVO state but an SVO state does not necessarily indicate a ventilator inoperative con dition Ventilator inoperative The ventilator declares a ventila tor inoperative condition if a hardware failure or criti cal software error that could compromise safe ventila tion occurs In case of a ventilator inoperative condi tion the ventilator enters the SVO state To correct a ventilator inoperative condition the ventilator must be turned off then powered on again at power on a qualified service technician must run EST The ventila tor must pass EST before normal ventilation can resume SVO The safety valve allows the patient to breathe room air unassisted when the ventilator is in the SVO state The ventilator remains in the SVO state until the con dition that caused the SVO state is corrected or if the ventilator declared a ventilator inoperative condition POST verifies that power levels to the ventilator are acceptable and that the major electronics systems are functioning correctly The ventilator enters the SVO state if a hardware or soft ware failure occurs that could compromise safe ventila tion both air and oxygen supplies are lost or an occlu sion is detected In case of a malfunction that prevents software from op
4. NO AIR SUPPLY NO O2 SUPPLY PROCEDURE ERROR Pressing ALARM RESET has no effect on patient data If an alarm condition persists the alarm becomes active again according to the detection algorithm for that alarm For example if the APNEA alarm is active ALARM RESET resets the apnea detection algorithm to its initial state and returns the ventilator to normal ventilation 840 Ventilator Pocket Guide 27 Pressing ALARM RESET cancels alarm silence if active this avoids silencing an alarm condition that arises short ly after pressing ALARM RESET Pressing ALARM RESET clears any high urgency alarm that has autoreset and the steadily lit high urgency alarm indicator turns off ALARM RESET gives you a way to return the ventilator to normal operation if an alarm condition has been resolved without waiting for alarm detection algorithms to reset the alarm Alarm log To view the alarm log touch the ALARM LOG button on the upper screen The alarm log shows alarm events including time and date stamped alarms silences and resets in order of occurrence with the most recent event at the top of the list see Figure 12 The alarm log can store up to 80 of the most recent entries Completing a new patient setup clears the alarm log A question mark in a triangle appears on the ALARM LOG button if the log includes an event that hasn t been viewed yet The question mark in a triangle disappears after you ve viewed the event T
5. dus 43 BiLevel with pressure support 45 Inspiratory pause maneuver displays 16 Alarm m essageS oorr e doce PEORES 31 Ideal body weight IBW and tube LD 47 Individual test results in SST 50 Overall SST fear gap awia oq 51 Maintenance summary 23 840 Ventilator Pocket Guide Introduction This pocket guide gives you a quick overview of how to set up and use the 840 Ventilator System As you read through this pocket guide this symbol r gt asks you to take an action This pocket guide is intended to supplement not replace the 40 Ventilator Operator s and Technical Reference Manual which should always be available while using the ventilator Different versions of the 840 Ventilator can have minor variations in labeling e g keyboard overlays and oft screen alarm status indicators For more detailed information on any of the topics cov ered in this pocket guide please see the 840 Ventilator Operator s and Technical Reference Manual Also please see the 840 Ventilator Service Manual 840 Ventilator Pocket Guide 1 The 840 Ventilator The 840 Ventilator includes a breath delivery unit BDU that controls ventilation and a graphic user interface GUI that monitors and displays ventilator and moni tored data see Figure 1 The ventilator supplies manda tory pressure or volume controlled or spontaneous breaths inspiratory flows of up to 200 L min
6. left of the screen Touch Plot 1 then turn the knob to select any one of the waveforms If you select pressure volume which uses the entire screen Plot 2 disappears r gt Touch Plot 2 if applicable Turn the knob to select either of the two remaining waveforms or none If you select none only one enlarged plot with higher resolution appears r gt Touch CONTINUE to display the graphics you ve selected You don t have to press ACCEPT 840 Ventilator Pocket Guide 39 Once graphics are displayed Setting baseline pressure r gt To move the baseline on a lt gt Er ressure volume loop touch the baseline pressure button then use the knob to position the baseline The default position of the baseline is the PEEP setting If the PEEP setting changes the baseline resets to PEEP Adjusting scales r gt To adjust vertical and horizontal scales touch the arrow buttons then turn the knob to select 40 840 Ventilator Pocket Guide The key The key on the GUI displays basic operating information about the 840 Ventilator including e A few basics information about screens sounds keys and symbols e Ventilator alarm and apnea settings New patient setup how to configure the ventilator for a new patient How to view patient data including graphics Graphics setting up viewing and freezing waveforms and loops e Alarm handling what to do in case of alarm e Short self
7. limits are automatically determined based on the IBW The pro posed value is shown in red r gt Touch CONTINUE this button does not appear until you touch IBW or touch RESTART to return to the Ventilator Startup screen r gt At the New Patient Setup screen settings for mode mandatory type for manual inspirations if the select ed mode is SPONT spontaneous type 1f applicable and trigger type appear For any setting you want to change touch its button then turn the knob to select the value When you are finished changing settings touch CONTINUE r gt At the New Patient Settings screen more settings appear Touch each setting you want to change then turn the knob to select its value To cancel a high lighted change press CLEAR t Press ACCEPT to put all settings into effect Normal ventilation begins once a patient is connected Any time before you press ACCEPT you can touch RESTART to restart setting changes 840 Ventilator Pocket Guide 13 Apnea settings Although you aren t required to change or confirm apnea settings you should verify that they are appropriate for the patient Apnea settings are automatically determined based on IBW but can be changed r gt If you selected NEW PATIENT the Current Apnea Settings screen appears at the end of patient setup r gt If you selected SAME PATIENT touch the APNEA button at the bottom of the lower screen to view apnea settings r gt If you change
8. test SST e Service including O sensor calibration cleaning peri odic maintenance and when to call for help 840 Ventilator Pocket Guide 41 BiLevel BiLevel is a breath mode in which the patient has the ability to breathe spontaneously at two levels of PEEP Its pressure waveform resembles pressure controlled ventila tion but differs in its ability to allow unrestricted sponta neous breathing at both the upper and lower pressure lev els Therefore only a minimally necessary degree of venti latory augmentation needs to be applied Patient Setup To select BiLevel ventilation r gt Touch the SETUP button on the lower screen r gt ouch the Mode button then turn the knob to select BiLevel NOTE Once you have selected BiLevel the PC mandatory breath type is selected and cannot be changed r gt Select PS or none as the spontaneous type or TC if this option is active select P trig or V rric as your trigger type then press CONTINUE t Settings for BiLevel are displayed For each setting you want to change touch its button and turn the knob to set its value NOTE PEEP must always be set at least 5 cmH gt O greater than PEEP Otherwise the settings for PEEP and PEEP do not affect each other When you have fin ished changing settings press ACCEPT to put all set tings into effect NOTE Rise time determines the rise time to reach the pres sure target in pressure support Psupp or tra
9. the ALARM SETUP button lower screen to view the current alarm setup see Figure 9 r gt Touch the alarm you want to change r gt Turn the knob to set the value you want Proposed values are shown in red You can change several alarm settings in a batch change To cancel a highlighted change press CLEAR r gt Review all settings r gt Press ACCEPT to apply the new alarm settings Press the ALARM SETUP button to cancel all alarm changes You can touch the ALARM SETUP button at any time during ventilation to show the current limits and moni tored value for each alarm If an alarm annunciates the alarm slider on the Alarm Setup screen will turn color indicating the urgency of the alarm state red for high urgency yellow for medium and low urgency m JE e pes W Figure 9 Alarm setup NOTE The upper limits for the spontaneous exhaled tidal vol ume and mandatory exhaled tidal volume alarms are always the same Changing the upper limit of one alarm automatically changes the upper limit of the other 840 Ventilator Pocket Guide 21 Main setting changes Main settings are the buttons displayed at the top of the lower screen and you can only change them individually Follow these steps to change main settings t Touch the setting you want to change r gt Turn the knob to the set value r gt Press ACCEPT to apply the new setting Remember touch turn ACCEPT 22 840 Ventilator Pocket Guide Mode
10. the patient is not connected to the circuit and that the patient wye is unblocked WARNING Disconnect the ventilator from the patient before running SST Running SST while the ventilator is connected to the patient can injure the patient r gt Turn the power switch at the front of the ventilator to the ON position You can only run SST immediately after you turn on the ventilator r gt At the Ventilator Startup screen touch SST then press the TEST button on the side of the ventilator within five seconds Waiting longer than five seconds cancels SST r gt At the Current SST Setup screen select the patient circuit and humidification type and humidifier volume if applicable then press ACCEPT r gt The ventilator automatically starts the test sequence Some tests SST flow sensor Expiratory filter and Circuit resistance require your intervention and will wait indefinitely for your response Otherwise you don t need to do anything until a test result is ALERT or FAILURE or SST is complete t As each test is performed the SST Status screen shows test results see Table 4 WARNING M To ensure reliable SST results DO NOT repeat an individual test with a different patient circuit if the test result is FAILURE or ALERT If you suspect a defective patient circuit restart SST from the beginning with a different patient circuit 840 Ventilator Pocket Guide 49 Table 4 Individual test res
11. u A34 q 2unssaJd ur o ua19grrp au JUIWQJNSPIUI apgenax JO p ousa1u y MO 9q SI MOTT juaned moj ay s qeuonsonb y Japuas udin ur p nom yoargm uonenbo gt au 03 syndur apqeuornsanb 03 sjurod siy I uwy 1 0 gt Ao j auened Jo OtHurp yTui 0 gt 9D SUBOUL JJ SJS 1 J9Y1O Aq paieaorp se 9SessoJA S ji Y DULISISOY IO D 5uer duuo5 29s no RYK 840 Ventilator Pocket Guide 16 Table 1 Inspiratory pause maneuver displays continued 938J IOJPI Idsai 3onpar pue au uoneiidsur u231ous o qrssod JI eA1o3ur AI 03e1idxo 31uorornsur ue 10 YOY JIn2JIO juaned ornerpad e Sur e1sur 1oprs U09 BY pc gt MAI sauened ou J sosneo Sul K ropun 10 ynom 1uoned y pue SULIOJ2A A Suru1e q IYI uonoe J9JUI JOJPJNUIA JUANEd 34 YoY snp OG e qeuonsonb sanpea Mo po euxo 101 pue oinssoid 10je11dx3 pua si p U31 SIY I a39 duroo Jou sem uone eux e qeuonsonb are Y pue O Yog LSS Woy poAuop o utrI duroo urojs s Surq1ea1q IOJPJNUIA Joc L 5 sjanyea andur pjouso qns SHUNT jeorgojorsAyd JO apts jno 318 sjuoulroJnseaul SAYI S T OTHUD DOS 7 21 49 S VOCH 0 a sueaui 3j uone euxo 9jo durooug AAA M poABJOsIp Ji W ueisisoW IO uone euxo 319Jduroouy XXX ID 51537 19440 Aq porenorp se ogessoJq D D e ueiduro 29s no WJM 17 840 Ventilator Pocket Guide Table 1 Inspiratory pause maneuver displays conti
12. u dt eres Nene Le 42 Constant during rate change 24 asc ede w e em 43 Using pressure support with BiLevel 44 Manual inspiration in BiLevel Mode 45 Tube Compensation 4 4a acc d rdc ORC cde pause e ea 46 Ventilator self tests se aae 2 2 carpa ce erase pa raioni 48 Rimming 55 NE EN ees 48 K GE EF SCR Boii upan Keira d ok debe RUP EUR d 53 Preventive AAGE na avc pru np EY RU PE s lee a 55 840 Ventilator Pocket Guide III Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Tables Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 840 Ventilator components 3 Connecting the ventilator power cord 4 Connecting the air and oxygen supplies 6 Connecting the patient circuit iuo urea 8 Installing the expiratory filter and collector Vial o5 ul Susu a NE 9 Using the collector vial with or without qI ae yo a bie E mma Oe X PX 10 Ventilator Startup screen _ 4 o 12 840 Ventilator graphic user interface GUI 20 Alarm SOLU reserse dod oh SCR UR dd ee 21 Constant during rate change inspiratory time selected 25 Alarmi MACON 4 2d ere i eot eee aa 26 Alami log x3 22x 90b Nea 29 Alarm message format 30 Pressure volume loop 38 BiLevel breath timing b t i
13. 287 131 150 288 330 aN CA a CA 840 Ventilator Pocket Guide 47 Ventilator self tests The 840 Ventilator has three self tests to verify micro processor pneumatic and circuit integrity The tests include Power on self test POST A several second test that automatically checks microprocessor function when you power up the ventilator e Short self test SST A short and simple sequence of tests that verify proper ventilator operation SST checks the patient circuit for leaks and measures cir cuit compliance e Extended self test EST A more exhaustive test of ventilator integrity designed to be run by a qualified service technician Running SST Use SST to check the patient circuit for leaks and to calculate circuit compliance and resistance Always rerun SST whenever you change the circuit type or the humidification type or when you install a new or sterilized exhalation filter WARNING dd Incorrectly specifying the patient circuit type or humidification type or changing either type after you ve run SST can affect the accuracy of compli ance calculation and measured exhaled tidal vol ume You must rerun SST to change the circuit type You can change the humidification type dur ing ventilation by touching the OTHER SCREENS then the More Settings buttons Humidifier Volume allows you to mimimize inaccuracies due to a change in humidifier type 48 840 Ventilator Pocket Guide r gt Ensure that
14. PURITAN BENNETT 840 Ventilatc User s Pocket Guide User s Pocket Guide 540 Ventilator System PURITAN BENNETT The 840 Ventilator System is manufactured in accordance with Puritan Bennett proprietary information covered by one or more of the following U S Patents and foreign equivalents 4 954 799 5 161 525 5 271 389 5 301 921 5 319 540 5 339 807 5 368 019 and 5 390 666 840 Flow by Dual View SandBox SmartAlert and BiLevel are trademarks of Puritan Bennett The information contained in this manual is the sole property of Puritan Bennett and may not be duplicated without permission This manual may be revised or replaced by Puritan Bennett at any time and without notice While the information set forth herein is believed to be accurate it is not a substitute for the exercise of professional judgment The ventilator should be operated and serviced only by trained professionals Puritan Bennett s sole responsibility with respect to the ventilator and its use is as stated in the limited warranty provided Nothing in this publication shall limit or restrict in any way Puritan Bennett s right to revise or otherwise change or modify the equipment including its software described herein without notice In the absence of an express written agreement to the contrary Puritan Bennett has no obligation to furnish any such revisions changes or modifications to the owner or user of the equipment including its softw
15. any apnea settings press ACCEPT to put new settings into effect Calibrating the oxygen sensor Press the 100 O CAL 2 MIN key This causes the ventilator to deliver 100 oxygen if available for 2 minutes and calibrates the oxygen sensor The ventilator s oxygen monitoring feature is always active unless you disable the oxygen sensor see the More Settings screen The oxygen sensor is always enabled when you power up the ventilator Once patient setup is complete Once the settings are accepted you can attach a patient to the ventilator Ventilation only begins when the ventila tor senses that a patient is attached If you attach a patient before completing setup the ventilator begins safety ventilation and declares a PROCEDURE ERROR alarm that resets once patient setup is complete 14 840 Ventilator Pocket Guide Inspiratory Pause Pressing the INSP PAUSE key causes the ventilator to schedule an automatic pause maneuver as follows see Table 1 At the next scheduled inspiration the inspiratory and expiratory valves close to allow pressure to equilibrate between the patient and circuit The inspiratory pause continues until a stable pressure is reached or until 2 seconds elapse whichever comes first The graphics screen will automatically be displayed if it is not already active The trace freezes and the val ues for compliance and resistance are displayed You can extend the pause beyond 2 seconds to a ma
16. are described herein II 840 Ventilator Pocket Guide Table of contents Miodu Oies auae d qoae Ped h 3 ERR e Rede M olde 1 The 840 Vent latot o oed x xot ete Re dc 2 Connections 0 atk pikes be See ee ee Cae ee eee aes 4 Air and oxygen supplies 6 Patience beeen seus Soe ore E S dra Q e Quam a 8 Pienet seee ET eis q u SRM Ed RUE 12 New patient SECUS on ce soho eee Fa EUSEB CO ED RR s g bua w 13 Ne u ya Sa we HS OR SOROR See oe es 14 Calibrating the oxygen sensor 14 Once patient setup is complete ius uy vua vie aw kn 14 Inspiratory Pause caa ru dues Bee eee eee ee epos 15 DX pitdatot y PAUse Ly y yu a l pass oii e ewe ne EPs On BES 15 Alarm SOT INOS u J uu ew CR ORC CO Ende d aS dC pac d 21 Main setting changes em Rc RR cs 22 Mode breath type and batch multiple changes 23 bd OD ON MD euo m as PSOE Soe eee pa 23 Humidification type humidifier volume O sensor enable disable and disconnect sensitivity Dj4 24 Constant during rate change 25 MN 26 Ea sen GE EE SE EE Vee Eee e kukaa 21 MSG 27 FETE ETT eh aay Be 28 Alarm messaged u l prd e dee wee de d wed 29 cit EE TR TOT TT 37 eka cay acura ar ede be RACER TR oe 37 Qr L ae E oes 37 lui c ENRICO rm 39 PIGbSSDHD 2s a qa NN EE ee bd d ied mid 39 Once graphics are displayed 1522 cci y D Ro 40 UTI PP HC 41 Pl TET 42 PAGO Sete
17. breath type and batch multiple changes r gt Touch the SETUP button on the lower screen The Current Vent Setup screen appears r gt To change ventilation setup mode mandatory breath type spontaneous type or trigger type touch its but ton then turn the knob to set the value Proposed changes are shown in red Press CLEAR to cancel a change you ve just made r gt Once you ve made all the changes you want you don t have to make any changes at all touch CONTINUE Appropriate settings for the ventilation setup you ve selected appear on the lower screen C For each of the current ventilator settings you want to change touch its button then turn the knob to set its value Press CLEAR to cancel a change you ve just made r gt Once you ve made any changes you want review the settings then press ACCEPT to apply all the new set tings at the same time Touch SETUP to cancel all changes Previous setup Once ventilator settings are in effect the PREVIOUS SETUP button appears at the bottom of the lower screen when you press SETUP and allows you to restore the entire previous setup including alarm and apnea settings that was in effect immediately before you made settings changes using the Ventilator Setup screen t To restore the previous setup touch PREVIOUS SETUP then press ACCEPT 840 Ventilator Pocket Guide 23 Humidification type humidifier volume O sensor enable disable and disconnect se
18. ening the safety valve there is also an analog circuit that opens the safety valve if system pres sure exceeds 100 to 120 cmH O 54 840 Ventilator Pocket Guide Preventive maintenance Table 6 summarizes maintenance intervals and procedures Several times a day or as required by your institu tion s policy 250 hours or more often if required Annually or after 100 autoclave cycles Every two years or as necessary Every 10 000 hours Table 6 Maintenance summary Check patient circuit for water buildup empty and clean as necessary Inspect and check the resistance across inspi ratory and expiratory filters before every use after 15 days of continuous use in the exhala tion limb or if you suspect excess resistance SST checks the resistance of the expiratory filter Collector vial water traps and drain bag check and empty as needed Air inlet filter bowl if cracked replace bowl If any sign of moisture is visible remove ven tilator from use and contact service or main tenance Clean compressor inlet filter Replace reusable inspiratory and expiratory bacteria filters Sterilize between patients and circuit changes or according to your institu tion s policy Sterilize before nondestructive disposal Replace oxygen sensor and BPS internal bat tery pack Must be replaced by a qualified service technician according to instructions in the 840 Ventilator Service Manual Use appro
19. from use and con tact service Check patient If prompted to do so obtain alternate ventilation or con tact service 31 Table 2 Alarm messages continued When you see this message O2 SENSOR TParc High circuit pressure To High delivered O TVre High exhaled tidal volume TVs tor High exhaled total minute volume 32 It means Background checks have detected a problem with the O sensor The measured airway pressure is equal to or greater than the set limit Reduced tidal volume likely The 03 measured during any phase of a breath cycle is 7 12 during the first hour of operation or more above the 03 setting for at least 30 seconds These per centages increase by 5 for 4 minutes fol lowing a decrease in the O2 setting The patient s exhaled tidal volume for any breath is equal to or greater than the set limit The patient s expira tory minute volume is equal to or greater than the set limit 840 Ventilator Pocket Guide Do this O sensor is out of calibration or has failed Press 10096 O CAL replace or disable the sensor Check patient patient circuit and endotracheal tube Check patient air and oxygen sup plies oxygen analyzer and ventilator Check patient and settings Consider whether the patient s compli ance or resistance has changed Check patient and settings Table 2 Alarm messages continued W
20. hen you see this message TV SPONT Alarm Tfror High respira tory rate TPvenr High internal ventilator pressure TPcowr INOPERATIVE BATTERY INSPIRATION TOO LONG It means The delivered volume of any tube compensated TC breath is equal to or greater than the inspired tidal volume limit Ventilator transi tions to exhalation The breath rate from all breaths is greater than or equal to the set limit The inspiratory pressure transducer has mea sured a pressure of at least 100 cmH O Active only during vol ume controlled breaths Ventilator transitions to exhalation Reduced tidal volume likely The target pressure of a tube compensated TC breath equals the TPcnc limit This limit is equal to the setting of Ppgax Inspiration pressure is limited during this alarm BPS is installed but not functioning IBW based inspiratory time for a spontaneous breath exceeds ventila tor set limit 840 Ventilator Pocket Guide Do this Check patient Check for leaks tube type I D setting Check patient and settings Check patient Obtain alternate ventilation Remove ventila tor from use and contact service Check patient Check for leaks tube type I D setting Contact service Check patient Check for leaks 33 Table 2 Alarm messages continued When you see this message LOSS OF POWER LOW BATTERY 34 It means The ventilator power swi
21. ide diameter I D of gt 4 5 mm TC can be used within SPONT BILEVEL or SIMV With the BiLevel option selected TC supports spontaneous breaths at both PEEP levels Patient Setup To select TC option 1 Touch the VENT SETUP button on the lower screen 2 Touch the MODE button and turn the knob to select either SPONT BILEVEL or SIMV all of which allow for TC to be selected as the spontaneous type 3 Touch the SPONTANEOUS TYPE button and turn the knob to select TC 4 Touch the CONTINUE button The settings applicable to the selected mode and for TC appear on the lower screen 5 Touch the on screen button for each setting you wish to change and then turn the knob to set the desired value see Table 3 for tube I D and IBW Proposed changes are highlighted Press the CLEAR key above the knob to cancel any changes you ve just made Flashing arrows indicate TC settings NOTE If you select an I D that does not match the IBW you must touch the OK button to continue The tube type and tube I D indicators flash if TC is a new selection 8 When you have made the settings you want press the ACCEPT key above the knob to apply the new set tings or the CLEAR key to cancel the last change 46 840 Ventilator Pocket Guide Table 3 Ideal ani weight IBW and tube I D IBW I ET Trach LD ET Trach LD mm low mm high 37 42 80 93 94 108 109 117 nano mel 131 132 133152 a 515 15517 175 220 221
22. ned settings and a high pressure limit of 20 cmH O until the setup is complete Apnea ventilation The ventilator monitors the time from the start of one breath to the start of the next If that time exceeds the operator set apnea interval the venti lator begins apnea ventilation according to operator determined settings Apnea ventilation continues until the patient initiates two consecutive breaths and the exhaled volume is equal to or greater than 50 of the delivered volume autoreset May also be manually reset by the operator Occlusion status cycling OSC The ventilator checks the patient circuit for severe occlusions during all modes of breathing to protect the patient from excessive air way pressures If the ventilator detects a severe occlu sion it opens the safety valve and enters OSC In OSC the ventilator periodically attempts to deliver a pres sure based breath while monitoring for a severe occlu sion Normal ventilation resumes once the occlusion is corrected Idle mode disconnect detection Once the ventilator detects a patient circuit disconnect it enters idle mode in which the exhalation valve opens idle flow 5 L min flow at 100 On if available begins and breath triggering is disabled The ventilator displays the length of time that the patient has been without ventilatory support Once the ventilator confirms that the disconnect has been corrected normal ventilation resumes 840 Ventilator Pocket
23. nsitions from PEEP to PEEP 42 840 Ventilator Pocket Guide NOTE Expiratory sensitivity Espns applies to all spontaneous breaths Constant during rate change In BiLevel ventilation as in pressure control you can select one of three timing variables inspiratory time Ty EE ratio Ty T ratio and expiratory time Ti to be held constant when the frequency setting changes r gt Touch SETUP r gt Touch CONTINUE The breath timing bar appears in the lower screen see Figure 15 r gt ouch one of the lock icons to select Ty Ty Ti or TL as the setting that remains constant when the respira tory rate changes and to determine which timing vari able will be present on the timing button r gt Review settings and change if necessary then press ACCEPT The value displayed is the one held constant during rate changes and becomes the only setting you can adjust directly Figure 15 BiLevel breath timing bar 840 Ventilator Pocket Guide 43 NOTE You can change the value of the constant setting at any time but the value does not change as a result of changing the respiratory rate setting Using pressure support with BiLevel Spontaneous breaths in BiLevel mode can be augmented with pressure support according to these rules e Pressure support can assist spontaneous breaths at PEEP and PEEPy and is always relative to PEEPI If Psypp PEEP is less than PEEPy all spontaneous breaths at PEEP are augme
24. nsitivity Dens To view or change r gt Touch the OTHER SCREENS button then touch the More Settings button t Touch each setting you want to change you can change multiple settings then turn the knob to set its value To leave settings unchanged touch the OTHER SCREENS button again r gt Press ACCEPT to apply the new settings 24 840 Ventilator Pocket Guide Constant during rate change If you selected pressure control PC you can select one of three timing variables inspiratory time I E ratio or expiratory time to be held constant when the respiratory rate setting changes r gt Touch SETUP r gt Touch CONTINUE The breath timing bar appears in the lower screen see Figure 10 r gt ouch one of the lock icons to select Ty EE or Tg as the setting that remains constant when the rate setting changes r gt Review settings and change if necessary then press ACCEPT The value displayed is the one held constant during rate changes and becomes the only setting you can adjust directly Figure 10 Constant during rate change inspiratory time selected NOTE You can change the value of the constant setting at any time but the value does not change as a result of changing the rate setting 840 Ventilator Pocket Guide 25 Alarm handling The SmartAlert Alarm System offers prioritized alarm annunciation that distinguishes primary alarms from sec ondary dependent alarms that is alarms that ari
25. nted by the Psupp setting and all spontaneous breaths at PEEP are augmented by 1 5 cmH 0 If Psypp PEEP is greater than PEEPy all spontaneous breaths at PEEP are augmented by the Psupp setting and all spontaneous breaths at PEEPy are augmented by Psupp PEEP PEEPp For example if PEEP 5 cmH O and PEEP 15 cmH 0 and Psupp 15 cmH50 e All spontaneous breaths at PEEP are augmented by 15 cmH5O of pressure support Psupp PEEP for a total pressure of 20 cmH O e All spontaneous breaths at PEEPy are augmented by 5 cmH5O of pressure support Psupp PEEP PEEP for a total pressure of 20 cmH5O see Figure 16 44 840 Ventilator Pocket Guide PS 5 cmH O Actual Peak PS Pressure 20 cmH O PEEPH 15 cmH20 n PEEPL 5 cmH O Figure 16 BiLevel with pressure support Manual inspiration in BiLevel mode Pressing the MANUAL INSP key during BiLevel mode causes the ventilator to e Switch from PEEPy to PEEP if pressed during a PEEP phase e Switch from PEEP to PEEPy if pressed during a PEEP phase 840 Ventilator Pocket Guide 45 Tube Compensation Tube Compensation TC assists a patient s spontaneous breath by delivering positive pressure proportional to the inspired flow which overcomes the estimated resistance of an artificial airway TC supports all spontaneous breaths for patients with an ideal body weight gt 7 0 kg 15 4 lb and for endotracheal tracheostomy tubes with an ins
26. nued syndur jqeuons nb assay 1noqe soan o 10J gyep JUaned pojojuoui pue SULIOJ2A A SUIYIPIIQ IYI YOY syndur jqeuons nb assay ynoqe sanyo 10 rep 1u oned paroyuow pue SUIIOJJAPM Suru1e91iq 2u1 JOYO posil Sut q JINIIID Suru1e iaq L 10 doo Zze amp ur Sursuopuoo INJSTOW 10 yoyo o qe1sun sr neo1e d J JJno y punoze qrssod Ind Surt1e24q u1 ut Yeo L 107 YoY surop o1 senunuoo neawejd J snp OG gt A qissod e3ep andur o qeuonsonb WoT SYNSIT sq S T OTHW OST lt YU e qeuonsonb y stapuas osje on eA oSutJI Jo 1no STY J kJep andur ajqeuonsanb WOI SINS siu I OCHWI TU Qr gt D e qeuonsonb gt pue y 1opua1 surajqoad s u ASIOU JAISS3OX3 SEM 91nss 1d asned Jo o1e1qi mbo 30u prp sainssaid NMO pue Sunj ILJ JOU SI neo1e q sueaur 3j 3gue1 JO MO AKA M JUIWDJINSPIW a qeuonsand AKA M neoje d ON AAA M poAvydsip 31 Y DULISISOY IO JUIWDJNSPJIW 9 qeuonsoan XXX ID oSue1 Jo MO xxx D neoje d ON XXX I D 5uer duuo5 29s no WJM 840 Ventilator Pocket Guide 18 Table 1 Inspiratory pause maneuver displays continued jeu r p se sour Ajayes aq ued um oA epn 21 j APYSys p jejgur sun 3uer duroo Aysry e 107 J2 Ad A1 p seg Jo puo y nun uonedrdsur p Xe p 1uaned y 19Y13YM 228 01 UIIOJJABM JUIT aInssaid Iy JOIO snp OG n eA y o qeuonsonb p UI Sj ns21 SIY I
27. o scroll through the alarm log move the scroll box up or down and turn the knob to page through the alarm log An icon shows your relative position in the log 28 840 Ventilator Pocket Guide Anl ELI EFi eas PPP tind TE WT te Ne JETHI eee LL aim Alarm log Touch scroll box I button symbols to and turn rotary see definition encoder to scroll Indicates that at bottom of through log log includes screen unread entries Figure 12 Alarm log Alarm messages The upper screen displays the two highest urgency active alarms Alarms are color coded both on the Alarm Setup screen and in the alarm status section on the upper screen Red for high urgency yellow for medium and low urgency An alarm icon flashes on the MORE ALARMS button if there are other active alarms Pressing the icon displays a full screen of up to eight active alarms Each alarm message consists of a base message an analy sis message supplementary information that includes any associated alarm conditions and a remedy message that suggests corrective actions see Figure 13 840 Ventilator Pocket Guide 29 The base message The analysis message The remedy identifies the alarm gives the root cause of message Touch alarm symbol the alarm May also suggests how to view definition include dependent to resolve on lower screen alarms that have arisen the alarm due to the initial alarm condition The two highest priority active alarm message
28. priate preventive maintenance kit preventive maintenance must be performed by a qualified service technician according to instructions in the 840 Ventilator Service Manual 840 Ventilator Pocket Guide 55 56 840 Ventilator Pocket Guide tyco Healthcare Puritan Bennett O 2002 Nellcor Puritan Bennett Inc All rights reserved O c 0690 0402 VE07000 4280 Hacienda Drive Tyco Healthcare UK LTD Pleasanton CA 94588 154 Fareham Road Tel 925 463 4000 Gosport UK PO13 OAS Toll Free 1 800 635 5267 Tel 44 1329 224000 www puritanbennett com
29. r cord Power cord retainer To ac power Figure 2 Connecting the ventilator power cord 4 840 Ventilator Pocket Guide Normally the 840 Ventilator System is mains powered The mandatory 802 Backup Power Source BPS operates the ventilator when ac power drops below a minimum level The ventilator recharges the BPS during ac power operation NOTE The BPS is designed for short term use only and is not intended as a primary alternative power source The BPS is intended to power the BDU and GUI only In case of ac power loss no power is available for the compressor or humidifier If you turn on the ventilator after it has been unplugged for an extended period the LOW BATTERY alarm may become active If so recharge the BPS by leaving it con nected to an operating ventilator for up to eight hours If the LOW BATTERY alarm is still active or if the INOP ERATIVE BATTERY alarm is active the BPS battery must be replaced by a qualified service technician 840 Ventilator Pocket Guide 5 Air and oxygen supplies r gt Connect air and oxygen supplies to the ventilator see Figure 3 The ventilator can use air and oxygen from cylinder or wall supplies Supply pressures must be 35 to 100 psi 241 to 690 kPa Air inlet connector Air inlet filter bowl Oxygen inlet connector Air hose from air supply Oxygen hose from oxygen supply Figure 3 Connecting the air and oxygen supplies Connec
30. rely occluded Obtain alternate ventilation if neces sary Check patient circuit for crimps blocked filter If problem persists remove ventilator from use and con tact service 36 840 Ventilator Pocket Guide Graphics The graphics function displays real time patient data including e Pressure time curve Flow time curve e Volume time curve e Pressure volume loop Display r gt To display the most recently selected graphics press the graphics button at the bottom of the upper screen e f the pressure volume loop is selected the loop for the next full breath is displayed then updated every other breath The inspiratory area is calculated based on the area inside the loop to the left of the baseline see Figure 14 e Curves pressure time flow time and volume time are drawn on the screen at the start of a breath begin ning with the last 0 5 second of the previous breath Color Curves and loops are enhanced by color e Inspiration is green e Expiration is yellow e Spontaneous breaths are orange 840 Ventilator Pocket Guide 37 LP rom LE lire And TOE Inspiratory area Figure 14 Pressure volume loop Graphics are automatically displayed when you press the EXP PAUSE or INSP PAUSE key The measured values for intrinsic and total PEEP are displayed at the end of the expiratory pause The measured values for compliance and resistance for VC with a square flow pattern are di
31. s Table 5 Overall SST results If the test It means Do this result is Passed All tests passed Touch one of these buttons then press ACCEPT EXIT SST To exit SST and begin normal ventilation RESTART SST To repeat SST from the beginning One or more Touch one of these buttons noncritical then press ACCEPT problems were RESTART SST detected Foll he To repeat SST from the your institution s protocol for beginning overriding an ALERT To override the alert as Immediate allowed by your institu ee tion s protocol touch required EXIT SST then press ACCEPT to begin normal ventilation 840 Ventilator Pocket Guide 51 Table 5 Overall SST results continued If the test It means Do this result is FAILURE One or more Restart SST with a different critical problems patient circuit were detected Touch The ventilator RESTART SST enters a ventilator inoperative state and cannot be used for normal ventilation until If the failure persists contact it passes SST a qualified service technician Service required then press ACCEPT to repeat SST from the beginning 52 840 Ventilator Pocket Guide Safety modes The 840 Ventilator offers these safety modes Safety ventilation If you attach a patient before completing setup the ventilator alarms and begins safety ventilation Safety ventilation delivers pressure control PC mandatory breaths with predetermi
32. s are displayed here Touch flashing MORE ALARMS button to view messages for up to six additional active alarms Figure 13 Alarm message format Table 2 lists possible alarm messages WARNING When more than one alarm is active and the alarm messages vary in their degree of seriousness you should assume that the most serious message is applicable 30 840 Ventilator Pocket Guide When you see this message AC POWER LOSS CIRCUIT DISCONNECT COMPRESSOR INOPERATIVE DEVICE ALERT Table 2 Alarm messages It means The power switch is ON ac power is not available and the ventilator is being powered by the back up power source BPS The set apnea interval has elapsed without the ventilator patient or operator triggering a breath There is a disconnection in the patient circuit before the patient wye or patient disconnect is detected following power restoration from an unintentional power loss with the power switch ON Compressor cannot maintain sufficient supply pressure A background test or power on self test POST has detected a problem 840 Ventilator Pocket Guide Do this Prepare for power loss Obtain alter nate ventilation Check integrity of ac power source Contact service if necessary Check patient and settings Check patient Reconnect patient circuit Press ALARM RESET Check patient Obtain alternate ventilation Remove ventilator
33. se due to the initial alarm condition and indicates the urgency level of each alarm An alarm log keeps a time and date stamped record of alarms alarm silences and resets in order of occurrence Alarms on the 840 Ventilator are classified as high medium or low urgency see Figure 11 High urgency alarm indicator red Immediate attention required to ensure patient safety Medium urgency alarm indicator yellow Prompt attention required Low urgency alarm indicator yellow Indicates a change in the patient ventilator system Figure 11 Alarm indicators NOTE You can always change an alarm setting even when alarms are active You do not need to press ALARM RESET or wait for the alarm to autoreset 26 840 Ventilator Pocket Guide Alarm silence Pressing ALARM SILENCE mutes the alarm sound for two minutes The key s LED lights during the silence period and turns off if the alarm is reset Every time you press ALARM SILENCE the two minute silence period restarts An on screen alarm silence notification appears on the display when alarm silence is active WARNING dd Never leave patient unattended when ALARM SILENCE is activated ALARM RESET will cancel silence Alarm reset Pressing the off screen ALARM RESET key resets the detection algorithms of all active alarms except for these AC POWER LOSS COMPRESSOR INOPERATIVE DEVICE ALERT O2 SENSOR INOPERATIVE BATTERY LOW AC POWER LOW BATTERY
34. splayed at the end of an inspiratory pause During both the expiratory pause and inspiratory pause the most recently selected graphics are displayed and frozen Graphics won t be displayed when e The ventilator begins apnea ventilation or safety venti lation However you can choose to redisplay graphics by pressing the graphics button e You touch the MORE PATIENT DATA ALARM LOG MORE ALARMS or OTHER SCREENS button 38 840 Ventilator Pocket Guide Freezing Follow these steps to freeze graphics on the screen r gt Touch FREEZE The screen flashes the message FREEZING the UNFREEZE button appears and the scaling buttons disappear Plotting continues until the screen is full r gt Once the screen is filled and frozen the other onscreen scaling buttons reappear You can now redo the plot setup and adjust the scales for the last 48 seconds of frozen data The pressure volume display shows the most recent full breath within the 48 second freeze period r gt Press UNFREEZE at any time to resume real time graphics display Graphics remain frozen even if you switch to another screen for example MORE ALARMS Plot setup You can choose to display one or two time curves at a time The pressure volume loop uses the entire screen so no other waveform can be displayed at the same time r gt Touch the graphics button at the lower left of the upper screen Graphics appear r gt Touch PLOT SETUP at the upper
35. t only air to the air inlet and only oxygen to the oxygen inlet Do not attempt to switch air and oxygen or connect any other gas 6 840 Ventilator Pocket Guide WARNING ll To ensure that a constant gas supply is available to the patient always connect at least two gas sources to the ventilator There are three gas source connections the compressor air inlet and oxygen inlet CAUTION h X 3 To prevent damage to the ventilator ensure that the connections to the air and oxygen supplies are clean and unlubricated and that there is no water in the air or oxygen supply gas If you suspect water in the air supply gas use an external wall air water trap to prevent water damage to the ventilator and its components 840 Ventilator Pocket Guide 7 Patient circuit r gt Connect the patient circuit to the ventilator see Figure 4 From patient To patient Expiratory filter Expiratory limb nspiratory filter of patient circuit Inspiratory limb of patient circuit Humidifier Figure 4 Connecting the patient circuit 8 840 Ventilator Pocket Guide r gt Figure 5 shows you how to install the expiratory filter and collector vial to ventilator Attach the expiratory limb of the patient circuit to the filter s expiratory limb connection Pull latch up Slide filter rim to install onto these tracks filter pull down to hold filter and collector vial in place Expiratory limb connection
36. tch is on and there is insufficient power from the ac supply and the BPS There may not be a visual indicator for this alarm but an independent audio alarm sounds for at least 120 seconds Mains ac power has dropped below 80 of nominal voltage for at least one second Warns that ac power has dropped signifi cantly and that a more severe power drop may be immi nent The ventilator turns off the compres sor if installed and otherwise operates normally The BPS has less than approximately 2 min utes of operational time remaining 840 Ventilator Pocket Guide Do this Check integrity of ac power and BPS connections Obtain alternate ventilation Check integrity of connection to ac power Check ac power supply Replace BPS or allow it to recharge during normal ven tilator operation Table 2 Alarm messages continued When you see this message 143595 Low delivered O YV E MAND Low exhaled mandatory tidal volume VV te spont Low exhaled spontaneous tidal volume JVE ror Low exhaled total minute volume NO AIR SUPPLY It means The 03 measured during any phase of a breath cycle is 7 12 during the first hour of operation or more below the O2 setting for at least 30 seconds or below 18 These percentages increase by 5 for 4 minutes following an increase in the O2 setting The patient s exhaled mandatory tidal volume is less than or eq
37. tion use pediatric circuits for patients whose ideal body weight IBW is 24 kg 53 lbs or less and adult circuits for patients whose IBW is more than 24 kg 840 Ventilator Pocket Guide 11 mm a i oi wi EG wt GA RD I Once you turn on the ventilator or run SST the ventilator runs POST then displays the Ventilator Startup screen see Figure 7 on the lower screen NOTE If TC was used on the previous patient setup a note emphasizing tube type and tube I D appears below the SAME PATIENT button explanation AR VIL P TRIG Bal ko g P Ya pem LI i M 16 ss 363 21 85 2 07 100 T PEEP 0 0 Lu 30 Ventilator Startup venn Lie siti Peele GENE Eser BDrl yes FErF1mig raw pailit makan Parfum Sho Sak Teri 557 ad cadizraee drrud Figure 7 Ventilator Startup screen r gt Touch SAME PATIENT then press ACCEPT to continue ventilating with the most recent settings Ventilation does not begin until a patient is connected r gt Touch NEW PATIENT to begin ventilating with new settings 12 840 Ventilator Pocket Guide NOTE If you are unsure of the meaning of any symbol for ventilator settings alarms or monitored data touch the symbol on the screen its definition will appear at the left bottom corner of the lower screen Figure 8 shows where symbol definitions appear on the GUI New patient setup t Touch the IBW button then turn the knob to adjust the IBW Many initial settings and setting
38. ual to the set limit The patient s exhaled spontaneous tidal vol ume is less than or equal to the set limit The minute volume for all breaths is less than or equal to the set limit Air supply pressure is less than the minimum required pressure for correct ventilator oper ation throughout its range of flows Accurate O2 delivery may be compromised You cannot set or dis able the NO AIR SUPPLY alarm 840 Ventilator Pocket Guide Do this Check patient air and oxygen sup plies oxygen ana lyzer and ventilator Calibrate oxygen sensor press 100 O CAL 2 min key Check patient Check for leaks or changes in the patient s resistance or compliance Check patient and settings Check patient and settings Check patient and air source Obtain alternate ventilation 35 Table 2 Alarm messages continued When you see It means Do this this message Oxygen supply pres Check patient sure is less than the and oxygen source minimum required Obtain alternate pressure for correct ventilation ventilator operation throughout its range of flows Accurate O2 delivery may be compromised You cannot set or disable the NO O SUPPLY alarm PROCEDURE Patient attached Provide alternate ERROR before ventilator ventilation startup is complete Complete ventila Safety ventilation is tor startup proce active dure SEVERE Patient circuit is Check patient OCCLUSION seve
39. ults in SST If the test It means Do this result is Passed No problems Nothing unless prompted by found the ventilator ALERT Test results not Touch one of these buttons ideaal but not then press ACCEPT oia SST RESTART SST ts a Repeat SST from the beginning REPEAT Repeat the test NEXT Skip to the next test FAILURE A critical Touch one of these buttons problem has then press ACCEPT been detected and un cannot Repeat SST complete until uu RUNE from the beginning passes the failed test Repeat the test r gt You can touch EXIT SST during SST to halt testing You can touch EXIT SST again to resume testing or press ACCEPT to restart the ventilator if SST has not detected an ALERT or FAILURE WARNING To ensure ventilation that correctly compensates for circuit resistance and compliance do not exit SST and begin normal ventilation until the entire SST has been successfully completed with the cir cuit to be used attached 50 840 Ventilator Pocket Guide When all of the tests in SST are complete the SST Status screen displays all individual test results and SST out come Table 5 summarizes overall SST outcomes and how to proceed in each case t To begin normal ventilation if SST has not detected an ALERT or FAILURE touch EXIT SST then press ACCEPT The ventilator reruns POST r gt The ventilator displays the Ventilator Startup screen Confirm or change the last valid setting
40. with or without pressure support with a preset oxygen concen tration Breaths can be pressure or flow triggered using Flow by DualView Touch Screens display monitored data sepa rately from ventilator settings for easy assessment of your patient s condition The SandBox allows you to preview settings before applying them to your patient and the SmartAlert Alarm System helps you to quickly determine the urgency and root cause of alarm conditions The optional 806 Compressor provides compressed air to the BDU and can be used in place of wall or cylinder air The standard 802 Backup Power Source BPS provides dc power to the BDU and GUI in the event that ac power is lost 840 Ventilator mounting options include a cart pole mount or wall mount 2 840 Ventilator Pocket Guide Graphic User Interface GUI Optional cart Breath Delivery Unit BDU 802 Backup Power Source BPS Optional 806 Compressor Figure 1 840 Ventilator components 840 Ventilator Pocket Guide 3 Connections This section tells you how to connect the 840 Ventilator to ac power air and oxygen supplies and the patient circuit Power r gt Plug the ventilator power cord to ac power see Figure 2 The power cord retainer protects against accidental disconnection and must always be in place during operation To avoid electrical shock hazard connect the venti lator power cord into a grounded ac power outlet Powe
41. xi mum of 7 seconds by holding down the INSP PAUSE key Expiratory Pause Pressing the EXP PAUSE key causes the ventilator to schedule an automatic expiratory pause maneuver as follows Press EXP PAUSE key to schedule automatic expirato ry pause maneuver During the next exhalation the inspiratory and expira tory valves close to allow pressure to equilibrate between the circuit and the patient The expiratory pause continues until a stable pressure is reached or 2 seconds elapse whichever comes first The graphics screen will automatically be displayed if it is not already active The trace freezes and the val ues for intrinsic auto PEEP and total PEEP are dis played You can extend the pause beyond 2 seconds to a maxi mum of 20 seconds by holding down the EXP PAUSE key 840 Ventilator Pocket Guide 15 Table 1 Inspiratory pause maneuver displays sosneo SurA Iopun 10 WNO 1uoned au pue sur0J2AeA SUTYILIIq IY uonoeo1ur JOJPEJINUIA JUINE ou YI9YD syndur qguons nb assay 1noqe sanyo 10 3ep uated pojojruoui pue SUIIOJJAPM SuIQ1e2Jq I YOY syndur qguons nb assay 1noqe s n o JOJ ejep JUaned pasoyuow pue SUIIOJJAPM SUTYIeIIG IYI YY snp OG SHUNT peo180 OIS4yd JO pts1no 21e syuouronseoui s u J O Hupy Tu 00 gt D 10 O HUuD Tu 02 D e qeuonsonb 210j21911 IIE san eA O pue Y IL uonn oso Teter JO sau OG OTe SI ST Oc HUD 0 gt uone euxo pus pue neoj1e d pue
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