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1.
J Int Med Res ; 50(11): 3000605221135446, 2022 Nov.
Article in English | MEDLINE | ID: covidwho-2098199

ABSTRACT

OBJECTIVE: To determine the incidence and significance of ventilator avoidance in patients with critical coronavirus disease 2019 (COVID-19). METHODS: This prospective observational cohort study evaluated hospital mortality and 1-year functional outcome among critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-associated acute respiratory distress syndrome (ARDS). The explanatory variable was ventilator avoidance, modeled as 'initial refusal' of intubation (yes/no). Modified Rankin Scale (mRS) scores were obtained from surviving patients (or their surrogates) via phone or email questionnaire. RESULTS: Among patients for whom intubation was recommended (n = 102), 40 (39%) initially refused (95% confidence interval [CI] 30%, 49%). The risk of death was 79.3% (49/62) in those who did not initially refuse intubation compared with 77.5% (31/40) in those who initially refused, with an adjusted odds ratio for death of 1.27 (95% CI 0.47, 3.48). The distribution of 1-year mRS scores was not significantly different between groups. CONCLUSION: Among critically ill patients with COVID-19-associated ARDS, ventilator avoidance was common, but was not associated with increased in-hospital mortality or 1-year functional outcome.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Humans , SARS-CoV-2 , Critical Illness , Prospective Studies , Respiratory Distress Syndrome/therapy , Ventilators, Mechanical
2.
Am J Case Rep ; 23: e937147, 2022 Oct 25.
Article in English | MEDLINE | ID: covidwho-2090898

ABSTRACT

BACKGROUND Inhaled nitric oxide (iNO) is used as a treatment for pulmonary arterial hypertension (PAH). Severe hypoxia with hypoxic vasoconstriction caused by severe acute respiratory distress syndrome (ARDS) can induce pulmonary hypertension with hemodynamic implications, mainly secondary to right ventricle (RV) systolic function impairment. We report the case of the use of iNO in a critically ill patient with bilateral SARS-CoV-2 pneumonia and severe ARDS and hypoxemia leading to acute severe PAH, causing a ventilation/perfusion mismatch, RV pressure overload, and RV systolic dysfunction. CASE REPORT A 36-year-old woman was admitted to the Intensive Care Unit with a severe ARDS associated with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Severe hypoxia and hypoxic vasoconstriction developed, leading to an acute increase in pulmonary vascular resistance, severe to moderate tricuspid regurgitation, RV pressure overload, RV systolic function impairment, and RV dilatation. Following 24 h of treatment with iNO at 15 ppm, significant oxygenation and hemodynamic improvement were noted, allowing vasopressors to be stopped. After 24 h of iNO treatment, echocardiography showed very mild tricuspid regurgitation, a non-dilated RV, no impairment of transverse free wall contractility, and no paradoxical septal motion. iNO was maintained for 7 days. The dose of iNO was progressively decreased with no adverse effects and maintaining an improvement of oxygenation and hemodynamic status, allowing respiratory weaning. CONCLUSIONS Sustained acute hypoxia in ARDS secondary to SARS-CoV-2 pneumonia can lead to PAH, causing a ventilation/perfusion mismatch and RV systolic impairment. iNO can be considered in patients with significant PAH causing hypoxemia and RV dysfunction.


Subject(s)
COVID-19 , Hypertension, Pulmonary , Respiratory Distress Syndrome , Tricuspid Valve Insufficiency , Female , Humans , Adult , Nitric Oxide/therapeutic use , Hypertension, Pulmonary/drug therapy , Hypertension, Pulmonary/etiology , COVID-19/complications , Administration, Inhalation , SARS-CoV-2 , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy , Hypoxia/etiology
5.
Crit Care ; 26(1): 272, 2022 09 12.
Article in English | MEDLINE | ID: covidwho-2089223

ABSTRACT

RATIONALE: It is unknown how to titrate positive end-expiratory pressure (PEEP) in patients with COVID-19-related acute respiratory distress syndrome (ARDS). Guidelines recommend the one-size-fits-all PEEP-FiO2 table. In this retrospective cohort study, an electrical impedance tomography (EIT)-guided PEEP trial was used to titrate PEEP. OBJECTIVES: To compare baseline PEEP according to the high PEEP-FiO2 table and personalized PEEP following an EIT-guided PEEP trial. METHODS: We performed an EIT-guided decremental PEEP trial in patients with moderate-to-severe COVID-19-related ARDS upon intensive care unit admission. PEEP was set at the lowest PEEP above the intersection of curves representing relative alveolar overdistention and collapse. Baseline PEEP was compared with PEEP set according to EIT. We identified patients in whom the EIT-guided PEEP trial resulted in a decrease or increase in PEEP of ≥ 2 cmH2O. MEASUREMENTS AND MAIN RESULTS: We performed a PEEP trial in 75 patients. In 23 (31%) patients, PEEP was decreased ≥ 2 cmH2O, and in 24 (32%) patients, PEEP was increased ≥ 2 cmH2O. Patients in whom PEEP was decreased had improved respiratory mechanics and more overdistention in the non-dependent lung region at higher PEEP levels. These patients also had a lower BMI, longer time between onset of symptoms and intubation, and higher incidence of pulmonary embolism. Oxygenation improved in patients in whom PEEP was increased. CONCLUSIONS: An EIT-guided PEEP trial resulted in a relevant change in PEEP in 63% of patients. These results support the hypothesis that PEEP should be personalized in patients with ARDS.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , COVID-19/complications , COVID-19/therapy , Electric Impedance , Humans , Respiration, Artificial , Respiratory Distress Syndrome/therapy , Retrospective Studies
6.
Medicine (Baltimore) ; 101(41): e31077, 2022 Oct 14.
Article in English | MEDLINE | ID: covidwho-2077960

ABSTRACT

Acute respiratory distress syndrome (ARDS) with (COVID-19 often result in mortality. Treatment outcomes among puerperant, when compared with non-pregnant women (NPW) with the same syndrome. Physiological changes underwent within the gestation period have a considerable impact on the immune system, respiratory system, cardiovascular function, and coagulation. Through this research, it was aimed to compare intensive care unit (ICU) follow-up and treatment results of postpartum-period patients with those of non-pregnant ones. During the first week of ICU, 23 puerperant COVID-19 patients with ARDS and 34 non-pregnant COVID-19 patients took part in the study. Age, height, and predictive body weight (PBW) at admission to the ICU were compared with the clinical parameters of disease severity, such as FiO2 (fraction of inspired oxygen), PaO2 (arterial oxygen partial pressure), Horowitz index (PaO2/FiO2), procalcitonin (PCT), and C-reactive protein (CRP). Respiration parameters were recorded a meta-vision back server. Demographic data, FiO2, PaO2, Horowitz index, PCT, CRP and respiration parameters values were similar in both groups. The duration of non-mechanical ventilation and number of patients were seen to be significantly greater among the puerperant group than control group (P; .04 and .002, respectively). The duration of mechanical ventilation was similar in both groups (P; .07), while the mortality rate was lower in the puerperant group (P; .004). The postpartum women with COVID-19 induced ARDS were observed to have better ICU follow-up results and lower mortality. However, it is considered that the present results need to be supported greater number of participants.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , C-Reactive Protein , COVID-19/complications , COVID-19/therapy , Critical Care , Female , Humans , Intensive Care Units , Oxygen , Postpartum Period , Procalcitonin , Respiration, Artificial , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy
10.
Rev Esp Anestesiol Reanim (Engl Ed) ; 69(9): 544-555, 2022 11.
Article in English | MEDLINE | ID: covidwho-2069621

ABSTRACT

BACKGROUND: The Severe Acute Respiratory Syndrome (SARS)-Coronavirus 2 (CoV-2) pandemic pressure on healthcare systems can exhaust ventilator resources, especially where resources are restricted. Our objective was a rapid preclinical evaluation of a newly developed turbine-based ventilator, named the ACUTE-19, for invasive ventilation. METHODS: Validation consisted of (a) testing tidal volume (VT) delivery in 11 simulated models, with various resistances and compliances; (b) comparison with a commercial ventilator (VIVO-50) adapting the United Kingdom Medicines and Healthcare products Regulatory Agency-recommendations for rapidly manufactured ventilators; and (c) in vivo testing in a sheep before and after inducing acute respiratory distress syndrome (ARDS) by saline lavage. RESULTS: Differences in VT in the simulated models were marginally different (largest difference 33ml [95%-confidence interval (CI) 31-36]; P<.001ml). Plateau pressure (Pplat) was not different (-0.3cmH2O [95%-CI -0.9 to 0.3]; P=.409), and positive end-expiratory pressure (PEEP) was marginally different (0.3 cmH2O [95%-CI 0.2 to 0.3]; P<.001) between the ACUTE-19 and the commercial ventilator. Bland-Altman analyses showed good agreement (mean bias, -0.29, [limits of agreement, 0.82 to -1.42], and mean bias 0.56 [limits of agreement, 1.94 to -0.81], at a Pplat of 15 and 30cmH2O, respectively). The ACUTE-19 achieved optimal oxygenation and ventilation before and after ARDS induction. CONCLUSIONS: The ACUTE-19 performed accurately in simulated and animal models yielding a comparable performance with a VIVO-50 commercial device. The acute 19 can provide the basis for the development of a future affordable commercial ventilator.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Sheep , Animals , COVID-19/therapy , Ventilators, Mechanical , Tidal Volume , Respiratory Distress Syndrome/therapy , SARS-CoV-2
11.
JAMA Netw Open ; 5(10): e2235219, 2022 10 03.
Article in English | MEDLINE | ID: covidwho-2059198

ABSTRACT

Importance: Although vaccination substantially reduces the risk of severe COVID-19, it is yet unknown whether vaccinated patients who develop COVID-19 and require invasive mechanical ventilation have lower mortality than controls. Objective: To examine the association between COVID-19 vaccination status and mortality among critically ill patients who require invasive mechanical ventilation owing to acute respiratory distress syndrome (ARDS) related to COVID-19. Design, Setting, and Participants: This multicenter cohort study was performed between June 7, 2021, and February 1, 2022, among 265 consecutive adult patients with COVID-19 in academic intensive care units who underwent invasive mechanical ventilation owing to ARDS. Exposures: Patients in the full vaccination group had completed the primary COVID-19 vaccination series more than 14 days but less than 5 months prior to intubation. This time threshold was chosen because guidelines from the US Centers for Disease Control and Prevention recommend a booster dose beyond that time. The remaining patients (ie, those who were unvaccinated, partially vaccinated, or fully vaccinated <14 days or >5 months before intubation) comprised the control group. Main Outcomes and Measures: The primary outcome was time from intubation to all-cause intensive care unit mortality. A Cox proportional hazards regression model including vaccination status, age, comorbid conditions, and baseline Sequential Organ Failure Assessment score on the day of intubation was used. Results: A total of 265 intubated patients (170 men [64.2%]; median age, 66.0 years [IQR, 58.0-76.0 years]; 26 [9.8%] in the full vaccination group) were included in the study. A total of 20 patients (76.9%) in the full vaccination group received the BNT162b2 vaccine, and the remaining 6 (23.1%) received the ChAdOx1 nCoV-19 vaccine. Patients in the full vaccination group were older (median age, 72.5 years [IQR, 62.8-80.0 years] vs 66.0 years [IQR, 57.0-75.0 years]) and more likely to have comorbid conditions (24 of 26 [92.3%] vs 160 of 239 [66.9%]), including malignant neoplasm (6 of 26 [23.1%] vs 18 of 239 [7.5%]), than those in the control group. Full vaccination status was significantly associated with lower mortality compared with controls (16 of 26 patients [61.5%] died in the full vaccination group vs 163 of 239 [68.2%] in the control group; hazard ratio, 0.55 [95% CI, 0.32-0.94]; P = .03). Conclusions and Relevance: In this cohort study, full vaccination status was associated with lower mortality compared with controls, which suggests that vaccination might be beneficial even among patients who were intubated owing to COVID-19-related ARDS. These results may inform discussions with families about prognosis.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Adult , Aged , BNT162 Vaccine , COVID-19/complications , COVID-19 Vaccines , ChAdOx1 nCoV-19 , Cohort Studies , Humans , Male , Respiratory Distress Syndrome/therapy , SARS-CoV-2 , United States/epidemiology , Vaccination
12.
BMC Anesthesiol ; 22(1): 307, 2022 10 01.
Article in English | MEDLINE | ID: covidwho-2053860

ABSTRACT

BACKGROUND: Data on the efficacy of non-invasive ventilation (NIV) after progression of respiratory failure in patients who have already received oxygen therapy, or CPAP outside ICU is limited. The study aimed to find predictors of NIV failure based on breathing pattern, gas exchange, and accessory respiratory muscles evaluation in patients who progressed to moderate-to-severe COVID-19 ARDS. METHODS: This was a prospective observational study in patients with moderate-to-severe COVID-19-ARDS on NIV (n = 80) admitted to COVID-ICU of Sechenov University. The combined success rate for conventional oxygen and CPAP outside ICU was 78.6% (440 of 560 patients). The primary endpoints were intubation rate and mortality. We measured respiratory rate, exhaled tidal volume (Vte), mean peak inspiratory flow (PIF), inspiratory time (Ti), PaO2, SpO2, end-tidal carbon dioxide (PETCO2), and Patrick score, and calculated ROX index, PaO2/FiO2, ventilatory ratio, and alveolar dead space (Vdalv/Vt) on Days 1, 3, 5, 7, 10, and 14. For all significant differences between NIV success and failure groups in measured data, we performed ROC analysis. RESULTS: NIV failure rate in ICU after deterioration of respiratory failure outside ICU was 71.3% (n = 57). Patients with the subsequent NIV failure were older at inclusion, more frail, had longer duration of disease before ICU admission, and higher rate of CPAP use outside ICU. ROC-analysis revealed that the following respiratory parameters after 48 h of NIV can serve as a predictors for NIV failure in moderate-to-severe COVID-19-associated ARDS: PaO2/FiO2 < 112 mmHg (AUROC 0.90 (0.93-0.97), p < 0.0001); PETCO2 < 19.5 mmHg (AUROC 0.84 (0.73-0.94), p < 0.0001); VDalv/VT > 0.43 (AUROC 0.78 (0.68-0.90), p < 0.0001); ROX-index < 5.02 (AUROC 0.89 (0.81-0.97), p < 0.0001); Patrick score > 2 points (AUROC 0.87 (0.78-0.96), p = 0.006). CONCLUSION: In patients who progressed to moderate-to-severe COVID-19-ARDS probability of NIV success rate was about 1/3. Prediction of the NIV failure can be made after 48 h based on ROX index < 5.02, PaO2/FiO2 < 112 mmHg, PETCO2 < 19.5 mmHg, and Patrick score > = 2. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04667923 , registered on 16/12/2020.


Subject(s)
COVID-19 , Noninvasive Ventilation , Respiratory Distress Syndrome , Respiratory Insufficiency , COVID-19/complications , COVID-19/therapy , Carbon Dioxide , Humans , Intensive Care Units , Oxygen , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , Respiratory Muscles , Respiratory Rate
14.
Am J Respir Crit Care Med ; 205(11): 1300-1310, 2022 06 01.
Article in English | MEDLINE | ID: covidwho-2053493

ABSTRACT

Rationale: The most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown, and current practice is variable. Objectives: To compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS. Methods: We conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using grading of recommendations assessment, development and evaluation methodology. Measurements and Main Results: We included 18 randomized trials (4,646 participants). Compared with a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (risk ratio [RR], 0.77; 95% credible interval [CrI], 0.60-0.96, high certainty), the posterior probability of benefit of the esophageal pressure-guided strategy was 87% (RR, 0.77; 95% CrI, 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR, 0.83; 95% CrI, 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR, 1.06; 95% CrI, 0.89-1.22, low certainty). Compared with a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR, 1.37; 95% CrI, 1.04-1.81, moderate certainty). Conclusions: In patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death than lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared with higher PEEP without LRM.


Subject(s)
Positive-Pressure Respiration , Respiratory Distress Syndrome , Adult , Bayes Theorem , Humans , Lung , Network Meta-Analysis , Positive-Pressure Respiration/methods , Respiratory Distress Syndrome/therapy
15.
Sci Rep ; 12(1): 16528, 2022 Oct 03.
Article in English | MEDLINE | ID: covidwho-2050546

ABSTRACT

Real-time effects of changing body position and positive end-expiratory pressure (PEEP) on regional lung overdistension and collapse in individual patients remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP in supine and prone body positions seeking to reduce lung collapse and overdistension in mechanically ventilated patients with coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). We hypothesized that prone positioning with bedside titrated PEEP would provide attenuation of both overdistension and collapse. In this prospective observational study, patients with COVID-19-induced ARDS under mechanical ventilation were included. We used electrical impedance tomography (EIT) with decremental PEEP titration algorithm (PEEPEIT-titration), which provides information on regional lung overdistension and collapse, along with global respiratory system compliance, to individualize PEEP and body position. PEEPEIT-titration in supine position followed by PEEPEIT-titration in prone position were performed. Immediately before each PEEPEIT-titration, the same lung recruitment maneuver was performed: 2 min of PEEP 24 cmH2O and driving pressure of 15 cmH2O. Forty-two PEEPEIT-titration were performed in ten patients (21 pairs supine and prone positions). We have found larger % of overdistension along the PEEP titration in prone than supine position (P = 0.042). A larger % of collapse along the PEEP titration was found in supine than prone position (P = 0.037). A smaller respiratory system compliance was found in prone than supine position (P < 0.0005). In patients with COVID-19-induced ARDS, prone body position, when compared with supine body position, decreased lung collapse at low PEEP levels, but increased lung overdistension at PEEP levels greater than 10 cm H2O.Trial registration number: NCT04460859.


Subject(s)
COVID-19 , Positive-Pressure Respiration , Pulmonary Atelectasis , Respiratory Distress Syndrome , COVID-19/complications , COVID-19/therapy , Humans , Lung/pathology , Prone Position , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy
17.
Lancet ; 400(10358): 1145-1156, 2022 10 01.
Article in English | MEDLINE | ID: covidwho-2050101

ABSTRACT

Acute respiratory distress syndrome (ARDS) is a common clinical syndrome of acute respiratory failure as a result of diffuse lung inflammation and oedema. ARDS can be precipitated by a variety of causes. The pathophysiology of ARDS is complex and involves the activation and dysregulation of multiple overlapping and interacting pathways of injury, inflammation, and coagulation, both in the lung and systemically. Mechanical ventilation can contribute to a cycle of lung injury and inflammation. Resolution of inflammation is a coordinated process that requires downregulation of proinflammatory pathways and upregulation of anti-inflammatory pathways. The heterogeneity of the clinical syndrome, along with its biology, physiology, and radiology, has increasingly been recognised and incorporated into identification of phenotypes. A precision-medicine approach that improves the identification of more homogeneous ARDS phenotypes should lead to an improved understanding of its pathophysiological mechanisms and how they differ from patient to patient.


Subject(s)
Respiratory Distress Syndrome , Anti-Inflammatory Agents , Humans , Inflammation , Phenotype , Respiration, Artificial , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy
18.
Lancet ; 400(10358): 1157-1170, 2022 10 01.
Article in English | MEDLINE | ID: covidwho-2050100

ABSTRACT

Acute respiratory distress syndrome (ARDS) is characterised by acute hypoxaemic respiratory failure with bilateral infiltrates on chest imaging, which is not fully explained by cardiac failure or fluid overload. ARDS is defined by the Berlin criteria. In this Series paper the diagnosis, management, outcomes, and long-term sequelae of ARDS are reviewed. Potential limitations of the ARDS definition and evidence that could inform future revisions are considered. Guideline recommendations, evidence, and uncertainties in relation to ARDS management are discussed. The future of ARDS strives towards a precision medicine approach, and the framework of treatable traits in ARDS diagnosis and management is explored.


Subject(s)
Respiratory Distress Syndrome , Respiratory Insufficiency , Adult , Diagnostic Imaging , Humans , Phenotype , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy
19.
Acta Med Indones ; 54(3): 444-450, 2022 Jul.
Article in English | MEDLINE | ID: covidwho-2047003

ABSTRACT

Mortality rate among maintenance hemodialysis (HD) patients with COVID-19 is alarmingly high. In Fatmawati General Hospital, most of HD patients with COVID-19 presented with acute respiratory distress syndrome (ARDS). Hemoperfusion (HP) is a blood purification therapy used to remove cytokines and inflammatory mediators to prevent ARDS worsening and organ failure. We report 6 cases of COVID-19 in maintenance HD patients. HP and HD were performed in two consecutive days when patient developed early ARDS as indicated by inflammatory markers elevation. HP and HD were conducted by using resin-containing cartridge and high-flux dialyzer, respectively, for 4 hours. Improvements in CRP levels, PaO2/FiO2 ratios, and chest X-rays were observed after 2 sessions of HP in most of our patients. Based on our clinical experience, the timing of HP delivery is critical and should be undertaken in the early phase of ARDS, but larger studies are still needed.


Subject(s)
COVID-19 , Hemoperfusion , Respiratory Distress Syndrome , COVID-19/complications , COVID-19/therapy , Cytokines , Humans , Inflammation Mediators , Renal Dialysis , Respiratory Distress Syndrome/etiology , Respiratory Distress Syndrome/therapy
20.
Trans Am Clin Climatol Assoc ; 132: 107-116, 2022.
Article in English | MEDLINE | ID: covidwho-2046393

ABSTRACT

Acute respiratory distress syndrome (ARDS), originally described in 1967, affects more than 3 million individuals each year throughout the world and accounts for approximately 10% of all admissions to the intensive care unit. Despite substantial progress in defining the epidemiology and pathogenesis of the syndrome, there is no specific treatment and mortality rates remain high. Barriers to finding specific therapeutic interventions include the inability to predict who will get ARDS, inadequate definitions and specific diagnostic markers, the heterogeneity of the patient population, complexities of the pathogenesis, and the impact of clinical care. Measurements of biomarkers have identified these barriers as well as contributed to the current understanding of the disease. The COVID-19 pandemic resulted in a dramatic increase in patients with ARDS, driving an urgent need to understand the pathogenesis and develop and implement therapeutic interventions. Past studies of biomarkers in ARDS can provide insight that could help to meet those needs more rapidly.


Subject(s)
COVID-19 , Respiratory Distress Syndrome , Biomarkers , Humans , Pandemics , Respiratory Distress Syndrome/diagnosis , Respiratory Distress Syndrome/epidemiology , Respiratory Distress Syndrome/therapy
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