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 "slug": "pressure-support-ventilation",
 "title": "Pressure support ventilation",
 "updated": "2026-10-15",
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 "excerpt": "Pressure support ventilation (PSV) is a mode of mechanical ventilation in which every breath is patient-triggered and assisted with a set inspiratory pressure, used for weaning.",
 "snippet": "Pressure support ventilation (PSV) is a mode of mechanical ventilation in which every breath is patient-triggered and assisted with a set inspiratory pressure, used for weaning.",
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 "markdown": "# Pressure support ventilation\n\nPressure support ventilation (PSV) is a mode of mechanical ventilation in which every breath is triggered by the patient and assisted with a set level of positive inspiratory pressure, used in critical care to unload the respiratory muscles during respiratory failure, weaning, and noninvasive ventilation. Each breath is patient-triggered, pressure-limited or pressure-targeted, and normally flow-cycled, meaning inspiration ends when inspiratory flow falls to a preset fraction of its peak.<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup> Because every breath must be patient-triggered, the respiratory rate is set by the patient, and PSV is described as the most frequently used partially supported mode of ventilation.<sup>[2](https://link.springer.com/chapter/10.1007/978-3-030-26664-6_22)</sup><sup> • </sup><sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7417783/)</sup> It can be delivered invasively or noninvasively.<sup>[4](https://www.ncbi.nlm.nih.gov/sites/books/NBK482391/)</sup>\n\n| Key fact | Detail |\n|---|---|\n| Breath type | Patient-triggered, pressure-targeted, flow-cycled; no mandatory breaths, so no minimum minute ventilation is ensured<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup><sup> • </sup><sup>[5](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)</sup> |\n| Typical support level | 5–20 cm H2O, with 5 cm H2O the minimum to overcome endotracheal tube resistance<sup>[4](https://www.ncbi.nlm.nih.gov/sites/books/NBK482391/)</sup><sup> • </sup><sup>[6](https://ecampusontario.pressbooks.pub/mcvresource/chapter/6-5-pressure-support-settings-and-how-to-set-them/)</sup> |\n| Unloading effect | Pressure support of 5 cm H2O decreases patient work of breathing by 30 to 40%<sup>[7](https://link.springer.com/article/10.1186/s13054-020-2764-3)</sup> |\n| Expiratory cycling | At an absolute flow of 2–6 L/min or a fixed percentage of peak inspiratory flow (commonly 25%), depending on the ventilator<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup><sup> • </sup><sup>[8](https://aneskey.com/pressure-support-ventilation/)</sup> |\n| Apnea vulnerability | No backup rate in plain PSV; patients are more likely to have apnea and sleep-disordered breathing<sup>[9](https://doctorlib.org/therapy/critical/130.html)</sup> |\n| Common ICU level | 10 cm H2O was the most common support level (45.1% of observations) in prolonged-ventilation patients<sup>[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC10692625/)</sup> |\n| Extubation predictor | Rapid shallow breathing index (rate ÷ tidal volume in liters) below 105 predicts successful extubation; above 105 weaning failure is virtually guaranteed<sup>[5](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)</sup><sup> • </sup><sup>[4](https://www.ncbi.nlm.nih.gov/sites/books/NBK482391/)</sup> |\n\n## How it works\n\nPSV applies a preset positive pressure during each inspiratory effort, which increases tidal volume and improves gas exchange while reducing respiratory muscle work.<sup>[11](https://publications.ersnet.org/content/erj/18/1/107)</sup> The assist is constant: the ventilator delivers the same pressure every breath regardless of the patient's effort, so the patient's own drive determines rate and, within limits, tidal volume.<sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7417783/)</sup>\n\nThe interaction between support level, effort, and tidal volume is nonlinear. A 2024 conceptual model describes a patient-specific assistance window within which the patient modulates inspiratory effort (Pmus) to keep tidal volume near a desired target; below the window is under-assistance and above it over-assistance.<sup>[12](https://link.springer.com/article/10.1186/s13054-024-05144-2)</sup> In the over-assistance phase, tidal volume increases with pressure support and is determined by the support level and respiratory system compliance alone, with the pressure-muscle index (PMI) at or below zero; under-assistance classically occurs when required effort exceeds about 40% of maximal inspiratory pressure.<sup>[12](https://link.springer.com/article/10.1186/s13054-024-05144-2)</sup>\n\n## How it is done\n\n**Triggering.** Pressure sensitivity of 0.5 to 2.0 cm H2O or flow sensitivity of 1 to 5 L/min is typical; triggering difficulty during PSV is usually due to intrinsic PEEP (auto-PEEP).<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup> On some ventilators the pressure trigger can be set from 0 to −20 cm H2O, as sensitive as possible without auto-triggering.<sup>[13](https://www.getinge.com/dam/hospital/documents/english/mcv00106667-flow-family-sw-4.7-pocket-guide-74723-en.pdf)</sup>\n\n**Pressure level.** A starting point of 10 cm H2O is reasonable, titrated within minutes against respiratory rate and tidal volume (target 4–8 mL/kg ideal body weight), with an arterial blood gas checked within 30–60 minutes of any change.<sup>[6](https://ecampusontario.pressbooks.pub/mcvresource/chapter/6-5-pressure-support-settings-and-how-to-set-them/)</sup> The level can be adjusted up to 30 or 60 cm H2O on some ventilators, but levels above 30 cm H2O are rarely used clinically.<sup>[8](https://aneskey.com/pressure-support-ventilation/)</sup> Settings also include PEEP and FiO2.<sup>[5](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)</sup>\n\n**Rise time and cycling.** [Rise time](https://www.edgepedia.org/rise-time) is the time required for the ventilator to reach the support setting at inspiration onset; a fast rise time gives high initial flow and a slow rise time lower initial flow.<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup> [Patient](https://www.edgepedia.org/patient) comfort shows a U-shaped response to pressurization rate with marked interindividual variability.<sup>[11](https://publications.ersnet.org/content/erj/18/1/107)</sup> Expiration starts when inspiratory flow falls to the preset cycling criterion, commonly 25% of peak flow or a fixed flow such as 5 L/min; a higher cycling threshold (for example 50% of peak) shortens the breath and may suit obstructive disease, while a lower one (5%) suits restrictive disease.<sup>[9](https://doctorlib.org/therapy/critical/130.html)</sup> Ventilators add safety limits: on one Flow Family device, expiration also starts if pressure rises 3 cm H2O or 10% above the support level, if the upper pressure limit is exceeded, or if inspiration exceeds 2.5 s in adults (1.5 s in infants).<sup>[13](https://www.getinge.com/dam/hospital/documents/english/mcv00106667-flow-family-sw-4.7-pocket-guide-74723-en.pdf)</sup>\n\n**Backup and monitoring.** Because no mandatory breaths are given, most ventilators provide an apnea backup, often defaulting to a 20-second interval, switching to pressure control until the patient triggers again.<sup>[6](https://ecampusontario.pressbooks.pub/mcvresource/chapter/6-5-pressure-support-settings-and-how-to-set-them/)</sup><sup> • </sup><sup>[13](https://www.getinge.com/dam/hospital/documents/english/mcv00106667-flow-family-sw-4.7-pocket-guide-74723-en.pdf)</sup> A heart rate or blood pressure rise of 20% above baseline after a setting change suggests poor tolerance.<sup>[6](https://ecampusontario.pressbooks.pub/mcvresource/chapter/6-5-pressure-support-settings-and-how-to-set-them/)</sup>\n\n## Origin\n\nPSV became available in the 1980s, providing a titratable pressure boost to every inspiratory effort, with weaning accomplished by gradually decreasing the level of that boost.<sup>[14](https://www.nejm.org/doi/full/10.1056/NEJM199502093320601)</sup> The early physiological characterization came from Neil R. MacIntyre's \"Respiratory Function during Pressure Support Ventilation\" (CHEST Journal, 1986).<sup>[15](https://doi.org/10.1378/chest.89.5.677)</sup> [Laurent Brochard](https://www.edgepedia.org/laurent-brochard), Frédéric Pluskwa, and François Lemaire reported improved efficacy of spontaneous breathing with inspiratory pressure support in 1987 in the American Review of Respiratory Disease,<sup>[16](https://doi.org/10.1164/ajrccm/136.2.411)</sup> and Brochard and colleagues showed in 1989 that inspiratory pressure support prevents diaphragmatic fatigue during weaning.<sup>[17](https://doi.org/10.1164/ajrccm/139.2.513)</sup> MacIntyre and Li-Ing Ho later examined how initial flow rate and breath termination criteria shape the mode.<sup>[18](https://doi.org/10.1378/chest.99.1.134)</sup> The weaning context came from earlier work: John B. Downs and colleagues coined intermittent mandatory ventilation in 1973 in CHEST Journal as a weaning approach based on gradually decreasing the mandatory breath rate.<sup>[19](https://doi.org/10.1378/chest.64.3.331)</sup>\n\n## Variants\n\n**Bilevel or biphasic positive airway pressure (BIPAP)** is a ventilation mode.<sup>[2](https://link.springer.com/chapter/10.1007/978-3-030-26664-6_22)</sup> **Airway pressure release ventilation** was reported by M. Christine Stock, John B. Downs, and Deborah A. Frolicher in Critical Care Medicine in 1987.<sup>[20](https://doi.org/10.1097/00003246-198705000-00002)</sup> **Proportional assist ventilation** was introduced as theory by Magdy Younes in the American Review of Respiratory Disease in 1992; unlike fixed-level PSV, it scales assist to instantaneous effort.<sup>[21](https://doi.org/10.1164/ajrccm/145.1.114)</sup> **NAVA** ([neurally adjusted ventilatory assist](https://www.edgepedia.org/neurally-adjusted-ventilatory-assist)) was reported by Christer Sinderby and colleagues in [Nature Medicine](https://www.edgepedia.org/nature-medicine) in 1999; it delivers assist in proportion to diaphragm electrical activity (EAdi) measured by a dedicated nasogastric tube with electrodes.<sup>[22](https://doi.org/10.1038/71012)</sup><sup> • </sup><sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7417783/)</sup> **Noisy (variable) PSV**, in which the per-breath support level follows an approximately Gaussian distribution within a set variability range, was reported by Marcelo Gama de Abreu and colleagues in Critical Care Medicine in 2008.<sup>[23](https://doi.org/10.1097/01.ccm.0000299736.55039.3a)</sup> **PAV+** adds load-adjustable gain factors to PAV, estimating effort from the equation of motion of the respiratory system.<sup>[24](https://doi.org/10.1007/s00134-011-2297-y)</sup><sup> • </sup><sup>[3](https://pmc.ncbi.nlm.nih.gov/articles/PMC7417783/)</sup> Adaptive support ventilation is a further alternative, addressed in recent guidelines as an adaptive mode.<sup>[25](https://karger.com/res/article/doi/10.1159/000549732/941429/Clinical-Guideline-for-Treating-Acute-Respiratory)</sup>\n\n## Applications\n\n**ICU weaning.** In a multicenter observational study of prolonged invasive ventilation, 90 of 142 patients (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% of ventilation moments, most commonly at 10 cm H2O.<sup>[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC10692625/)</sup> Spontaneous breathing trials on PSV commonly use 5–8 cm H2O of driving pressure with PEEP 5–8 cm H2O and FiO2 ≤40%, with comfortable breathing for 30–120 minutes favoring extubation.<sup>[5](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)</sup>\n\n**Noninvasive ventilation.** Initial noninvasive settings are IPAP 10–15 cm H2O and EPAP 5–10 cm H2O, with driving pressure (IPAP minus EPAP) of at least 5 cm H2O.<sup>[5](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)</sup> In a multicenter observational study of noninvasive ventilation for acute respiratory failure, the PSV group had a higher NIV success rate than the pressure-controlled ventilation group (81.4% vs 55.2%, P=0.020), and PSV was independently associated with success (OR 3.302, 95% CI 1.21–9.36).<sup>[26](https://pmc.ncbi.nlm.nih.gov/articles/PMC7330335/)</sup>\n\n## Limitations and alternatives\n\n**Apnea vulnerability.** With no backup rate, patients on PSV are more likely to have apnea and sleep-disordered breathing.<sup>[9](https://doctorlib.org/therapy/critical/130.html)</sup> Parthasarathy and Tobin showed sleep fragmentation was increased with PSV compared with assist-control ventilation, mostly because of central apneas caused by the support level lowering PCO2.<sup>[8](https://aneskey.com/pressure-support-ventilation/)</sup>\n\n**Auto-PEEP.** Increased auto-PEEP decreases the driving pressure gradient and thus tidal volume; delivered volume would theoretically be zero if auto-PEEP equaled the support setting.<sup>[1](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)</sup>\n\n**Over- and under-assistance.** Under-assistance can induce vigorous efforts, negative alveolar pressure, patient self-inflicted lung injury (P-SILI), and diaphragm myotrauma; over-assistance leads to low drive, diaphragm atrophy, ineffective efforts, apneas, and impaired sleep.<sup>[12](https://link.springer.com/article/10.1186/s13054-024-05144-2)</sup> Over-assistance is common in practice: in prolonged-ventilation patients, mean tidal volume during PSV was 8.3 (IQR 7.0–9.5) mL/kg predicted body weight versus 7.5 (7.0–8.3) during mandatory ventilation, and 97 of 122 PSV-exposed patients (79.5%) showed likely over-assistance by rapid shallow breathing index criteria.<sup>[10](https://pmc.ncbi.nlm.nih.gov/articles/PMC10692625/)</sup> In a 48-hour physiological comparison, PSV patients were frankly over-assisted for most of the time whereas NAVA patients were properly or slightly under-assisted, and PSV showed significantly more missed efforts and prolonged cycles, with a higher asynchrony index.<sup>[27](https://link.springer.com/article/10.1186/s13054-015-1178-0)</sup>\n\n**Contraindications and leaks.** Patients with a significant acid-base abnormality, a higher PEEP requirement (8 cm H2O or above), and an FiO2 of 50% or more in a controlled setting should not be considered for pressure support mode; PSV is relatively contraindicated in depressed respiratory drive, very high oxygen consumption, or elevated airway resistance.<sup>[4](https://www.ncbi.nlm.nih.gov/sites/books/NBK482391/)</sup> With large leaks in noninvasive use, flow cycling can prolong inspiratory time and cause asynchrony, whereas pressure-controlled ventilation is time-cycled.<sup>[26](https://pmc.ncbi.nlm.nih.gov/articles/PMC7330335/)</sup>\n\n**Weaning strategies.** The 2017 ATS/ACCP guidelines suggested that the initial spontaneous breathing trial be conducted with inspiratory pressure augmentation of 5–8 cm H2O rather than without (T-piece or CPAP) in patients ventilated for more than 24 hours.<sup>[28](https://pmc.ncbi.nlm.nih.gov/articles/PMC11024068/)</sup><sup> • </sup><sup>[29](https://pmc.ncbi.nlm.nih.gov/articles/PMC9424483/)</sup> Trial evidence is mixed: in a 2019 multicenter randomized trial of 1153 adults, successful extubation occurred in 82.3% of a 30-minute PSV trial group versus 74.0% of a 2-hour T-piece group (P=.001),<sup>[30](https://pmc.ncbi.nlm.nih.gov/articles/PMC6563557/)</sup> but a 2020 meta-analysis of 10 randomized trials including 3165 patients found no significant difference in successful extubation between T-piece and PSV trials (OR 0.91; 95% CI 0.78–1.07; P=0.27).<sup>[7](https://link.springer.com/article/10.1186/s13054-020-2764-3)</sup> Network meta-analyses found automatic tube compensation achieved superior weaning success compared with T-piece and PSV, and proportional assist ventilation had the highest probability of being the most effective weaning mode; PSV's constant pressure may not match respiratory demand, with asynchrony and over-assistance proposed as explanations.<sup>[29](https://pmc.ncbi.nlm.nih.gov/articles/PMC9424483/)</sup> A meta-analysis of 7 randomized trials with 1214 patients found weaning success of 50.0% with PAV+ versus 43.9% with PSV (pooled RR 1.12, 95% CI 1.02–1.23).<sup>[31](https://pmc.ncbi.nlm.nih.gov/articles/PMC12975930/)</sup>\n\n## References\n\n1. [Pressure Support Ventilation (Respir Care 2005;50(2):166–183), copy hosted on usanhr.org](http://www.usanhr.org/uploads/5/0/3/8/5038746/02.05.0166.pdf)\n2. [Ventilatory Modes: Pressure Support Ventilation and Other Ventilatory Options (Springer chapter)](https://link.springer.com/chapter/10.1007/978-3-030-26664-6_22)\n3. [Proportional modes of ventilation: technology to assist physiology](https://pmc.ncbi.nlm.nih.gov/articles/PMC7417783/)\n4. [Pressure Support (StatPearls, NCBI Bookshelf)](https://www.ncbi.nlm.nih.gov/sites/books/NBK482391/)\n5. [Pressure Support Ventilation - StatPearls (NCBI Bookshelf)](https://www.ncbi.nlm.nih.gov/sites/books/NBK546706/)\n6. [6.5 Pressure Support: Settings and How to Set Them – Breathe Easy (RT resource)](https://ecampusontario.pressbooks.pub/mcvresource/chapter/6-5-pressure-support-settings-and-how-to-set-them/)\n7. [Comparison of T-piece and pressure support ventilation as spontaneous breathing trials in critically ill patients: a systematic review and meta-analysis (Critical Care, 2020)](https://link.springer.com/article/10.1186/s13054-020-2764-3)\n8. [Pressure-Support Ventilation (Anesthesia Key, chapter from Principles and Practice of Mechanical Ventilation, Tobin ed.)](https://aneskey.com/pressure-support-ventilation/)\n9. [Invasive Ventilatory Support Modes - Civetta, Taylor, & Kirby's Critical Care, 4th ed.](https://doctorlib.org/therapy/critical/130.html)\n10. [Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation (2023)](https://pmc.ncbi.nlm.nih.gov/articles/PMC10692625/)\n11. [The effects of pressurization rate on breathing pattern, work of breathing, gas exchange and patient comfort in PSV (Eur Respir J 2001;18:107)](https://publications.ersnet.org/content/erj/18/1/107)\n12. [Pressure support, patient effort and tidal volume: a conceptual model for a non linear interaction (Critical Care, 2024, Docci et al.)](https://link.springer.com/article/10.1186/s13054-024-05144-2)\n13. [Getinge Flow Family ventilator pocket guide (SW 4.7)](https://www.getinge.com/dam/hospital/documents/english/mcv00106667-flow-family-sw-4.7-pocket-guide-74723-en.pdf)\n14. [A Comparison of Four Methods of Weaning Patients from Mechanical Ventilation (NEJM 1995)](https://www.nejm.org/doi/full/10.1056/NEJM199502093320601)\n15. [Neil R. MacIntyre (1986). Respiratory Function during Pressure Support Ventilation. CHEST Journal.](https://doi.org/10.1378/chest.89.5.677)\n16. [Laurent Brochard, Frédéric Pluskwa, François Lemaire (1987). Improved Efficacy of Spontaneous Breathing with Inspiratory Pressure Support. American Review of Respiratory Disease.](https://doi.org/10.1164/ajrccm/136.2.411)\n17. [Laurent Brochard and colleagues (1989). Inspiratory Pressure Support Prevents Diaphragmatic Fatigue during Weaning from Mechanical Ventilation. American Review of Respiratory Disease.](https://doi.org/10.1164/ajrccm/139.2.513)\n18. [Neil R. MacIntyre, Li-Ing Ho (1991). Effects of Initial Flow Rate and Breath Termination Criteria on Pressure Support Ventilation. CHEST Journal.](https://doi.org/10.1378/chest.99.1.134)\n19. [John B. Downs and colleagues (1973). Intermittent Mandatory Ventilation: A New Approach to Weaning Patients from Mechanical Ventilators. CHEST Journal.](https://doi.org/10.1378/chest.64.3.331)\n20. [M. CHRISTINE STOCK, JOHN B. DOWNS, DEBORAH A. FROLICHER (1987). Airway pressure release ventilation. Critical Care Medicine.](https://doi.org/10.1097/00003246-198705000-00002)\n21. [Magdy Younes (1992). Proportional Assist Ventilation, a New Approach to Ventilatory Support: Theory. American Review of Respiratory Disease.](https://doi.org/10.1164/ajrccm/145.1.114)\n22. [Christer Sinderby and colleagues (1999). Neural control of mechanical ventilation in respiratory failure. Nature Medicine.](https://doi.org/10.1038/71012)\n23. [Marcelo Gama de Abreu and colleagues (2008). Noisy pressure support ventilation: A pilot study on a new assisted ventilation mode in experimental lung injury*. Critical Care Medicine.](https://doi.org/10.1097/01.ccm.0000299736.55039.3a)\n24. [R. Costa and colleagues (2011). A physiologic comparison of proportional assist ventilation with load-adjustable gain factors (PAV+) versus pressure support ventilation (PSV). Intensive Care Medicine.](https://doi.org/10.1007/s00134-011-2297-y)\n25. [Clinical Guideline for Treating Acute Respiratory Insufficiency with Invasive Ventilation and ECMO (Respiration, Karger, 2025)](https://karger.com/res/article/doi/10.1159/000549732/941429/Clinical-Guideline-for-Treating-Acute-Respiratory)\n26. [Non-invasive ventilation for acute respiratory failure: pressure support ventilation vs. pressure-controlled ventilation](https://pmc.ncbi.nlm.nih.gov/articles/PMC7330335/)\n27. [Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV (Critical Care, 2015)](https://link.springer.com/article/10.1186/s13054-015-1178-0)\n28. [SBT with pressure support on PEEP and extensive NIV versus T-piece in difficult-to-wean patients: randomized controlled trial (2024)](https://pmc.ncbi.nlm.nih.gov/articles/PMC11024068/)\n29. [Methods of liberation from mechanical ventilation: Which one is best? (2022, commentary on network meta-analyses)](https://pmc.ncbi.nlm.nih.gov/articles/PMC9424483/)\n30. [Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation (JAMA 2019, Subirà et al.)](https://pmc.ncbi.nlm.nih.gov/articles/PMC6563557/)\n31. [Effect of proportional assist ventilation plus versus pressure support ventilation on successful weaning: systematic review, meta-analysis, and trial sequential analysis (2025/2026; also mirrored at Frontiers in Medicine 2026, https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2026.1775614/full)](https://pmc.ncbi.nlm.nih.gov/articles/PMC12975930/)\n\n---\n*Topic: Encyclopedia › Life and health › Human health and medicine › Clinical assessment and procedures › Medical devices, prosthetics, and implants*\n\n*Initially written Sep 29, 2026 · Reviewed: Sep 30, 2026 · Edited: Oct 15, 2026 · Last review: Sep 30, 2026*\n\n*Copyright 2026 EdgeChat AI, a subsidiary of Biostate AI.*\n\nLicense: Edgepedia Community License 1.0, https://www.edgepedia.org/edgepedia/license\n",
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