VOLUMETRIC DIFFUSIVE VENTILATION (VDR®)

What is VDR® all about?

The term, Volumetric Diffusive Respiration (VDR®) was coined by Dr. Forrest M Bird in 1980, to define his original novel ability to internally Percuss the lungs, creating ”Intrapulmonary Percussive Mixing” with secondary Diffusion, which was programmed between normal Tidal Volume Deliveries. This logic provided for increased diffusive Oxygen transport into the Alveoli as well as the Convective Wash out of CO₂ from the peripheral airways. VDR® programming is NOW based upon a continuous Intrapulmonary Percussive Ventilation IPV® with Sub Tidal Volume deliveries, injected at selectable frequencies of from under 50 to over 900 cycles per minute. The amplitude (band width) of the Pulsatile Oscillation can be controlled, through Pulsatory Inspiratory Flowrate selection, as well as programmable i/e ratios and/or both.

The basic Intrapulmonary Percussive Ventilation (IPV®) programming, is phasically controlled through selectable VDR® I/E ratios, to create sinusoidal amplitude changes, between the Inspiratory and Expiratory Intervals; thus, eliminating the original sequencing of independent Diffusive Convective programming. The addition of a programmable tertiary Oscillatory Pressure Rise, made the VDR® Sinusoidal Percussionators very flexible ventilators, capable of gently ventilating the smallest Neonatal lungs, while having the reserve power to percussively ventilate the lowest compliance Giant Picwickian adult lungs.

Therefore, the ability to create a "Sinusoidal Percussive Ventilation”, with a selectable Oscillatory Equilibrium (Peak Oscillatory Delivery Pressures), during the Inspiratory Interval and a programmable Oscillatory Demand CPAP for elevated expiratory baseline control; became possible. The VDR® concept provides ventilatory flexibility not found in any other Ventilatory device. The Patient may physiologically shift base lines without impairment, during spontaneous "breathe through”, which may serve to increase convective tidal exchange.

VDR® can be programmed for Weaning, by scheduling an Oscillatory Demand CPAP to stabilize the pulmonary structures to reduce the work of breathing. Additionally, while assisting spontaneous respiration, it serves to wash out both the Mechanical as well as upper Anatomical Dead Spaces during the Expiratory Interval, thus reducing end tidal CO2.

Essentially, the family of VDR® Ventilators, provide for two concurrent Intrapulmonary Ventilations. One is programmed for Percussive Mechanical Mixing within the pulmonary structures, by means of high velocity, repetitive, Sub Tidal Volume Deliveries to enhance Intrapulmonary Diffusion. The other Time Cycled Ventilator, provides for convective periodic Tidal Exchange, to wash out CO2. Both diffusive and convective intrapulmonary ventilation’s can be precisely "balanced” to address metabolic oxygen or carbon dioxide imbalances, as well as be programmed for maximum cardiac output.

Independent nominal VDR® programming, provides for serialized Percussive Sub Tidal Volume deliveries, under selected i/e Ratios (computed in milliseconds), for delivery rates of from 50 to 900 cycles per minute. Concurrent, low Frequency Convective Ventilation, (computed in seconds) with selectable I/E ratios, allow periodic scheduled increases in Lung Volumes, at rates of from 2 to 40 cycles per minute.

Both Diffusive and Convective Ventilation’s, have the ability to be scheduled with "negative or positive” Inspiratory or Expiratory time Ratios. The unique VDR® "step inflation and deflation of the lungs”, reduces the potential for "Dependent Lung Barotrauma” by precisely controlling proximal/distal inflow gradients (in milli-seconds). Volume Oriented Ventilators are capable of maintaining proximal-distal inflow gradients (in seconds), creating high PIP’s, which can be distally transmitted down Preferential Airways to produce Barotrauma in hyperinflated Dependent Lung Structures.

The standard VDR® Breathing Circuit can be accessorily configured to accommodate Heated Aerosol Devices and/or for Dense Aerosol Lavage. Aerosolized topically active medications can be continuously or periodically delivered.

Standard Percussionaire® VDR® Breathing circuits must not be adulterated!

Briefly Describe the available VDR® Percussionators?

The VDR®-4 is a stand alone Percussionator® Ventilator, with self contained monitoring and failsafe alarming. There are several accessory "Educational Monitoring Devices” available for all VDR® Percussionators®, they are:

The Analog Monitron I and the Digitalized Monitron II.

The VDR-4 is pneumatically powered with a self contained Bird® Oxygen Air Blender which receives conventional unrestricted Air and Oxygen sources from Institutional Wall Sources.

THE VDR®-3 AUTOCYCLE® RESPIRATOR (PERCUSSIONATOR®) IS A (UNIVERSAL) CONVENTIONAL SELF CONTAINED CMV and IMV VENTILATOR, WITH INTEGRATED PERCUSSIVE HIGH and LOW FREQUENCY PROVISIONS FOR CRITICAL CARE AND WEANING PROCEDURES.

The VDR® clinical protocols and administering devices, were conceived by Dr. Forrest M Bird. They are NOT High Frequency Jet Ventilators (HFJV) or High Frequency Oscillatory Ventilators (HFOV) nor are they Oscillatory Vibrators.

In principal VDR devices are precise, synchronized, high and low frequency Time Cycled Ventilators. The VDR® technique is often referred to, as High Frequency Percussive Ventilation (HFPV).

VDR® has the unique (patented) ability, to percussively "step inflate the lung” to a selected increase in lung volume, before entering into an Oscillatory Equilibrium, ventilating the lung with continuously programmed, "percussive sub tidal volume deliveries”, without a further increase in lung volumes.

Exhalation is passive with a programmable step deflation of the lung down to a scheduled "oscillatory demand continuous positive airway pressure” (OD-CPAP).

Because there is no sustained proximal/distal Inspiratory Flow Gradient, beyond a few milliseconds, with VDR® programming, the potential for barotrauma associated with standard Volume Oriented Ventilators (CMV), is potentially eliminated.

Therefore, while VDR® might be said to have all the contraindications of any trach-positive medical ventilator, its inherent design limits the opportunities for barotrauma, unless the programming Clinician deviates from accepted programming techniques, established for the VDR® devices.

Clinicians who are administering to a patient with a VDR® protocol, must be qualified Medically and Technologically to program and maintain the VDR® Clinical regimes. This is accomplished by abiding by the published Texts in terms of acceptable programming, while honoring the "Cautions and Warnings” set fourth in the VDR® Manuals and Operational Limitations.

Initially, the Universal VDR® Percussionators® were reserved for critical care patients in all patient populations, failing conventional Volume Oriented Ventilation. For example; over the years, the VDR® protocols have proven to be extremely effective in Burn Patients with Inhalational Injury. All too often, the VDR® devices were withheld until a patient developed IRDS or ARDS and was incapable of being managed on Volume Oriented Ventilators. In spite of these delaying administrative initiations, many patients with major barotrauma were reversed, by employing the VDR® protocols at a late hour. Increasingly, VDR® Ventilators are being employed routinely on patients requiring critical mechanical Cardiorespiratory Care.

Essentially, Intrapulmonary Percussive Ventilation (IPV®) and Volumetric Diffusive Respiration (VDR®), are exactly the same in terms of Percussive Wave Form generation, which provides the Ability to Mobilize Airway and control blood gases. The major difference is, the vast Universal programmability of the VDR® critical care devices. All VDR® devices, can be programmed to give IPV® therapy, through Endotracheal Tubes for Airway Secretion Removal, the Resolution of Atelectasis, Hypoventilation and associated Hypercarbia.

BIBLIOGRAPHY FOR VOLUMETRIC DIFFUSIVE RESPIRATION:

1. SMOKE INHALATION IS A MULTILEVEL INSULT TO THE PULMONARY SYSTEM; Lentz, Christoper W., MD; H.D. Peterson, DDS, MD.; Critical Care, 1996, 2:230- 235.

2. VENTILATOR STRATEGIES FOR SMOKE INHALATION: Mlcak, R.P., The Journal for Respiratory Care Practitioners, February/March 1996; 103-106.

3. COMBINED PRESSURE CONTROL/HIGH-FREQUENCY VENTILATION IN ADULT RESPIRATORY DISTRESS SYNDROME AND SICKLE CELL ANEMIA: Baird, J.S., Johnson, J.L., Escudero, J., Powers, D.R.: Chest 1994; 106(6): 1913-1916.

4. THE FIFTH QUINQUENNIUM: 1989 to 1993; Warden, Glenn: Burn Care Rehabilitation 1993.

5. DECREASED PULMONARY DAMAGE IN PRIMATES WITH INHALATION INJURY TREATED WITH HIGH-FREQUENCY VENTILATION; Cioffi, William G. and others; Surgery 1993; 218:3. 328-337.

6. DECREASED PULMONARY BAROTRAUMA WITH THE USE OF VOLUMETRIC DIFFUSIVE RESPIRATION IN PEDIATRIC PATIENTS WITH BURNS; Rodeberg, DA and others; Burn Care Rehabilitation 1992; 13:506-511. Abstract published in Year Book of Surgery 1993; pages 80-81.

7. PROPHYLACTIC USE OF HIGH-FREQUENCY PERCUSSIVE VENTILATION IN PATIENTS WITH INHALATION INJURY; Cioffi, William G. and others; Surgery 1991; 213:6 575-582.

8. HIGH FREQUENCY PERCUSSIVE VENTILATION; Davis, K. and others; Problems in Respiratory Care 1989; 2:1. 39-47.

9. HIGH-FREQUENCY PERCUSSIVE VENTILATION IN PATIENTS WITH INHALATION INJURY; Cioffi, William G. and others; Trauma 1989; 29:3. 350-354.

10. THE ROLE OF HIGH-FREQUENCY VENTILATION IN POST-TRAUMATIC RESPIRATORY INSUFFICIENCY; Hurst, J.M. and others: Trauma 1987; 27:3. 236-241.

11. HIGH-FREQUENCY PERCUSSIVE VENTILATION COMPARED WITH CONVENTIONAL MECHANICAL VENTILATION; Gallagher, T. James and others; Presented at Society of Critical Care Medicine, May, 1985; updated in Intensive Care and Emergency Medicine, 1987.

12. LUNG COMPLIANCE, AIRWAY RESISTANCE, AND WORK OF BREATHING IN CHILDREN AFTER INHALATION INJURY; Mlcak, R. and others: Journal of Burn Care and Rehabilitation NOV/DEC 1997; 531-534.

13. THE USEFULNESS OF COMBINED HIGH-FREQUENCY PERCUSSIVE VENTILATION DURING ACUTE RESPIRATORY FAILURE AFTER SMOKE INHALATION; P. Reper, R. Dankaert, F VanHille, Y. VanLaeke, L. Duinslae ger, A. Vanderkelen; Burns, 1998; 24:34-38.

14. FIFTY YEARS OF POSITIVE PRESSURE BREATHING; Bird Institute of Biomedical Technology, F.M. Bird 2000

15. INTRAPULMONARY PERCUSSIVE VENTILATION (IPV®) AND ASSOCIATED MECHANICAL INTRATHORACIC VESICULAR PERISTALSIS; Bird Institute of Biomedical Technology, F.M. Bird 2000

BASIC VDR®-4 ADULT SET UP INSTRUCTIONS

Explain how to Basically set up a VDR®-4 Percussionator®?

CLINICAL STRATEGIES

Programming of the VDR®-4, to correct arterial blood gas abnormalities is an art, based upon a few simple principles and the rationalization of pressure limited ventilation, as well as understanding the advantages and disadvantages of traditional high frequency ventilation.

INITIAL PATIENT SET UP (ADULT)

INITIATING VDR® PROGRAMMING

DEFINITIONS AS THEY MAY RELATE TO THE PERCUSSIVE DIFFUSIVE/CONVECTIVE MECHANICAL VENTILATION OF THE PULMONARY STRUCTURES

Define the key Definitions as they apply to VDR® Protocols?

CONTINUOUS MECHANICAL VENTILATION (CMV)- A mechanically programmed intrapulmonary tidal volume delivery based upon a scheduled volume with a selected cyclic delivery rate.

CONVECTIVE TIDAL VOLUME DELIVERIES- The delivery into the pulmonary structures of programmed volumes of a respiratory gas (measured in cubic centimeters) that exceed the anatomical dead space, favoring the wash out of carbon dioxide.

DEMAND CONTINUOUS POSITIVE AIRWAY PRESSURE (DEMAND-CPAP)- A pneumatically energized flow accelerator that is servoed by physiological proximal airway pressure change. A certain minimal proximal airway pressure is selected (such as 5 cm H2O) for maintenance during the spontaneous physiological expiratory phase, which additionally provides for a mechanically programmed inspiratory flow acceleration, to accommodate physiological inspiratory demand to reduce the work of spontaneous breathing.

DEMAND-CPAP is a form of Inspiratory Pressure Support.

DIFFUSIVE SUB TIDAL VOLUME DELIVERY- The mechanical programming of repetitive intrapulmonary Percussive Volume Deliveries (measured in milliliters and/or cubic centimeters) that are less than the patient's anatomical dead space. Higher Frequency

SUB TIDAL VOLUME deliveries favor diffusive activities within the pulmonary structures, enhancing oxygen uptake.

DIGITAL FREQUENCY MONITORING- A COMPONENT OF VDR MONITORING, pulsatile frequencies generated by aVDR® device, can be presented in a traditional LED format.

DYNAMIC FUNCTIONAL RESIDUAL CAPACITY (D/FRC)- The average amount of gas remaining within the Pulmonary Structures during Oscillatory Equilibrium, when the Elastomeric and Frictional Forces within the Lungs are in Equilibrium with the Pulsatile Sub Tidal Volume Delivery Pressures, without further increase in Lung Volumes. (D/FRC) is resultant from either an Inspiratory or Expiratory Oscillatory Equilibrium.

EFFECTIVE ALVEOLAR VENTILATION- The amount of physiological tidal exchange delivered into peripheral pulmonary structures during effective intrapulmonary diffusion and perfusion.

EXPIRATORY INTERVAL- A COMPONENT OF VENTILATORY PROGRAMMING, describing the scheduled time at a selected expiratory baseline between repetitive Inspiratory Oscillatory Intervals.

FAILSAFE SENSITIVITY- VDR HIGH PRESSURE FAILSAFE SECURITY PROVISION, guarding against an internal ventilator failure and/or an obstructed Phasitron delivery tubing. Whenever the Phasitron delivery pressures exceed the selected pressure rise for approximately two (2) seconds, an aural alarm is sounded concomitant with a regulated drop in patient delivery pressures. The Failsafe Sensitivity selection determines the sustained pressure required (within programmable limits) within the patient servoing circuit to provoke a pressure rise alarming.

FUNCTIONAL RESIDUAL CAPACITY- The amount of gas remaining within the Pulmonary Structures at the end of Passive Exhalation, when the Elastomeric Forces within the Lung are in Equilibrium with Ambient Pressures.

GROSS TIDAL VOLUME- A COMPONENT OF VDR PROGRAMMING, relating to a passive convective intrapulmonary gas exchange, realized during the programmed Expiratory Interval, when Percussively elevated Lung Volumes, are decreased to the programmed Baseline.

HIGH FREQUENCY PULMONARY VENTILATION (HFPV)- A loose definition of methods employed in attempting to create a greater diffusive component during intrapulmonary ventilation than would normally be expected with conventional mechanical lung ventilation (CMV). "i/e"

PULSE RATIO- A COMPONENT OF VDR PROGRAMMING, expressing the pulsatile (sub tidal volume) flow/no flow relationships in milliseconds). Valve open -flow time/valve closed -no flow time.

INTEGRATED MANOMETER- A COMPONENT OF VDR® MONITORING, whereby a rotary switch allows the selection of a highly dampened integrated proximal airway pressure. The manometric mechanism is calibrated with a time constant well beyond repetitive (cyclic) programming. Information is clinically significant in determining the efficacy of the selected program in terms of "mean functional pressures" as they reflect upon blood gases and cardiac output.

INTERMITTENT MANDATORY VENTILATION (IMV)- A mechanical ventilatory program scheduled to deliver a certain number of controlled tidal volumes per minute while allowing the patient to breathe spontaneously with a reduced work of breathing, provided by mechanical pressure support, etc.

INTRAPULMONARY PERCUSSION- A method of delivering repetitive high velocity bursts (sub tidal volumes) of respiratory gases into the proximal physiological airway, with precise pneumatic control over pressure/flow/volume relationships for maximum bilateral intrapulmonary distribution, while impaction forces are maintained below "stretch receptor" threshold and barotraumatic potentials.

INTRAPULMONARY PERCUSSIVE VENTILATION (IPV® expanded)- A cyclic method of controlled percussive intrapulmonary (sub tidal) breath stacking, increasing the existing Functional Residual Capacity of the pulmonary structures to a selected level (pulsatile equilibrium) at which point repetitive sub tidal volume delivery do not further increase lung volumes. Each percussive inspiratory interval (timed in seconds) is associated with percussive, diffuse intrapulmonary gas mixing concomitant with aerosol delivery; followed by a passive exhalation of a Gross Tidal Volume to a selected baseline.

INTRAPULMONARY PERCUSSIVE VENTILATION (IPV)- A mechanical means of introducing (aerosol laden) successive sub tidal intrapulmonary breath stacking, reaching a controlled percussive Apneustic Plateau within the pulmonary structures, for the purpose of endobronchial secretion mobilization and the resolution of associated atelectasis, while maintaining the mechanical ventilation of the lung.

JET INSUFFLATOR (VENTILATOR)- A mechanical device usually consisting of a Solenoid Valve, with control over valve opening and closing ratios, as well as over the flowrate of pulsatile gas delivery into the physiological airways, through an uncuffed indwelling airway catheter (with a tip located) immediately above the Carina.

MANOMETRIC DAMPENING- A COMPONENT OF VDR MONITORING, A method of dampening the needle of a manometer looking at proximal airway pressure change during VDR® programming. A standard calibration provides the clinician with a "mean pressure interpretation" of the phasic pressure alterations at the physiological proximal airway.

MECHANICAL PULSE GENERATOR (FLOW INTERRUPTER)- A pneumatically energized, diaphragm controlled, differential flow valve for the controlled cyclic interruption of a pressure/flow regulated respiratory gas.

MINUTE VENTILATION- The amount of mechanically delivered respiratory gas (measured in liters) cyclically delivered into the pulmonary structures each minute.

OSCILLATORY APNEUSTIC PLATEAU- is resultant from an Oscillatory Inspiratory Equilibrium, after the Inspiratory Increase in Lung Volume has been satisfied, and the lung is being ventilated by Percussive Sub Tidal Volume deliveries through an Inspiratory Pressure Wedge; without a further increase in Lung Volume.

OSCILLATORY DEMAND CONTINUOUS POSITIVE AIRWAY PRESSURE (OD-CPAP)- A COMPONENT OF VDR® PROGRAMMING, allowing the selection of an Oscillatory Expiratory Baseline while maintaining a Positive End Expiratory Pressure, with an Inspiratory Flow Acceleration to assist a Spontaneous Inspiratory Effort.

PERCUSSION/BASELINE RATIO (P/B RATIO)- A COMPONENT OF VDR® PROGRAMMING, expressing the ratio of the PERCUSSIVE sub tidal (inspiratory) interval in relation to the time at BASELINE (expiratory) interval. A method of describing the VDR® CONVECTIVE I/E RATIO. For example: A 15 second Inspiratory Percussive Interval divided by a 5 second Expiratory Baseline equals a P/B Ratio of 3.

PHASING RATE- A COMPONENT OF VDR® PROGRAMMING, describing the number of cyclic inspiratory/expiratory intervals per minute, counted as Convective Returns to a programmed Expiratory Baseline.

PHYSIOLOGICAL DEAD SPACE- A pulmonary unit that is void of cyclic gas exchange, diffusion across the alveolar membranes, perfusion of the pulmonary capillaries and/or any combination thereof.

POSITIVE DISPLACEMENT OSCILLATOR VENTILATOR- A mechanical piston type device with a reciprocating relatively fixed stroke, causing (to and fro positive and sub ambient) displacements of a respiratory gas into and out of a mechanical breathing circuit. A biased proximal airway inflow and outflow is often employed to control the circulation of respiratory gases.

PRESSURE LIMITED VENTILATION- A peak inspiratory pressure limit (measured in cm H2O) established to limit the maximum delivery pressure within the pulmonary structures during the mechanical ventilation of the lung.

PRESSURE RISE AND FALL ALARMING- VDR® HIGH and LOW PRESSURE FAILSAFE SECURITY PROVISIONS, available systems to monitor and alarm on a rapid or sustained proximal airway pressure rise. A battery operated HI/LO SIG-ALERT can monitor selectable time related pressure drops which can provoke an alarm as well as a pressure rise above a programmed value. Additionally, a Wave Form Monitor (MONITRON®) can perform a similar task with programming accomplished on a CRT.

PROXIMAL AIRWAY PRESSURE- A sampling point adjacent to the physiological airway where mechanical and/or physiologically altered pressures are recorded. Proximal airway pressure alterations provide the pulmonary (proximal/distal) pressure gradients for potential intrapulmonary inflow and outflow.

PROXIMAL AIRWAY WAVE FORM ANALYSIS- A COMPONENT OF VDR® MONITORING, whereby proximal airway pressures are directed against a transducer with sufficient speed capacities to relate the rapid pressure changes associated with VDR/IPV scheduling. Therefore, a means for presenting Proximal Airway Pressure changes on a cathode ray tube (CRT) are enhanced. Desirable pressure scales and sweep speeds can be selected, allowing the Clinician to program and interpret Proximal Airway Pressure potentials as they may effect physiological parameters. Additionally, proximal airway pressure tracings and digitalized integrations, can be documented on strip chart recorders.

PULSATILE AMPLITUDE and/or PULSATILE FLOWRATE- A COMPONENT OF VDR® PROGRAMMING, describing the (proximal airway) pressure rise during selected sub tidal volume deliveries, secondary to the programmed flowrate of respiratory gases, delivered from the orifice of the Phasitron.

PULSE (PERCUSSIVE) FREQUENCY- A COMPONENT OF VDR® PROGRAMMING, describing the number of Pulsatile Sub Tidal Volume deliveries per minute.

VDR® "I/E" RATIO- A COMPONENT OF VDR® PROGRAMMING, describing the ratio between the length of time (in seconds) that sub tidal volumes are intrapulmonarily delivered (OSCILLATORY INSPIRATORY INTERVAL), to the length of time a scheduled interruption at baseline (EXPIRATORY INTERVAL) is programmed. Oscillatory Inspiratory time interval/expiratory time interval.

VDR/IPV® PERCUSSIONATOR/VENTILATOR- A mechanical device capable of delivering sequential percussive bursts (sub tidal volumes) of a selected respiratory gas, with flow generated at the proximal physiological airway for delivery into the pulmonary structures, through a mechanical/physiological interface (combination injector exhalation valve) called a Phasitron®. A Sinusoidal Pressure change pattern can be programmed.

VOLUME LIMITED VENTILATION- A selected volume (measured in milliliters) programmed for intrapulmonary delivery under a preselected pressure limit, whereby the mechanical ventilator will cycle on either the selected volume and/or pressure limit, based upon which limit is first reached.

VOLUMETRIC DIFFUSIVE RESPIRATION (VDR® expanded)- A cyclic method of precisely controlling the intrapulmonary delivery of successive (aggregate) sub tidal volumes, to a selected equilibrium (increase in lung volume) ultimately reaching an Oscillatory Apneustic Plateau (Oscillatory Equilibrium), followed by the passive exhalation of a gross tidal volume down to a programmed static and/or pulsatile baseline.

VOLUMETRIC DIFFUSIVE RESPIRATION (VDR®)- A Sinusoidal Wave Form applied against the physiological proximal airway to more independently (mechanically) control PaO2, PaCO2 and Cardiac Output.

Notes:

ILLUSTRATIVE JUSTIFICATION FOR VDR® INTERVENTION

Illustrate several Patients receiving VDR® Critical Care protocols?

THE VDR® PERCUSSIONATORS® CONTINUE TO BE THE VENTILATOR OF CHOICE WHEN VENTILATING BURNED PATIENTS WITH MAJOR INHALATIONAL INJURIES

TYPICAL CRITICAL CARE PATIENT UNDER VDR® INTENSIVE CARE

WEANING A BABY OFF VDR®

Where can I find additional Technical information about IPV® and VDR®?

THIS DOCUMENT IS NOT ALL INCLUSIVE, ADDITIONAL DATA AND INFORMATION, AS WELL AS, CLINICAL RESTRICTIONS MAY BE FOUND IN ASSOCIATED OPERATIONAL MANUALS AND LABELING.

Where can Percussionaire® be contacted?

V      volumetric                                          a twenty year learning curve 1980-2000
D     diffusive                                               by PERCUSSIONAIRE® corporation
R®  respiration

© Percussionaire® Corporation 2000

US and Foreign Patents issued and pending

Representante Exclusivo para o Brasil:

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( (013) 3234-1130 (Santos) ou (011) 274-2019 (São Paulo)
FAX: (013) 3236-6319

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