Compensation of breath delivery

Abstract

The present invention relates to a method of delivering gas during ventilation of a patient using a system for breath delivery. The method of gas delivery includes real-time compensation of gas compression losses, in the current breath delivery phase, and gas leakage losses. The present invention further relates to a system for breath delivery. Still further, the present invention relates to a computer implemented method adapted of delivering gas during ventilation of a patient using a system for breath delivery.

Claims

1. A method for calculating, in real-time, an amount of gas during ventilation of a patient using a system for breath delivery comprising: a Patient-Tubing system coupled with an outlet of a gas delivery system for conveying gas to a patient during gas-supplemented inhalations; a flow sensor coupled with said outlet for sensing the gas flow; a Patient-Tubing system pressure sensor coupled with said Patient-Tubing system for sensing gas pressure therein and providing Patient-Tubing system pressure signals representative thereof; and a processor coupled with said sensors and operable for receiving said pressure and flow signals therefrom, said processor operable to perform, using said received pressure and flow signals, the method comprising the steps of: obtaining, in each of a plurality of sample intervals, flow information from said flow sensor, wherein each sample interval is a breath; obtaining, from each of the plurality of sample intervals, pressure information from said Patient-Tubing system pressure sensor; calculating for each of the plurality of sample intervals, based on a compliance of the tubing and a calculated derivative of the pressure information from the Patient-Tubing system pressure sensor, a Patient-Tubing system flow; and continuously calculating in real-time for each of the plurality of sample intervals, based on the calculated Patient-Tubing system flow and on the flow information from the flow sensor, the amount of gas needed to compensate for gas lost in pressurization of the Patient-Tubing system and gas lost through leakages in the Patient-Tubing system; wherein the compensation comprises the equation Q.sub.tube=C.sub.tubedP.sub.y/dt, where Q.sub.tube is Tubing gas flow, C.sub.tube is Tubing compliance and P.sub.y is tubing circuit wye pressure; and wherein calculating the amount of gas needed to compensate gas loss comprises determining an estimate for leakages in the patient-tubing system, which comprises the tubing circuit, the patient's airways and the patient's lungs, wherein compensation for flow lost due to leakages in the tubing system and/or the airway and/or the lung utilizes conductance for the equivalent orifice representing the tubing circuit leak and/or the lung leak and/or the total gas flow leak.

2. The method according to claim 1, comprising an initial step of supplying, by an operator, a target gas flow, and further wherein the step of calculating the amount of gas needed to compensate gas loss comprises determining compensation to reach said target gas flow.

3. The method according to claim 1, wherein compensation for flow lost due to leakages in the tubing system and/or the airway and/or the lung comprises the equation:
Qv(n)=PF(n)+Q.sub.exh(n)+K.sub.o(P.sub.y(n)).sup.m+K.sub.1(P.sub.AW(n)).sup.m+K.sub.2(P.sub.Lung(n)).sup.m+C.sub.tubedP.sub.y(n)/dt where: PF(n)=is the value of the peak flow waveform set by the user, for the control interval n; Q.sub.exh(n)=is the value of the exhalation flow sensor reading, for the control interval n; K.sub.o=is the conductance for the equivalent orifice representing the tubing circuit leak, for the control interval n; m=exponent; P.sub.y(n)=is the value of the tubing circuit pressure, for the control interval n; K.sub.1=is the conductance for the equivalent orifice representing the Lung leak, for the control interval n; P.sub.AW(n)=P.sub.y(n)R.sub.ETQ.sub.AW=the value of the Airway pressure, for the control interval n; P.sub.Lung(n)=P.sub.AW(n)R.sub.LQ.sub.o=the value of the Lung pressure, for the control interval n; P.sub.mus(n)=Patient's muscles pressure, for the control interval n; C.sub.tube=is the value of the tubing circuit compliance; and dP.sub.y(n)/dt=is the value of the tubing circuit pressure slope/derivative, for the control interval n.

4. The method according to claim 1, wherein calculating the Patient-Tubing system flow comprises the equations:
Q.sub.v(n)=Q.sub.tube(n)+Q.sub.L(n)+Q.sub.exh(n)+Q.sub.Total.sub._.sub.Leak(n) and Q.sub.v(n) =PF.sub.(n)+Q.sub.exh(n)+K(P.sub.o(n)).sup.m+C.sub.tubedP.sub.y(n)/dt wherein Q.sub.V(n) as a desired flow target, Q.sub.tube is Tubing gas flow, Q.sub.L is Lung gas flow, Q.sub.exh is Exhalation gas flow, Q.sub.Total.sub._.sub.Leak is the total gas flow leak, where Q.sub.Total.sub._.sub.Leak(n)=K(P.sub.o(n)).sup.m, PF(n) is a value of the peak flow waveform set by an operator, K is the conductance for the equivalent orifice representing the total gas flow leak, Po is the pressure at the pertinent pressure site where the leak is assumed to be located, Ctube is Tubing compliance, and Py is tubing circuit wye pressure.

5. A computer implemented program adapted for performing the steps of the method according to claim 1.

6. A system for calculating, in real-time, an amount of gas during breath delivery, the system comprising: a Patient-Tubing system coupled with an outlet of a gas delivery system for conveying gas to a patient during gas-supplemented inhalations; a flow sensor coupled with said outlet for sensing the gas flow; a Patient-Tubing system pressure sensor coupled with said Patient-Tubing system for sensing gas pressure therein and providing Patient-Tubing system pressure signals representative thereof; and a processor coupled with said sensors and operable for receiving said signals therefrom, wherein said processor is configured to: (if) obtain, in each of a plurality of sample intervals, flow information from said flow sensor, wherein each sample interval is a breath; (ii) obtain, from each of the plurality of sample intervals, pressure information from said Patient-Tubing system pressure sensor; (iii) calculate for the one sample interval, based on a compliance of the tubing and a calculated derivative of the pressure information from the Patient-Tubing system pressure sensor, a Patient-Tubing system flow; and (iv) continuously calculate for each of the plurality of sample intervals, based on the calculated Patient-Tubing system flow and on the flow information from the flow sensor, the amount of gas needed to compensate for gas lost in pressurization of the Patient-Tubing system and gas lost through leakages in the Patient-Tubing system; wherein the compensation comprises the equation Q.sub.tube=C.sub.tubedP.sub.y/dt, where Q.sub.tube is Tubing gas flow, C.sub.tube is Tubing compliance and P.sub.y is tubing circuit wye pressure; and wherein calculating the amount of gas needed to compensate gas loss comprises determining an estimate for leakages in the patient-tubing system, which comprises the tubing circuit, the patient's airways and the patient's lungs, wherein compensation for flow lost due to leakages in the tubing system and/or the airway and/or the lung utilizes conductance for the equivalent orifice representing the tubing circuit leak and/or the lung leak and/or the total gas flow leak.

7. The system according to claim 6, wherein the processor comprises a signal processor and a general processor, and wherein the signal processor is configured to obtain signals from the flow sensor and the Patient-Tubing system pressure sensor, and further wherein the general processor are configured to perform said calculations.

8. The system according to claim 6, further comprising an input unit configured to receive a target gas flow, and wherein the processor is configured to calculate the amount of gas needed to compensate gas loss including determining compensation to reach said target gas flow.

9. A computer implemented method adapted to calculate an amount of gas during ventilation of a patient using the system of claim 6.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) Embodiments of the invention will be described, by way of example only, with reference to the drawings, in which

(2) FIG. 1 schematically illustrates a breath curve,

(3) FIG. 2 is a schematic illustration of a simplified Ventilator-Patient-Tubing pneumatic model,

(4) FIG. 3 is a schematic diagram illustrating the Patient-Tubing pneumatic system including the different leak flows,

(5) FIGS. 4-9 schematically illustrates results of simulations,

(6) FIGS. 10-11 schematically illustrates breath curves,

(7) FIG. 12 schematically illustrates steps of a method according to the present invention, and

(8) FIG. 13 schematically illustrates a system according to the present invention.

DESCRIPTION OF EMBODIMENTS

(9) FIG. 1 schematically illustrates a breath curve. During ventilation, a ventilator injects gas into a tubing system connected to a patient, causing it to pressurize and in turn, this pressurization drives the gas into the patient's airway and ultimately into his/her lungs. During Volume Control Ventilation, the objective is to deliver a predetermined volume of gas into the patient lungs using a predetermined flow rate and a predetermined duration. The predetermined flow rate may have a particular shape/waveform such as a square or a descending ramp or a forward phased sinusoidal waveform, also the waveform could be any other type of waveform offered by the system or device. FIG. 1 illustrates a descending ramp waveform with the associated tubing circuit pressure waveform.

(10) In the absence of leakages in the tubing system or the lungs, the problem of accurate volume delivery into the patient's lung may be better explained by examination of the simplified Ventilator-Patient-Tubing pneumatic model that appears in FIG. 2 and discussed below.

(11) In FIG. 2 the following definitions are used: P.sub.i=inhalation pressure sensor P.sub.e=exhalation pressure sensor P.sub.y=tubing circuit wye Pressure P.sub.aw=airway pressure P.sub.Lung=lung pressure P.sub.mus=patient's muscles pressure Q.sub.v=ventilator gas flow Q.sub.tube=tubing gas flow Q.sub.L=lung gas flow Q.sub.exh=exhalation gas flow R.sub.insp=inspiratory limb resistance R.sub.exh=expiratory limb resistance R.sub.ET=ET tube resistance R.sub.L=lung resistance R.sub.exh valve=exhalation valve resistance C.sub.tube=tubing compliance C.sub.L=lung compliance

(12) From this model, it is possible to derive the relationship that links the different flows that are used in the system during ventilation. That is:
Q.sub.v=Q.sub.tube+Q.sub.L+Q.sub.exhEquation 1

(13) Since one objective in Volume Control Ventilation is to deliver a predetermined volume of gas into the patient lungs using a predetermined flow rate and/or a predetermined duration, then that means that Q.sub.L must possess these characteristics. However, when the user, i.e. health care person, sets the tidal volume (Tv) and the peak flow (PF) level, the ventilator does not know how much tubing volume is going to be required to pressurize the tubing system, as it is a function of the maximum tubing circuit wye pressure level (P.sub.y) developed and this pressure is only known at the end of the gas delivery phase.

(14) Related algorithms compute the volume used by the tubing once the gas delivery phase is over, via use of the equation 2 below, and add this volume to the tidal volume (Tv) set originally and then computes again the PF using this new Tv, while keeping the gas delivery phase duration (Ti) constant, and iterate this process on a breath to breath basis. If and when the pressure (P.sub.y) stabilizes (may be a function of patient activity), the volume intended for delivery to the patient lungs is finally obtained.
Tubing_volume=C.sub.tubeP.sub.yEquation 2

(15) This process typically takes from 10 to 15 breaths to achieve stability when there is no patient activity and depends on the patient lung and airway characteristics as well as the level of patient activity.

(16) The present invention transforms equation 2 by taking the derivative on both equation sides and since the derivative of volume is flow, obtains equation 3 below.
Q.sub.tube=C.sub.tubedP.sub.y/dtEquation 3

(17) The present invention uses equation 3, on a sample by sample basis to calculate Q.sub.tube in real time, since we have always access to the P.sub.y signal, and then recalculates the ventilator flow needed to achieve the user set PF at the entrance of the patient's lungs (i.e. QL). Thus at each sample interval, Q.sub.v is determined as the discrete equation below indicates.
Q.sub.v(n)=Q.sub.tube(n)+Q.sub.L(n)+Q.sub.exh(n)Equation 4

(18) Where n is the sample/control interval number, Q.sub.exh(n) is the value of the exhalation flow sensor reading for the control interval n, Q.sub.tube(n) is the value of the tubing flow estimate for the control interval n.

(19) To properly compensate for gas loss in the tubing, due to gas compression, Q.sub.L(n) is then set to be equal to the PF set by the user and having the waveform characteristic set by the user. Also note that Q.sub.exh(n) is typically zero, but can be any flow measured during the gas delivery phase. Finally, as explained above, Q.sub.tube(n) is estimated using equation 3, namely Q.sub.tube(n)=C.sub.tubedP.sub.y(n)/dt where dP.sub.y(n)/dt is the value of the tubing circuit pressure slope/derivative for the control interval n. Q.sub.v(n) is then updated every control interval during the gas delivery phase and used as the gas delivery control system target therefore reflecting the gas needed to compensate for the flow lost in pressurizing the tube as well as for the flow lost through the exhalation valve (if different from zero).

(20) The method according to the present invention may include extending Equation 1 to account for flow lost due to leakages in the tubing system and/or the airway (cuff deflated) and/or the lung (possibly due to a fistula). A pre-requisite for this operation is that these leakages can be characterized and estimated (via estimation of C.sub.L, R.sub.L and the P.sub.AW, P.sub.Lung and P.sub.mus pressures). The schematic diagram in FIG. 3 illustrates the Patient-Tubing pneumatic system including the different leak flows.

(21) The relationships between Q.sub.AW, and Q.sub.AW.sub._.sub.leak, Q.sub.L and Q.sub.L.sub._.sub.leak as we as those between Q.sub.V, Q.sub.tube, Q.sub.tube.sub._.sub.leak, Q.sub.exh, and Q.sub.AW are expressed below in equations 5a, 5b and 5c.
Q.sub.AW=Q.sub.o+Q.sub.AW.sub._.sub.leakEquation 5a
Q.sub.o=Q.sub.L+Q.sub.L.sub._.sub.leakEquation 5b
Q.sub.v=Q.sub.tube+Q.sub.AW+Q.sub.exh+Q.sub.tube.sub._.sub.leakEquation 5c

(22) Equation 6 below reflects these flow elements. Since the leakages in the tubing system and the lung are pressure dependent, it is possible to calculate the tubing and/or the lung leakages in real time and compensate the gas delivery so the intended PF is delivered to the lung.
Q.sub.v=Q.sub.tube+Q.sub.L+Q.sub.exh+Q.sub.tube.sub._.sub.leak+Q.sub.AW.sub._.sub.leak+Q.sub.L.sub._.sub.leakEquation 6

(23) In discrete form, equation 6 becomes
Q.sub.v(n)=Q.sub.tube(n)+Q.sub.L(n)+Q.sub.exh(n)+Q.sub.tube.sub._.sub.leak(n)+Q.sub.AW.sub._.sub.leak(n)+Q.sub.L.sub._.sub.leak(n)Equation 7

(24) Note that Q.sub.tube.sub._.sub.leak is a function of P.sub.y, Q.sub.AW.sub._.sub.leak is a function of P.sub.AW and Q.sub.L.sub._.sub.leak is a function of P.sub.Lung.

(25) Although it is not part of this invention, Q.sub.AW.sub._.sub.leak, Q.sub.tube.sub._.sub.leak and Q.sub.L.sub._.sub.leak are typically expressed (although other leak models may be used) in terms of the corresponding pressures as appears below.
Q.sub.tube.sub._.sub.leak(n)=K.sub.o(P.sub.y(n)).sup.mEquation 7a
Q.sub.AW leak(n)=K.sub.1(P.sub.AW(n)).sup.mEquation 7b
Q.sub.Lung.sub._.sub.leak(n)=K.sub.2(P.sub.Lung(n)).sup.mEquation 7c

(26) The equation 7 is implemented in discrete time as indicated by the equation below.
Q.sub.v(n)=PF(n)+Q.sub.exh(n)+K.sub.o(P.sub.y(n)).sup.m+K.sub.1(P.sub.AW(n)).sup.m+K.sub.2(P.sub.Lung(n)).sup.m+C.sub.tubedP.sub.y(n)/dtEquation 8

(27) Where: PF(n)=is the value of the peak flow waveform set by the user, for the control interval n. Q.sub.exh(n)=is the value of the exhalation flow sensor reading, for the control interval n. K.sub.o=is the conductance for the equivalent orifice representing the tubing circuit leak, for the control interval n. m=exponent (depends on the leak model but is typically around 0.6) P.sub.y(n)=is the value of the tubing circuit pressure, for the control interval n. K.sub.1=is the conductance for the equivalent orifice representing the Lung leak, for the control interval n. P.sub.Aw(n)=P.sub.y(n)R.sub.ETQ.sub.AW=the value of the airway pressure, for the control interval n. P.sub.Lung(n)=P.sub.AW(n)R.sub.LQ.sub.o=the value of the lung pressure, for the control interval n. P.sub.mus(n)=patient's muscles pressure, for the control interval n. C.sub.tube=is the value of the tubing circuit compliance. dP.sub.y(n)/dt=is the value of the tubing circuit pressure slope/derivative, for the control interval n. The term control interval refers to the interval where control is carried out. The control interval has a specific length, as opposed to the sample interval which could be of different length etc.

(28) Note that estimation of C.sub.L, R.sub.L, P.sub.y, P.sub.AW and P.sub.Lung are not discussed here. Estimation of K.sub.o, K.sub.1 and K.sub.2 are not discussed here either as this is thoroughly understood by those skilled in the subject of leak estimation.

(29) Thus complete compensation for flow losses occurring in the tubing circuit (due to gas compression or leaks or both) as well as flow losses due to leakages at the patient's airway or lungs or both is achieved by using the results of the calculation of equation 8, on a control interval by control interval basis and using the resulting Q.sub.V(n) as the desired flow target used by the flow controller responsible for control of the gas delivery output for the ventilator.

(30) Lastly, if it is only possible to characterize the Total leakage, equations 7 & 8 can be changed to reflect that as appears below, but the principle of compensation on a sample by sample basis remains.
Q.sub.v(n)=Q.sub.tube(n)+Q.sub.L(n)+Q.sub.exh(n)+Q.sub.Total.sub._.sub.Leak(n)Equation 9
Q.sub.v(n)=PF(n)+Q.sub.exh(n)+K(P.sub.0(n)).sup.m+C.sub.tubedP.sub.y(n)/dtEquation 10

(31) Where: K=is the conductance for the equivalent orifice representing the Total leak, for the control interval n. P.sub.o=the value of the pressure, at the pertinent pressure site where the leak is assumed to be located, for the control interval n.

(32) This last part of the compensation method is likely to be the most common one as it highly difficult to accurately estimate the different leakages even when prior knowledge of the leak sites are known. It is usually the case that during ventilation, the major leak occurs at the patient port site (as in non-invasive ventilation), but it is also common to find leakages at the airway (during invasive ventilation with the Endotracheal tube's cuff deflated). For these cases the P.sub.o pressure measurements would be assumed to be at the wye (P.sub.y) and the airway (P.sub.AW) respectively.

(33) Compensation for leakages, using the method of the present invention, avoids the iterative process associated with the use of volume feedback to compensate for the volume lost through the leak orifice(s) as well as the need for pressure stability in the system.

(34) The six graphs in FIGS. 4-9 illustrate, via depiction of the different flow and volume traces, the differences between no compliance or leak compensation, and the performance of the compliance compensation method being disclosed when no leaks are compensated for and when leaks are present and are compensated for.

(35) In FIG. 4 the result of a simulation is illustrated. Note that the flow delivered by the ventilator (Q.sub.vent), in steady state, is equal to the peak flow setting but the lung flow trace (Q.sub.Lung) is NOT.

(36) The settings for ventilation are: Peak Flow=60 lpm, Tidal Volume=1000 ml and Respiratory rate=12 bpm; And the Tubing Compliance=2 ml/cmH.sub.2O. For demonstration purposes, the leak is assumed to occur in the tubing circuit.

(37) In FIG. 5 the volume delivered by the ventilator (V.sub.vent) was 1000 ml while the volume delivered to the patient was 947.17 ml.

(38) Note: The I:E signal is a signal designed to indicate the gas delivery phase of a breath. It is >0 during the gas delivery phase of a breath and it is 0 (zero) during the exhalation phase of the breath. Furthermore, it has been amplified so it equals the Tidal Volume setting for ease of graphical assessment of the delivery accuracy.

(39) In FIG. 6 note that the lung flow trace (Q.sub.Lung) is equal, in steady state, to the peak flow setting and the Q.sub.vent trace is hi higher than the set Peak Flow. The difference between Q.sub.vent and Q.sub.Lung is Q.sub.tube.

(40) In FIG. 7 note that the volume delivered by the ventilator (Vvent) was more than 1000 ml while the volume delivered to the patient was 1004 ml. The reason why the lung volume continues to increase after the I:E signal has return to zero is that the lung flow remains positive for a little more as Q.sub.vent and Q.sub.tube also remain positive during that lapse (this can be attributed to the flow and exhalation valves responses).

(41) In FIG. 8 Note that the lung flow trace (Q.sub.Lung) is equal, in steady state, to the peak flow setting and the Q.sub.vent trace is higher than the set peak flow. The difference between Q.sub.vent and Q.sub.Lung is Q.sub.tube+Q.sub.leak.

(42) In FIG. 9 Note that the volume delivered by the ventilator (V.sub.vent) was significantly more than 1000 ml while the volume delivered to the patient was 1004 ml. The volume leaked was a little lower than 100 ml, as may be observed from the graph by looking at the cyan trace at the point where the I:E signal becomes zero (0).

(43) In FIGS. 10 and 11, the graphs illustrate that ALL breaths are similar to the first breath which demonstrates that no prior knowledge of the pressure level at the end of the delivery phase is needed for proper tubing compliance or leak compensation. For leak compensation, knowledge of the leak model is required for accurate compensation of the leak flow (not part of this invention), but the compensation algorithm does not make use of prior knowledge of the volume lost through the leak orifice(s) in order to carry out the compensation for the leaks. As explained before, both compensations are done via adjustment of the flow being delivered to the patient-tubing system while delivery is progressing.

(44) FIG. 12 schematically illustrates steps of a method according to the present invention. The method is performed on a system for breath delivery comprising a Patient-Tubing system coupled with an outlet of a gas delivery system for conveying gas to a patient during gas-supplemented inhalations; a flow sensor coupled with said outlet for sensing the gas flow, a Patient-Tubing system pressure sensor coupled with said Patient-Tubing system for sensing gas pressure therein and providing Patient-Tubing system pressure signals representative thereof; a processor coupled with said sensors and operable for receiving said pressure signals therefrom, said processor operable to determine, using said received pressure signals. The method comprises the step of obtaining in one sample pressure information from the flow sensor. The step of obtaining, in the one sample, pressure information from said Patient-Tubing system pressure sensor. And the step of calculating for the one sample, based on the information from said flow sensor and pressure information from said Patient-Tubing system pressure sensor, the amount of gas needed to compensate for gas lost in pressurization of the Patient-Tubing system and gas lost in interface between Patient-Tubing system and patient. Thereby the system is able to determine a new flow target for the flow controller, so as to deliver a compensated amount of gas.

(45) In general terms the method for compensation comprises at least the steps of calculating or estimating the gas losses in the Patient-Tubing using measurements or estimation of the pressure(s) in the Patient-Tubing system, at the appropriate places as described elsewhere in the text. On each sample or control interval, the method comprises computation of the new flow target for the flow controller (i.e. Qv(n)). Further, the method comprises the step of controlling the gas flow, using the flow sensor internal to the ventilator, so that the new target is achieved.

(46) The steps of the method may be repeated so as to create a control loop for a system monitoring and controlling a breath delivery system. Further steps may be performed in relation to the method as described elsewhere.

(47) FIG. 13 schematically illustrates parts of a system according to the present invention. The system comprises a Patient-Tubing system coupled with an outlet of a gas delivery system for conveying gas to a patient during gas-supplemented inhalations. A flow sensor is coupled with the outlet for sensing the gas flow. A Patient-Tubing system pressure sensor is coupled with the Patient-Tubing system for sensing gas pressure therein and providing Patient-Tubing system pressure signals representative thereof. A processor is coupled with the sensors and operable for receiving the signals therefrom. The processor is operable in one sample, to obtain flow information from the flow sensor, and the processor is arranged for obtaining, in the one sample, pressure information from the Patient-Tubing system pressure sensor. Thereby the processor is able to, in one sample, to calculate, based on the flow information from the flow sensor and pressure information from the Patient-Tubing system pressure sensor, the amount of gas needed to compensate for gas lost in pressurization of the Patient-Tubing system and gas lost in interface between Patient-Tubing system and patient so as to obtain the above mentioned advantages.

(48) While the invention has been illustrated and described in detail in the drawings and foregoing description, such illustration and description are to be considered illustrative or exemplary and not restrictive; the invention is not limited to the disclosed embodiments. Other variations to the disclosed embodiments can be understood and effected by those skilled in the art in practicing the claimed invention, from a study of the drawings, the disclosure, and the appended claims. In the claims, the word comprising does not exclude other elements or steps, and the indefinite article a or an does not exclude a plurality. A single processor or other unit may fulfill the functions of several items recited in the claims. The mere fact that certain measures are recited in mutually different dependent claims does not indicate that a combination of these measures cannot be used to advantage. A computer program may be stored/distributed on a suitable medium, such as an optical storage medium or a solid-state medium supplied together with or as part of other hardware, but may also be distributed in other forms, such as via the Internet or other wired or wireless telecommunication systems. Any reference signs in the claims should not be construed as limiting the scope.