A presente tese explora aspectos importantes do suporte nutricional, no paciente crítico: método e vias de administração da nutrição enteral, determinação do gasto energético, monitorização da adequação do suporte nutricional e seu efeito sobre os desfechos em curto e longo prazo. Em face da evidência de benefícios significativos, a nutrição enteral é recomendada como a primeira opção para a maioria dos pacientes, quando comparada à nutrição parenteral. É comum a intolerância gástrica associada ao uso de opióides, choque e vasopressores, o que reduz a entrega de energia e talvez aumente a incidência de pneumonia hospitalar. A subalimentação parece estar associada com consequências indesejáveis, que incluem o risco aumentado de infecção, o desmame da ventilação prolongada, o tempo de internação na UTI e as taxas elevadas de mortalidade, na UTI e no hospital. A determinação do gasto energético é alvo de debates, pois vários são os fatores que influenciam diretamente o gasto energético do paciente crítico. O método calorimetria indireta é apontado como o mais preciso para adequar o suporte nutricional, quando comparado com as equações preditivas. Vale destacar, porém, que ainda é necessária maior evidência clínica sobre a real influência da calorimetria indireta nos desfechos clínicos (Tempo em VM, tempo de UTI e mortalidade em UTI, mortalidade hospitalar). Os estudos avaliam os desfechos clínicos mais relevantes, em curto prazo, e há uma escassez de estudos que avaliam a qualidade de vida dos sobreviventes, em médio ou longo prazo. Para a realização da tese, foram desenvolvidos três estudos, um ensaio clínico randomizado, em que foi definida a incidência de pneumonia e avaliada a taxa de mortalidade na UTI, comparando a nutrição por sonda gástrica com a por sonda jejunal. Não encontramos diferença na taxa de pneumonia, quando é utilizada a sonda em posição gástrica ou jejunal. Não observamos diferenças na sobrevida na UTI e hospitalar. Em nossa revisão sistemática, analisamos quatro artigos da literatura sobre paciente crítico adulto e adequação do suporte nutricional guiado pela calorimetria indireta, de 1950 a maio de 2014. Não encontramos estudos suficientes para evidenciar o impacto da utilização da calorimetria indireta, como método de adequação do suporte nutricional sobre os desfechos clínicos. Realizamos estudo observacional, onde procuramos definir as relativas contribuições da adequação nutricional maior ou igual a 70%, em relação ao previsto nas primeiras 72 horas de internação na UTI, para os desfechos clínicos em curto e longo prazo (capacidade de realizar atividades da vida diária). Os pacientes que receberam um aporte calórico igual ou superior a 70%, nas primeiras 72 horas de internação, não apresentaram melhores desfechos em curto prazo (tempo em VM, tempo de UTI e mortalidade em UTI), bem como melhora da capacidade funcional em um ano. Esta tese se justifica por buscar melhor entendimento dos principais aspectos do suporte nutricional enteral, no paciente crítico, mecanicamente ventilado e submetido à terapia intensiva. Como aspectos da terapia nutricional, destacamos a importância de investigar evidências clínicas do impacto do suporte nutricional enteral sobre desfechos clínicos. / This thesis explores important aspects of nutritional support in critically ill patients: method and routes for enteral nutrition administration; determining energy expenditure; monitoring the optimal nutritional support and its effect on short- and long-term outcomes. Given the evidence of significant benefits, enteral nutrition is recommended as the first choice for most patients compared to parenteral nutrition. Gastric intolerance associated with opioid use, shock, and vasopressors is common, which reduces energy delivery and may increase the incidence of hospital-acquired pneumonia. Malnutrition appears to be associated with undesirable consequences, including increased risk of infection; weaning from prolonged ventilation; length of stay in ICU; and high mortality rates in ICU and hospital. Determining energy expenditure is subject to debate because several factors directly influence it for critically ill patients. The method of indirect calorimetry is pointed out as the most accurate for establishing adequate nutritional support compared with predictive equations. It is worth noting, however, that more clinical evidence is needed on the real influence of indirect calorimetry on clinical outcomes (length of ventilation; length of stay in ICU and mortality in ICU; hospital mortality). The studies evaluate the most relevant clinical outcomes in the short term, and there is shortage of works assessing survivors’ quality of life in the medium or long term. Three studies were developed for the thesis: a randomized clinical trial where the incidence of pneumonia was established and the mortality rate in ICU was evaluated, comparing nutrition by gastric gavage with a jejunal probe. No difference was found in the rate of pneumonia when using the gavage in gastric or jejunal position. No differences in survival in ICU and hospital were found. In our systematic review, we analyze four articles on critically ill adult patients and optimization of nutritional support guided by indirect calorimetry, from 1950 to May 2014. We did not find enough studies to show the impact of using indirect calorimetry for optimizing nutritional support on clinical outcomes. We conducted an observational study to define the relative contributions of nutritional optimization higher or equal to 70% relative to predictions in the first 72 hours of ICU admission for clinical outcomes in the short and long term (ability to perform daily activities). Patients who received caloric intake equal to or higher than 70% in the first 72 hours of admission did not show better outcomes in the short term (time under MV, ICU stay, and ICU mortality) as well as improved functional capacity within one year. This thesis is justified for seeking to improve understanding of the key aspects of enteral nutritional support in critically ill, mechanically ventilated patients who have underwent intensive therapy. Important aspects of nutrition therapy include investigating clinical evidence of the impact of enteral nutritional support on clinical outcomes.

Introdução: O reconhecimento da importância da nutrição enteral em pacientes hospitalizados gerou novos métodos de administração, o que leva a muitas perguntas: quais são os efeitos cronobiológicos da terapia nutricional contínua ou intermitente? Objetivo: O objetivo deste estudo foi avaliar o efeito do horário de administração da nutrição enteral como Zeitgeber do ritmo biológico no gasto energético e consumo de oxigênio, mensurados por calorimetria indireta. Métodos: Ensaio clínico randomizado, realizado de dezembro de 2009 a novembro de 2010, em 34 pacientes com doença neurológica, com idade entre 52 e 80 anos, alimentados através de uma sonda nasoenteral, 15 através de infusão contínua por 24 horas/dia e 19 em quantidades comparáveis de forma intermitente, a cada 4 horas, dás 8 às 20 horas. Foram realizadas 4 medidas de calorimetria indireta nas 24 horas (A: 07:30 h, B: 10:30 h, C: 14:30 h e D :21:30 horas), durante 3 dias, para cada paciente. Resultados: A idade média foi de 69,5±8,50% eram do sexo masculino, IMC 22 ±3,9 kg/m²(homens) e 25±5,6 kg/m²(mulheres). O gasto energético e o consumo de oxigênio mostrou diferença significativa entre os grupos contínuo e intermitente: 1478±817 kcal/24h, (IC: 1249 – 1706), 1782±862 kcal/24h (IC: 1579 – 1984) (p=0.05); 212±117 ml/min (IC: 179 – 245); 257±125 ml/min (IC: 227 – 286) (p=0.048), respectivamente. No gasto energético e consumo de oxigênio diferenças estatisticamente significativas foram encontradas entre as mensurações A, B, C e D em ambos os grupos. Comparando o gasto energético e consumo de oxigênio entre os grupos por Mann-Whitney, houve uma diferença estatisticamente significativa em tempo B e C (p = < 0,01). Conclusão: Foi observado neste estudo uma variação circadiana do gasto energético e consumo de oxigênio nos dois métodos de administração da nutrição enteral, sugerindo que apenas uma medida de calorimetria indireta no dia não é capaz de mostrar a verdadeira necessidade do paciente. Observamos também que o gasto energético foi mais elevado à noite nos dois métodos de administração da alimentação. Além disso, o gasto energético e o consumo de oxigênio foi maior no método de administração intermitente em todos os tempos. / Introduction: The importance of enteral nutrition has grown in recognition resulting in new methods of administration. That leads to many questions such as: what are the chronobiologic effects of continuous or intermittent nutrition therapy? Objectives: The aim of this study was to evaluate the use of enteral nutrition as a Zeitgeber of biological rhythm. Energy expenditure and oxygen consumption were measured by indirect calorimetry in continuous or intermittent nutrition patterns. Methods: A randomized clinical trial was conducted from December 2009 to November 2010. Thirty four neurological patients received through the same kind of calibrated nasogastric tube the standard protein and energy intakes calculated for each subject, 15 through continuous infusion for 24 hours/day and 19 intermittently in comparable quantities, every 4 hours, from 8:00 to 20:00 h. Four indirect calorimetry measures were carried out during the 24 hours (A: 07:30h, B: 10:30h, C: 14:30h and D: 21:30h), for 3 days, for each patient. Results: The mean age was 69.5±8, 50% were male; BMI 22±3.9kg/m² (men), 25±5.6 kg/m² (women). Energy expenditure end oxygen consumption presented a significant difference between the continuous and intermittent groups (1478±817 kcal/24h, (CI: 1249 – 1706), 1782±862kcal/24h (CI: 1579 – 1984) (p=0.05); 212±117 ml/min (CI: 179 – 245); 257±125 ml/min (CI: 227 – 286) (p= 0.048), respectively). In the energy expenditure and oxygen consumption, statistically significant differences were found between the A, B, C and D measures in both groups. By comparing the energy expenditure and the oxygen consumption between the groups by the Mann-Whitney test a statistically significant difference was observed for times B and C (p=< 0.01). Conclusion: A circadian variation of energy expenditure and oxygen consumption was observed in both enteral nutrition administration methods used in this work, suggesting that only one indirect calorimetry measure per day is not able to show the patient’s true needs. It was also observed that the energy expenditure was higher at night in both food administration methods. Moreover, the energy expenditure and oxygen consumption was higher in the intermittent administration method in all times.

Plusieurs études ont montré que certaines kinases situées dans le foie, « mammalian target of rapamycin » (mTOR), « adenosine monophosphate-activated protein kinase » (AMPK) et « general control non-depressible kinase 2 » (GCN2) répondent à la disponibilité en acides aminés.L’objectif de nos études a été de préciser le rôle de deux de ces voies, l’AMPK et GCN2, dans les adaptations du métabolisme énergétique et de la synthèse protéique en réponse aux variations en protéines du régime. Pour cela, des souris de type sauvage et des souris KO n’exprimant plus la voie AMPK ou GCN2 dans le foie ont été nourries pendant trois semaines avec un régime faible, normal ou fort en protéines. Les analyses ont montré que les souris KO-AMPK foie spécifique et nourries sous régime normoprotéique adaptent leur métabolisme hépatique notamment en sécrétant le facteur fibroblastique FGF21 ce qui leur permet de compenser l’absence d’AMPK et de présenter des profils d’oxydation normaux.Au contraire, les souris KO-AMPK foie spécifique nourries avec des régimes faibles ou forts en protéines présentent des altérations des profils d’oxydation des lipides et des glucides liées à une absence de modification du métabolisme hépatique.La délétion de GCN2 dans le foie, quant à elle, n’a d’effet que sous régime faible en protéines : les souris KO-GCN2 foie spécifique présentent une plus faible oxydation lipidique et une plus forte oxydation glucidique que les souris sauvages en période postprandiale dû à l’absence d’induction de la sécrétion de FGF21.Concernant le métabolisme des protéines, les kinases GCN2 et AMPK ne semblent pas impliquées dans l’intensité du flux de synthèse protéique dans le foie et en périphérie dans le muscle en période postprandiale.En conclusion, ces travaux montrent que les délétions de l’AMPK et de GCN2 hépatiques affectent le métabolisme énergétique mais pas le métabolisme protéique et que les conséquences dépendent de la composition du régime. / Several studies have reported that some kinases located in the liver respond to the availability of amino acids. These kinases are mammalian target of rapamycin '(mTOR), "adenosine monophosphate-activated protein kinase" (AMPK) and "general control non-depressible kinase 2" (GCN2).The aim of our study was to clarify the role of two of these signaling pathways, AMPK and GCN2 in the adaptations of energy and protein metabolism in response to the modulation of dietary protein content. Wild-type and liver AMPK-deficient or liver GCN2-deficient mice were fed either a low, a normal or high protein diet during three weeks. Analyzes showed that liver AMPK-deficient mice fed under a normo-protein diet exhibit an adapatation of liver metabolism and secret FGF21 which enables them to have normal postprandial oxidation profiles.In contrast, liver AMPK-deficient mice fed a low or a high protein diet exhibit an alteration in postprandial oxidation profiles. The deletion of GCN2 in the liver only has an effect under low protein diet as liver GCN2 deficient mice have a lower lipid oxidation and a higher carbohydrate oxidation linked to the absence of FGF21 secretion. Concerning protein metabolism, AMPK and GCN2 do not seem to be involved in protein synthesis rate in the posrprandial period in the liver and periphery in the postprandial muscle. In conclusion, these studies show that hepatic AMPK and GCN2 deletions affect energy metabolism, but not protein metabolism and that the consequences depend on diet composition.

Introduction: Indirect calorimetry (IC) is a very accurate and non-invasive method which is used in clinical practice to measure the resting metabolic rate. This method is based on the assumption that oxygen consumption, carbon dioxide production and nitrogen metabolite waste are in definite relation to energy consumption. Based on the measurement of resting metabolic rate, a nutritional therapist can individually determine daily energy intake of a respective individual, the optimal amount of specific nutrients and thus prevents excessive or inadequate intake of energy and nutrients. Objective: The main aim of this thesis is to compare for group of overweight patients the results of the measurement of the resting metabolic rate (RMR), values of the resting metabolic rate calculated according to the Harris-Benedict (HB) equation and the actual energy intake calculated from the diet report obtained from the patients. In addition, the body composition of the examined group with a focus on the amount of muscle tissue is also marginally evaluated. Methods: The research sample includes in total 50 persons-36 women and 14 men. These persons are patients of the General Faculty Hospital in Prague. The average age is 46 years for women and 51 years for men. The average BMI for women is 38,2 kg/m2 and for men...

Huntington's disease is a dominantly-inherited autosomal neurodegenerative disease manifested by disorders of motility, cognitive function, behaviour, and weight loss, which is conditioned multifactorially. The aim of the study was to determine whether there are eating disorders in Huntington's disease, as well as its etiology and severity. Neurological scaling, anthropometric examinations, evaluation of three-day diet records, measurements with a manual dynamometer, bioimpedance analyses, indirect colorimetry and predictions of energy expenditure were performed on 10 patients. Algorithms were applied for the diagnosis of sarcopenia and malnutrition. Unwanted weight loss was observed in all patients and 4 out of 10 showed malnutrition. No difference was found between the values of measured resting metabolism and calculated according to the predictive equation. However, it has been shown that strict nutritional recommendations based on this data can be misleading for some patients with HN, as real energy consumption can be significantly higher. All our patients had a positive energy balance. A new diagnostic algorithm for the early diagnosis of sarcopenia has proven its worth. Using bioimpedance analysis and examination of the force of the handshake, we identified possible sarcopenia and already-present...

Aims: The aim of this work was to determine whether a increased resting energy expenditure contributes to the nutritional risk for patients with pancreatic cancer. What the variability of resting energy expenditure is and whether it predicts weight loss. Another aim was to verify that lower protein-energy intake also has an impact on weight loss. Methods: Data for the diploma thesis were obtained from the project "Pancreatic Cancer: Metabolic Derangements Associated With Insulin Resistance", which takes place at the Department of Clinical Physiology of Metabolism at 2nd Department of internal medicine in the University Hospital Královské Vinohrady. The project includes 40 - 50 patients with pancreatic tumor resection per year. Data were collected from the beginning of December 2019 until the end of April 2020. The project is funded by the grant AZV NV19-01-00101. 10 consecutive patients (4 women and 6 men) with pancreatic cancer who had a complete dataset for analysis were selected for the research set for the diploma thesis. The patients underwent anthropometric examination, blood tests were taken, and indirect calorimetry was performed. Results: The first part of the research was focused on anthropometric parameters, parameters of nutritional status and the presence of cancer cachexia. The second...

Bakgrund: Aerob kapacitet är en viktig fysiologisk egenskap och kan mätas genom maximala- och submaximala tester. Ekblom-Bak testet (EB-testet) är ett submaximalt cykeltest medan Cooper 12 min test (CRT-12) är ett maximalt test, men dem båda uppskattar maximal syreupptagningsförmåga (VO2max) genom matematiska formler. Det finns fördelar med estimerade tester i idrottsvärlden, men tillförlitligheten varierar. Syftet var att undersöka validiteten av EB-testet och CRT-12 genom kriterievaliditet för ett urval av uthållighetsidrottare. Vidare syftar studien till att undersöka om det sker en eventuell över- eller underestimering av EB-testresultat och av CRT-12 testresultat. Metod: De rekryterade studiedeltagarna var åtta uthållighetsidrottare inom olika uthållighetsidrotter. Studien bestod av två testtillfällen. Vid första testtillfället genomfördes EB-test och ett VO2max test. Under andra testtillfället genomförde CRT-12. Uppmätt relativt syreupptag ställdes mot estimerade värden genom Bland-Altman analys och Interklass korrelation koefficient (ICC). Resultat: EB-testet hade måttlig överensstämmelse med ICC värde av 0,57. CRT-12 hade god överensstämmelse med ICC värde av 0,75. Både mätmetoderna överestimerade resultat vid jämförelse mot kriteriemetoden.  Konklusion: För studiens urval ansågs CRT-12 ge mer tillförlitliga resultat än EB-testet. För att kunna möjliggöra generalisering av resultatet behövs vidare forskning med en större urvalsgrupp av studiedeltagare. / Background: Aerobic capacity is a physiological component which can be measured through maximal- and submaximal tests. The Ekblom-Bak test (EB-test) is a submaximal cycle test whereas Cooper 12 min run test (CRT-12) is a maximal test, but they both estimate maximal oxygen consumption (VO2max) through mathematical formulas. There are advantages of estimated testing methods in the sports world, but reliability varies. The study aims to investigate the validity of the EB-test and the CRT-12 through criterion validity for a sample of endurance athletes. Further the study aims to investigate if there occurs an over- or under estimation of the EB-test results and of the CRT-12 results. Method: The recruited participants where eight endurance athletes from various sports. The study consisted of two test occasions. The first occasion consisted of the EB-test and the VO2max test. The second occasion consisted of the CRT-12. Measured relative oxygen consumption was opposed to the estimated values through a Bland-Altman plot and a interclass corelation coefficient (ICC). Results: The Ekblom-bak test was seen to have moderate agreement with an ICC of 0,57. The cooper 12 min run test was seen to have good agreement with an ICC of 0,75. Both tests overestimated the results when compared to the criterion method. Conclusion: For the population of the study, it was seen that CRT-12 is more reliable than the EB-test. To be able to generalise the results there is a need for further research with a larger study population.

Avaliar acuradamente o gasto energético de repouso (GER) é de extrema importância no suporte nutricional e a análise de composição corporal influencia seu valor. O estudo teve como objetivos desenvolver equações preditivas de GER por meio de dados de composição corporal obtidos por exame de bioimpedância eléctrica multifrequencial por espectroscopia (BIS); avaliar a adequação das fórmulas mais usuais de predição do GER; medir a correlação dos parâmetros gerados por BIS com o GER, analisar a concordância e a correlação dos dados gerados pelos aparelhos de bioimpedância de frequência simples (BIA) e BIS, além da concordância entre os métodos de classificação do estado nutricional por Índice de Massa Corporal (IMC) e por %MG (Porcentual de Massa Gorda) avaliada por BIA e BIS. Caracterizou-se como um estudo transversal observacional desenvolvido com brasileiros saudáveis, ambos os sexos, entre 20 e 40 anos de idade, estratificados em subgrupos pelo IMC (subnutrido, n=40; eutrófico, n=120; com sobrepeso, n=118 e com obesidade, n=114) e pelo %MG (baixa gordura, n=17; gordura adequada, n=101; excesso de gordura, n=91 e obesidade, n=183). O GER foi medido por calorimetria indireta (CI). Houve emprego do teste de correlação de Spearman e de Pearson e do gráfico de dispersão para avaliar as associações entre as variáveis e de modelos de regressão linear múltipla no desenvolvimento das equações, por método Stepwise. Aplicou-se o teste de BlandAltman, o coeficiente de correlação intraclasse, o teste de Wilcoxon e o coeficiente de correlação kappa para análise de concordância entre medidas e classificações e o teste de Mann-Whitney e Kruskal-Wallis para comparação entre os subgrupos (p<0,05). O GER predito foi considerado adequado quando se encontrou entre 90 e 110% do GER medido por CI. Desenvolveu-se uma equação para a amostra total por sexo e uma para cada categoria do IMC e do %MG e as mesmas apresentaram baixos valores de coeficientes de determinação (R2). As maiores correlações entre as variáveis independentes com o GER ocorreram para o peso, IMC, Massa Gorda7 (MG) e Massa de Tecido Adiposo. Todas as equações usuais avaliadas não foram capazes de predizer corretamente o GER em metade da amostra. As classificações do estado nutricional realizadas por meio do IMC e %MGBIA obtiveram concordância fraca com aquela por %MGBIS. A concordância entre BIA e BIS foi baixa: tecidos corporais de maior hidratação foram superestimados e os menos hidratados subestimados, por BIA frente a BIS, e os vieses entre os dois equipamentos foram maiores com o aumento do IMC. Assim, as equações desenvolvidas apresentaram baixo R2, impossibilitando sua aplicação no cenário clínico. Já as equações de predição do GER avaliadas exibiram baixa adequação, não se recomendando seu uso. A classificação do estado nutricional por meio do IMC subestima as quantidades de MG, sendo mais adequada a utilização de composição corporal para caracterização nutricional. BIA e BIS geram resultados distintos: o tamanho corporal aparece como um fator de confusão na distinção das massas corporais analisadas, mas, a distribuição e a quantidade de água corporal total apresentam-se como fatores limitantes de maior força / The accurate assessment of resting energy expenditure (REE) is extremely important in nutritional support for energy supply adjustment and body composition analysis plays a significant role in determining its value. The objectives of this thesis was to develop prediction equations of REE using body composition assessment data by bioelectrical impedance; assess the adequacy of the more usual prediction equations of REE against the measured value; measuring the correlation of the parameters generated by multifrequency spectroscopy bioelectrical impedance (BIS) in GER and analyze the agreement and correlation of data generated by bioelectrical impedance devices of simple frequency (BIA) and (BIS), in total sample and between subgroups stratified by body mass index (BMI) and body fat percentage (%BF), in addition to assess the agreement between the classification of nutritional state by BMI and %BF generated by BIA and BIS . This was an observational cross-sectional study with healthy Brazilians, both sexes, between 20 and 40 years old, stratified into subgroups by BMI (malnourished, n=40; eutrophic, n=120; overweight, n=118 and obese, n=114) and by %BF (low fat, n=17; suitable fat, n=101; excess fat, n=91 and obesity, n=183). There was the use of anthropometric and epidemiological parameters and those generated by BIS analysis in the equations\'s development. REE was measured by indirect calorimetry (IC). Employment Spearman correlation test and scatterplot to assess the associations between the variables and multiple linear regression models in the development of the equations. Application of Bland-Altman analysis, intraclass correlation coefficient, Wilcoxon test and kappa correlation coefficient for agreement analysis between measurements and classifications and the Mann-Whitney and Kruskal-Wallis test to compare the subgroups (p <0,05). Thus, an equation was developed for the total female sample and one for each of the last three categories of BMI and% BF, the same for males. The equations obtain low values of determination coefficient (R2). The highest correlations between the independent variables with REE occurred, for both females and males, with weight, BMI, BF and9 Adipose Tissue Mass. All the usual equations evaluated had low accuracy since none was able to correctly predict GER in 50% or more of the sample, either for the whole sample or stratified by BMI and %BF. The equations with the highest percentages of the sample within the adequacy limits were Owens, Henry-Rees and Livingston-Kohlstadt 2. The worst percentages of the sample within the adequacy limits were those of Ireton-Jones, FAO/WHO/UN 2 and Frankenfield 1. The nutritional status rankings performed through BMI and %BFBIA obtained weak agreement with that by %BFBIS, tending to classify the individual one or two levels below, underestimating the presence of %BF. The agreement between BIA and BIS was low since the equipment presented different results for all the variables, either in the total sample or in the stratified subgroups. The BIA against BIS underestimated the amounts related to the BF and total body water variables and overestimated those concerning the FFM and BCM. The biases between the two equipments were greater with the increase of BMI. Thus, the developed equations have low R2, which makes it impossible to apply them in the clinical setting. The most common and predictive GER prediction equations presented low accuracy, not proving to be adequate for use in clinical practice. The classification of nutritional status through BMI results in errors that compromise the approach of nutritional therapy, underestimating the amounts of BF and its deleterious potencies, so it is more appropriate to evaluate it through body composition. BIA and BIS generate different results, and body size appears as a confounding factor in the body mass distinction analyzed by BIA, but the distribution and amount of total body water is a limiting factor of greater strength for the BIA

Introdução: O desmame ventilatório é definido como o processo de liberação do suporte ventilatório e como avaliação dessa fase é conduzido o Teste de Respiração Espontânea (TRE). Um dos mais utilizados modos de TRE é a Pressão Positiva Contínua em Vias Aéreas (CPAP), a qual se aplica uma pressão positiva contínua tanto na inspiração quanto na expiração. Contudo, junto com os modos ventilatórios pode ser utilizado a Compensação Automática do Tubo (ATC) cujo objetivo é compensar a resistência imposta pelo tubo endotraqueal. Objetivos: O principal objetivo deste estudo foi comparar o Consumo de Oxigênio (VO2) a o Gasto Energético (GE) pela calorimetria indireta (CI) durante o TRE em CPAP com e sem a ATC. Métodos: O estudo foi randomizado, controlado tipo cross-over com quarenta pacientes em nove leitos de um Centro de Terapia Intensiva de um hospital terciário universitário (Hospital das Clínicas de Ribeirão Preto Universidade de São Paulo, Brasil). Os participantes foram alocados aleatoriamente no grupo 1, no qual era iniciado o TRE em CPAP em uso da ATC e posteriormente em CPAP sem o uso da ATC, ou no grupo 2, no qual era iniciado o TRE em CPAP sem a ATC e em seguida CPAP com a utilização da ATC. Resultados: Cinco pacientes foram excluídos depois da randomização por falha durante o TRE. Dos trinta e cinco restantes a maioria foi do sexo masculino (51%). A média de idade foi de 61,4 ± 16,1 anos. A diferença de VO2 entre os TREs com ATC e sem ATC foi de -1,6 mL.Kg-1.min-1; p=0,23 e intervalo de confiança de 95%: (-4,36; 1,07). Em relação ao GE a diferença foi de -5,4 kcal/d-1; p=0,5 e intervalo de confiança de 95%: (-21,67; 10,79) durante a comparação dos TREs em CPAP com e sem ATC. Conclusão: Não foram observadas diferenças quando se comparou os valores relacionados ao VO2 e GE durante o TRE com e sem ATC. / Introduction: Weaning from mechanical ventilation is defined as the process of release of ventilatory support and how the evaluation of this phase is conducted in the spontaneous breathing test (SBT). One of the most used modes of SBT is the Continuous Positive Airway Pressure (CPAP)which applies a continuous positive pressure in both inspiration and expiration. However, together with the mechanical ventilation modes it can be used the Automatic Tube Compensation (ATC) which compensates the resistance imposed by the endotracheal tube. Objectives: The main goal of this study was to compare the Oxygen Consumption (VO2) and Resting Energy Expenditure (REE) by indirect calorimetry (IC) during the SBT in CPAP with and without ATC. Methods: The study was a prospective randomized, controlled crossover trial, that enrolled 40 patients, in a 9-bed Intensive Care Unit of a tertiary University Hospital. (Clinics Hospital of Ribeirão Preto Medical School, University of São Paulo, Brazil). Participants were randomly allocated in Group 1, in which it was started the SBT in CPAP with ATC and later on CPAP without ATC, or in Group 2, which was started the SBT on CPAP without ATC and then CPAP with ATC.Results: Five patients were excluded after randomization for failure of the SBT. The thirty-five remaining patients were most male (51%). The mean age of the sample was 61.4 ± 16.1 years. The difference of VO2 between the SBT with ATC and no ATC obtained a value of -1.6 mL.Kg-1.min-1; p = 0.23 and 95% confidence interval: (-4.36; 1.07). To analyze the difference of REE between the SBT with ATC and no ATC, it was obtained an estimated value of -5.4 kcal/d-1, p = 0.5 and 95% and confidence interval (-21.67; 10.79). Conclusions: There were no differences in the comparison of VO2 and REE during the SBT with and without ATC.

De par leur importante diversité phénotypique (10000 espèces), les oiseaux ont colonisé la plupart des niches écologiques, aussi « extrêmes » soient-elles. Les zones polaires (Arctique et Antarctiques) et le climat extrêmement froid qui les aractérise, suscitent l’intérêt de nombreuses études. Ce travail de thèse avait pour but d’explorer les différents mécanismes intervenant dans la mise en place de la thermorégulation chez l’oiseau. Nous nous sommes principalement intéressés, par une approche intégrative, de l’animal entier (méthodes de calorimétrie indirecte) à l’expression génique (techniques de RT-PCR), à caractériser les modifications métaboliques et l’implication d’une protéine découplante (avUCP) dans les mécanismes de thermorégulation, et principalement la thermogenèse sans frisson (NST) en réponse à une exposition chronique au froid.Au cours de deux études menées chez le caneton de Barbarie, nous avons démontré l’aspect « adaptatif » de la NST ainsi que l’implication potentielle de l’UCP aviaire dans ce mécanisme en faisant varier tout d’abord la température d’acclimatation puis la durée d’exposition pour caractériser la mise en place de la NST au cours de la croissance. Lors d’une troisième étude, nous nous sommes intéressés à une étape clé de la vie des manchots royaux (passage en mer) caractérisée par un stress thermique important et une activité physique accrue dus aux longs séjours en eau froide. Ce contexte environnemental et physiologique entraine nécessairement des adaptations métaboliques, comme la mise en place d’un métabolisme lipidique efficace soutenant ainsi les dépenses énergétiques accrues lors des voyages en mer. / Because of their huge phenotypic diversity (10,000 species), birds were able to colonize many “extreme” ecological niches. Many studies have been focus on the polar areas (i.e. Arctic and Antarctica) with their typical cold climate. The aim of this work was to explore the onset of thermoregulatory mechanisms in birds. Using an integrative approach, from whole animal (indirect calorimetry) to gene expression (RT-PCR analysis), we investigated metabolic adaptations and avian uncoupling protein implication in non shivering thermogenesis (NST) during chronic cold exposure. In two studies, working on Muscovy ducklings, we have highlighted the “adaptative” aspect of NST and potential implication of avUCP in this mechanism in relation to different ambient temperatures of acclimation and to cold exposure duration.In a third study, we were interested by passage from shore to marine life of King Penguins that represents a key step of their life. This is defined by massive cold stress (cold water) and increase of physical activity (long-time swimming), leading great metabolic adaptations, such as an increase of lipid oxidative capacities which would sustain expensive energetic cost of marine life.