Made available in DSpace on 2015-04-14T13:20:38Z (GMT). No. of bitstreams: 1 462123.pdf: 2355690 bytes, checksum: da3bab7a666aea50975fb9b2a3689298 (MD5) Previous issue date: 2014-08-12 / The central theme of this study is to analyze the implementation of Reference Centres for Social Assistance (CRAS) in the town of Crickhowell, with a view to assessing Protective Services and Full Service Family (PAIF), the discussion of social assistance category is necessary, family and territory. It discusses the historical percussion of social welfare policy. It discusses the historical process of social assistance policy, highlighting some periods, such as the Federal Constitution of Brazil in 1988, the Organic Law of Social Assistance (LOAS) in 1993, until the term of the National Policy for Social Assistance establishing the System single Social Assistance (ITS) in 2004. Soon we discussed families, territory, Protective Services for Comprehensive Care of Family (PAIF), and the dilemmas and possibilities in strategies to work with families from the territory as a space for participation, but also of contradiction and following with a brief presentation of the diagnosis in the town of Crickhowell and then analyzing the results. This study constituted a qualitative exploratory research, anchored in the deductive method. The research is subject four coordinators Reference Centres for Social Assistance and the municipal manager of social welfare policy, addressed through recorded interviews and forms. The content analysis is based upon the study of Moraes (2007). The survey results point to a weakness in the materialization of social assistance rights in the territories of CRAS, as well as regarding the implementation, extreme weaknesses in contractual relationships, single statement of policy, human resources, continuing education of workers, ineffectiveness forward demands, turnover professional, technical and political weakness in the framework of the professionals as well as limits on the break and possibilities of conservative welfare arsenal, this historically in social welfare policy. The considerations of this study indicate difficulties and limitations in the management of CRAS front and the demand in the territories, on the other hand, technical direction and weakened the political materialization of working with families through Protective Services and Full Service Family (PAIF). / O tema central do presente estudo ? analisar a implementa??o dos Centros de Refer?ncia de Assist?ncia Social (CRAS) no munic?pio de Crici?ma, com vistas a avaliar o Servi?o de Prote??o e Atendimento Integral ? Fam?lia (PAIF), sendo necess?ria a discuss?o da categoria assist?ncia social, fam?lia e territ?rio. Discute-se a processo hist?rico da pol?tica de assist?ncia social, destacando alguns per?odos, como da Constitui??o da Rep?blica Federativa do Brasil em 1988, a Lei Org?nica de Assist?ncia Social (LOAS) em 1993, at? a vig?ncia da Pol?tica Nacional de Assist?ncia Social que institui o Sistema ?nico de Assist?ncia Social (SUAS) em 2004. Dialogamos sobre fam?lia, territ?rio, o Servi?o de Prote??o e Atendimento Integral ? Fam?lia (PAIF), os dilemas e possibilidades nas estrat?gias de trabalho com fam?lias a partir do territ?rio como espa?o de participa??o, mas tamb?m de contradi??o e seguindo com breve apresenta??o do diagn?stico no munic?pio de Crici?ma e posteriormente a an?lise dos resultados. Este estudo se constituiu numa pesquisa qualitativa de car?ter explorat?rio, ancorada no m?todo dedutivo. A pesquisa tem como sujeitos quatro coordenadores de Centros de Refer?ncia de Assist?ncia Social e o gestor municipal da pol?tica de assist?ncia social, abordados atrav?s de entrevistas gravadas e formul?rios. A an?lise ? a de conte?do, baseada no estudo de Moraes (2007). Os resultados da pesquisa apontam para uma fragilidade na materializa??o dos direitos socioassistenciais nos territ?rios de CRAS, bem como em rela??o ? implementa??o, extremas fragilidades nas rela??es contratuais, comando ?nico da pol?tica, recursos humanos, educa??o permanente dos trabalhadores, inoper?ncia frente ?s demandas, rotatividade profissional, fragilidade no arcabou?o t?cnico e politico dos profissionais, bem como limites nas possibilidades ruptura do arsenal conservador e assistencialista, presente historicamente na pol?tica de assist?ncia social. As considera??es deste estudo apontam dificuldades e limita??es na gest?o do CRAS e frente ?s demanda nos territ?rios, por outro lado, direcionamento t?cnico e pol?tico fragilizado na materializa??o do trabalho com fam?lias atrav?s do Servi?o de Prote??o e Atendimento Integral ? Fam?lia (PAIF).

Made available in DSpace on 2015-04-14T13:20:42Z (GMT). No. of bitstreams: 1 389780.pdf: 1147951 bytes, checksum: d86c152a8c7b38e6de390ca11b1de4b4 (MD5) Previous issue date: 2007-03-08 / O presente estudo versa sobre o trabalho do assistente social no contradit?rio espa?o s?cio-ocupacional do Programa Sa?de da Fam?lia. Problematiza como o assistente social desenvolve seu processo de trabalho nos PSFs da regi?o Norte do estado do Rio Grande do Sul, mais especificamente, nos munic?pios que comp?em a 6? Coordenadoria de Sa?de do Estado. Para tanto, realizou-se uma pesquisa qualitativa com o estudo explorat?rio na regi?o, orientada pelo m?todo dial?tico-cr?tico. A contextualiza??o do tema passa pelos principais marcos hist?ricos da pol?tica de sa?de brasileira at? chegar ao PSF como estrat?gia da Pol?tica Nacional de Aten??o B?sica para reordenar o modelo de sa?de, sendo prioritariamente a porta de entrada no Sistema ?nico de Sa?de. O tema de investiga??o ? relevante para o Servi?o Social no sentido de que, embora ainda n?o componha a equipe b?sica do Minist?rio da Sa?de, com a expans?o dos PSFs em todo o Brasil tem-se inclu?do o assistente social entre os profissionais que trabalham no programa. A pesquisa procura desvendar as contradi??es desse espa?o, mostrando como de fato se efetiva o processo de trabalho do assistente social, apontando para as contribui??es profissionais para esse programa e sua equipe b?sica. As an?lises do estudo direcionam para os limites e possibilidades vivenciadas pelos assistentes sociais no PSF e que s?o indissoci?veis do processo de reestrutura??o produtiva e as transforma??es no mundo do trabalho. Contudo, o Servi?o Social, enquanto profiss?o inserida na divis?o sociot?cnica do trabalho, ? demandado a responder ?s refra??es da quest?o social e a desenvolver compet?ncias para atuar na gest?o, formula??o e planejamento das pol?ticas sociais. Assim, potencializando o projeto ?tico-pol?tico, que se rege pelo princ?pio da emancipa??o dos sujeitos, refor?am-se princ?pios democr?ticos, na perspectiva da garantia de direitos, defendidos na Reforma Sanit?ria, SUS e pela profiss?o

Apesar dos crescentes avanços no controle e tratamento da insuficiência cardíaca, sejam eles na área clinica ou cirúrgica, o tratamento definitivo permanece sendo o transplante cardíaco. No entanto, o transplante cardíaco tem enfrentado o grave problema da escassez de doadores. Atualmente, estima-se que entre 20% e 40% dos pacientes selecionados falecem na fila de espera em todo o mundo sendo que a maioria, por falência circulatória progressiva. Para esses pacientes, a utilização de dispositivos de assistência circulatória mecânica é, muitas vezes, a única possibilidade de sobrevivência durante a espera do doador. No Brasil, a experiência com o emprego de métodos de assistência circulatória mecânica no tratamento do choque cardiogênico é pequena. Paralelamente, a expectativa de vida dos pacientes nesta situação, em particular os de etiologia chagásica, é muito limitada, e nenhum programa regular foi ainda introduzido com a finalidade de utilizar estes dispositivos no tratamento do choque cardiogênico refratário, especialmente como ponte para o transplante cardíaco. Objetivos: O objetivo deste estudo é determinar a viabilidade e segurança do implante do DAV-InCor como ponte para o transplante cardíaco, avaliando o seu desempenho hemodinâmico, a evolução clínica e as alterações da resposta inflamatória dos pacientes submetidos a este procedimento. Métodos: Este estudo foi realizado em pacientes que estavam na fila de espera para o transplante cardíaco, no período de outubro de 2003 a abril de 2006, e se apresentavam em quadro clínico de choque cardiogênico refratário. Durante os primeiros dias, foram analisadas as medidas de pressão capilar pulmonar (PCP), pressão de artéria pulmonar (PAP), pressão venosa central (PVC), débito cardíaco e índice cardíaco (IC). O cálculo do fluxo indexado era obtido pela divisão entre o fluxo do dispositivo pela superfície corpórea. Durante o seguimento pós-operatório imediato, a saturação venosa central de oxigênio (SVO2), os níveis de lactato sérico, uréia, creatinina, bilirrubinas e desidrogenase lática foram dosados diariamente. Os níveis séricos do peptídeo natriurético central (BNP), das interleucinas (IL6 e IL8), do fator de necrose tumoral alfa (TNF alfa) e da proteína C reativa (PCR) foram dosados nos três primeiros dias de seguimento e posteriormente a cada semana. Resultados: No período do estudo, 29 pacientes foram indicados em caráter de prioridade para o transplante cardíaco. Destes pacientes, 11 evoluíram em choque cardiogênico refratário à terapêutica farmacológica e ao implante de balão intra-aórtico. O implante do DAV-Incor foi realizado em sete destes pacientes. O diagnóstico etiológico foi cardiopatia chagásica em cinco (71%) e cardiomiopatia dilatada idiopática em dois (29%) dos sete pacientes estudados. Cinco pacientes eram do sexo masculino. A idade variou entre 34 e 54 anos (média de 39,5 anos). A assistência circulatória mecânica ao ventrículo esquerdo foi mantida nos 7 pacientes por períodos que variaram de 14 a 42 dias, com média de 26,2 dias. Neste período, o desempenho hemodinâmico foi adequado, sendo observada a normalização do índice cardíaco, das pressões em território pulmonar, da SVO2 e do lactato sérico. A avaliação da resposta inflamatória sistêmica demonstrou a elevação do TNF e das interleucinas, principalmente nos pacientes que evoluíram com alterações infecciosas. O transplante cardíaco foi realizado em 2 pacientes e os outros 5 faleceram em uso do DAV Incor por infecção sistêmica ou falência de múltiplos órgãos. Não ocorreram complicações relacionadas ao DAV em 6 pacientes nos primeiros 30 dias de seguimento. Um paciente apresentou episódio de acidente vascular cerebral extenso aos 26 dias de pós-operatório. Conclusões: Os resultados deste estudo demonstram que, apesar do alto índice de complicações apresentado pelos pacientes, a assistência circulatória mecânica ao ventrículo esquerdo pode ser realizada como ponte para transplante cardíaco em nosso meio. / Cardiac transplantation faces a serious problem of lack of donation. Between 20 and 40% of the listed patients died while waiting for heart transplantation, most of them because of progressive heart failure. For these patients, the use of mechanical circulatory assist devices is the only choice of surviving during that time. In Brazil, the experience with mechanical circulatory support is limited and there is no regular program of the use of these devices as bridge to heart transplantation. Objectives: To evaluate the hemodynamic performance and the systemic inflammatory response during the clinical application of the ventricular assist device type InCor (DAV-InCor) as bridge to heart transplantation. Methods: Between October 2003 and April 2006, 11 patients on the waiting list for heart transplantation have hemodynamic deterioration to refractory cardiogenic shock. Hemodinamic profile (cardiac index, capilar pressure, pulmonary artery pressure and central venous pressure) was analised during early post-operative days. Serum levels of central venous saturation, lactate, urea, creatinin, bilirrubin and lacti desidrogenase were measured every day Blood drawn from patients for 3 days and once a week was assayed for levels of BNP, interleukin 6, interleukin 8, and tumor necrosis factor-alfa. Results: During the study, 11 patients listed for cardiac transplantation as urgent status have deteriorated to refractory cardiogenic shock. Seven of these patients were submitted to DAV-InCor implantation for left ventricular assistance. The etiologic diagnosis was Chagas\' disease in 5 patients (71%) and idiopathic dilated cardiomyopathy in 2 (29%). There were 5 male and 2 female. The age ranged from 34 and 54 years (mean 39,5). Duration of left ventricular assistance ranged from 14 to 42 days (mean 26.2 days). During this period, the hemodynamic performance of the DAV-InCor was adequate to support a normal hemodynamic condition. There was normalization of cardiac index, central venous oxygen saturation and serum lactate. The systemic inflammatory response showed elevated TNF-alfa, Interleukin-6 and interleukin-8 concentrations. Two patients were submitted to heart transplantation, while the other 5 patients died under assistance due to infection and multiple organ failure. There were no complications related to the device in 6 patients. One patient had a stroke by the 26st day Conclusions: Mechanical circulatory support can be performed as bridge to heart transplantation with the DAV-InCor, in spite of the high incidence of complications.

Les pathologies respiratoires obstructives de l’enfant (asthme et broncho-alvéolites) sont l’une des principales causes d’admission en réanimation pédiatrique. Depuis plusieurs années, des progrès ont été faits pour réduire l’invasivité des soins se traduisant par une réduction de la morbidité. L’objectif de ce travail de thèse est de s’appuyer sur des mécanismes physiopathologiques pour proposer des stratégies d’optimisation ventilatoire et non ventilatoire chez ces enfants. Nous avons évalué l’impact du décubitus ventral couplé à la ventilation non invasive chez les nourrissons atteints de bronchiolite grave. Le décubitus ventral permet de réduire significativement l’effort inspiratoire et d’améliorer le couplage électromécanique du diaphragme. Ensuite nous avons évalué la « neurally adjusted ventilatory assist » (NAVA) qui est un mode ventilatoire proportionnel basé sur l’activité électrique du diaphragme. Nous avons démontré que la NAVA améliorait la synchronisation patient-respirateur et réduisait le travail respiratoire en comparaison à la « nasal continuous positive airway pressure » (nCPAP). Enfin, dans la pathologie asthmatique nous avons également décrit la faisabilité du haut débit nasal dans cette population. Ces stratégies nécessitent maintenant d’être validées sur des critères cliniques et feront l’objet de deux études multicentriques randomisées / Obstructive lung disease in children (asthma and bronchiolitis) are one of the main causes of admission to pediatric intensive care units. For several years, progress has been made to reduce the invasiveness of care resulting in a decrease in associated morbidity. The main objective of the thesis was to propose new ventilatory and non-ventilatory strategies based on physiopathology to optimize the care of such children.In children with severe bronchiolitis we evaluated the impact of prone position associated with non-invasive ventilation. The prone position decreases significantly the inspiratory work of breathing and improves the neuromechanical efficiency of the diaphragm. We also evaluated the effect of neurally adjusted ventilatory assist (NAVA) that is a proportional ventilatory mode based on the electrical activity of the diaphragm. We demonstrated that NAVA improved the patient-ventilator interactions and decrease the work of breathing in comparison with nasal continuous positive airway pressure (nCPAP). We also evaluated the feasibility of high flow nasal cannula as a respiratory support in children with severe asthma attack. These strategies need now to be validated on clinical outcomes and are the subject of two ongoing multicenter randomized trials

Made available in DSpace on 2014-12-17T15:46:24Z (GMT). No. of bitstreams: 1 EdnaraGO_DISSERT.pdf: 2758445 bytes, checksum: 9d4a800a7d52fa1d6c9987e3d49157ae (MD5) Previous issue date: 2009-12-04 / Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior / The present paper analyses the social assistance management in small cities, starting from the reality of Currais Novos City. Its main objective is to analyse the management of this politic in the context of the Nacional Sistem of Social Assistance (SUAS) through the management instruments materialized in the city: Social Assistance Plan, Budget, Management Report, Information Management, Monitorizing and Evaluation. It reveals a discrepancy between the instruments purpose and their concretude, and it identifies the main challenges in order to make them real, revealing the contradictions of such politic, through which the advances relate with the retrocesses. It remarks, in this context, the debate about Public Management and some aspects of the trajetory of the Social Assistance management in the brazilian context and the configurations of (SUAS) and of the politics in Currais Novos city. Such path allows us to identify the feebleness in the city ways to adopt the (SUAS) criteria, which is much more effective in burocratic aspects than in the change of the Social Assistance conception and in the effective incorporation of the (SUAS) principles and guidelines. Thus, problems are identified in what concerns to the important aspects for its effectivation, with the human resources, financing and social control mechanisms. It makes possible to reafirm the importance of the analysed management instruments for the effectivation of one participative and democratic management, as well as the urgency of its materialization as one of the important ellements for this politic to happen as a right and to make a stop to the unconformities between the (SUAS) determinations and its materialization / Este estudo analisa a gest?o da assist?ncia social em munic?pios de pequeno porte mais especificamente, a gest?o dessa pol?tica no contexto do Sistema ?nico de Assist?ncia Social (SUAS) por meio dos instrumentos de gest?o materializados nos munic?pios (Plano de Assist?ncia Social; Or?amento; Relat?rio de gest?o; Gest?o da Informa??o, Monitoramento e Avalia??o). Partindo da realidade da cidade de Currais Novos/RN no per?odo de 2004 a 2008, ele possibilita identificar uma disparidade entre as proposi??es dos instrumentos e a sua concretude, al?m de revelar os principais desafios postos ? sua materializa??o, expondo, assim, as contradi??es dessa pol?tica, cujos avan?os est?o em simbiose com retrocessos. Destacam-se, nesse contexto, o debate sobre gest?o p?blica, os aspectos da trajet?ria da gest?o da Assist?ncia Social no Brasil e as configura??es do Sistema ?nico de Assist?ncia Social e da gest?o dessa pol?tica em Currais Novos. O percurso realizado permite identificar as fragilidades no modo de ades?o desse munic?pio ao SUAS sistema este que se efetiva muito mais nos aspectos burocr?ticos do que na mudan?a de concep??o de assist?ncia social ou na real incorpora??o dos seus princ?pios e diretrizes ? realidade da cidade. Neste sentido, identificam-se problemas no que se refere a aspectos importantes da sua efetiva??o, com os recursos humanos, financiamento, mecanismos de controle social. O estudo permite, ainda, reafirmar a import?ncia dos instrumentos de gest?o analisados para a efetiva??o de uma gest?o democr?tica e participativa, assim como atenta para a urg?ncia da sua implementa??o como um dos elementos importantes para que essa pol?tica se realize enquanto direito e ponha fim ao descompasso entre as determina??es do SUAS e a sua materializa??o

Made available in DSpace on 2014-12-17T14:19:49Z (GMT). No. of bitstreams: 1 MarciaSPC.pdf: 1364639 bytes, checksum: ca382eed6b78eefc17ae3123ea87aeea (MD5) Previous issue date: 2009-03-31 / The current National Policy for Social Assistance (PNAS) is the instrument that regulates the organization and procedures of social-welfare actions. Developed and approved in 2004 since the Unified Social Assistance System (ITS) was crated in 2003, it reaffirms the democratic principles of the Social Assistance Organic Law (LOAS) focusing on the universalization of social rights and equality of rights when accessing the social-welfare system. In the SUAS point of view, the PNAS highlights the information, monitoring and evaluation fields for being the best way to assure the regulation, organization and control by the Federal Government paying attention to the principles of decentralization and participation. This political-institutional rearrangement occurs through the pact among all the three federal entities. The pact deals with the implementation of the task. It says that it has to be shared between the federal autonomous entities, established by dividing responsibilities. To the cities, considered as the smallest territorial unit of the federation and closer to the population, was given the primary responsibility, which is to feed and maintain the database of SUAS NETWORK and identify families living in situations of social vulnerability. In addition to these responsibilities, the cities that have full autonomy in the management of their actions, have the responsibility to organize the basic social protection and the special social protection, that using the Center of Social Assistance Reference (CRAS) and the Center of Specialized Social Assistance Reference (CREAS), are responsible for the provision of programs, projects and services that strengthen the family and community; that promote people who are able to enjoy the benefits of the Continuing benefit of Provisions (BPC) and transfer of incomes; that hold the infringed rights on its territory; that maximize the protective role of families and strengthen its users organization. In Mossor?/RN, city classified as autonomous in the social assistance management, has five units of CRAS that, for being public utilities, are considered the main units of basic social protection, since they are responsible for the connection between the other institutions that compose the network of local social protection. Also known as Family House, the CRAS, among other programs and services, offers the Integral Attention to Families Program (PAIF), Juvenile ProJovem Program, socio-educational coexistence services programs, as well as sending people to other public policies and social-welfare services network, provides information, among others. In this large field, social workers are highlighted as keys to implement the policy of social assistance within the city, followed by psychologists and educators. They should be effective public employees, as a solution to ensure that the provision of the services are to be continued, provided to the population living around the units. However, what we can find here is inattention to the standard rules of social assistance, which not only undermines the quality of programs and services, but also the consolidation of policy on welfare as public policy of social rights / A atual Pol?tica Nacional de Assist?ncia Social (PNAS) ? o instrumento que regulamenta a organiza??o e a presta??o de medidas socioassistenciais. Sistematizada e aprovada em 2004 a partir da Cria??o do Sistema ?nico da Assist?ncia Social (SUAS) em 2003, ela reafirma os princ?pios democr?ticos da Lei Org?nica da Assist?ncia Social (LOAS), com destaque para a universaliza??o e a igualdade dos direitos sociais no acesso aos atendimentos assistenciais. Na perspectiva do SUAS, a PNAS ressalta o campo da informa??o, monitoramento e avalia??o como forma de maior regula??o, organiza??o e controle por parte do Governo Federal atentando para os princ?pios da descentraliza??o e participa??o. Esse reordenamento pol?tico-institucional se d? atrav?s do pacto entre os tr?s entes federativos, em que a implementa??o da pol?tica torna-se tarefa compartilhada dos entes federados aut?nomos, estabelecido atrav?s da divis?o de responsabilidades. Ao munic?pio, considerado como menor unidade territorial da federa??o e mais pr?xima da popula??o usu?ria, cabe a responsabilidade b?sica de municiar e manter a base de dados da REDE SUAS atualizada e detectar fam?lias que vivem em situa??o de vulnerabilidade social. Para al?m dessas responsabilidades, os munic?pios que possuem total autonomia na gest?o de suas a??es, devem: organizar a prote??o social b?sica e a prote??o social especial que, atrav?s dos Centros de Refer?ncia da Assist?ncia Social (CRAS) e dos Centros de Refer?ncia Especializada da Assist?ncia Social (CREAS), s?o respons?veis pela oferta de programas, projetos e servi?os que fortale?am os v?nculos familiares e comunit?rios; promover os benefici?rios do Benef?cio de Presta??o Continuada (BPC) e transfer?ncia de renda; vigiar os direitos violados no seu territ?rio; potencializar a fun??o protetora das fam?lias e a organiza??o de seus usu?rios. Mossor?/RN, munic?pio qualificado como aut?nomo na gest?o da assist?ncia social, possui cinco CRAS que, como equipamentos p?blicos, s?o considerados as principais unidades de prote??o social b?sica, visto que s?o respons?veis pela articula??o com as demais institui??es que comp?em a rede de prote??o social local. Tamb?m conhecido como Casa da Fam?lia, o CRAS, dentre outros programas e servi?os, oferta o Programa de Aten??o Integral ?s Fam?lias (PAIF), o ProJovem Adolescente, servi?os de conviv?ncia socioeducativa, encaminhamentos para outras pol?ticas p?blicas ou rede de servi?os socioassistenciais, presta??o de informa??es, dentre outros. Neste vasto campo de atua??o, os assistentes sociais se destacam como principais agentes implementadores da pol?tica de assist?ncia social no ?mbito do munic?pio, seguidos por psic?logos e pedagogos que devem ser concursados, ou seja, servidores efetivos, como uma das formas de garantir uma presta??o de servi?o continuada ? popula??o que vive no entorno das unidades. Todavia, o que se verifica ? uma neglig?ncia para com o aparato normativo da assist?ncia social, que compromete n?o s? a qualidade dos programas e servi?os, mas tamb?m a consolida??o da pol?tica de assist?ncia social como pol?tica p?blica de direito social.

En ventilation assistée, les interactions patient-ventilateur, qui sont associés au pronostic, dépendent pour partie des algorithmes de ventilation. Objectifs : Caractériser l'intérêt potentiel des nouveaux algorithmes de ventilation dans l'optimisation des interactions patient-ventilateur : 1) en ventilation invasive, deux modes et leurs algorithmes nous ont semblé novateurs et nous avons cherché à personnaliser l'assistance du ventilateur en fonction de l'effort respiratoire du patient au cours de ces modes proportionnels : ventilation assistée proportionnelle (PAV+) et ventilation assistée neurale (NAVA) ; 2) en ventilation non-invasive (VNI) nous avons évalué si les algorithmes VNI des ventilateurs de réanimation et des ventilateurs dédiés à la VNI diminuaient l'incidence des asynchronies patient-ventilateur. Méthodes : 1) En PAV+ nous avons décrit un moyen de recalculer le pic de pression musculaire réalisée par le patient à chaque inspiration à partir du gain réglé et de la pression des voies aériennes monitorée par le respirateur. Nous avons alors évalué la faisabilité clinique d'ajuster l'assistance en ciblant un intervalle jugé normal de pression musculaire. 2) Nous avons comparé une titration de l'assistance en NAVA et en aide inspiratoire (AI) en se basant sur les indices d'effort respiratoire. 3 et 4) En VNI, nous avons évalué l'incidence des asynchronies patient-ventilateur avec et sans l'utilisation d'algorithmes VNI : sur banc d'essai au cours de conditions expérimentales reproduisant la présence de fuites autour de l'interface ; en clinique chez des patients de réanimation. Résultats : En PAV+, ajuster le gain dans le but de cibler un effort respiratoire normal était faisable, simple et souvent suffisant pour ventiler les patients depuis le sevrage de la ventilation mécanique jusqu'à l'extubation. En NAVA, l'analyse des indices d'effort respiratoire a permis de préciser les bornes d'utilisation et de comparer les interactions patient-ventilateur avec l'AI dans des intervalles d'assistance semblables. En VNI, nos données pointaient l'hétérogénéité des algorithmes VNI sur les ventilateurs de réanimation et retrouvaient une meilleure synchronisation patient-ventilateur avec l'utilisation de ventilateurs dédiés à la VNI pour des qualités de pressurisation par ailleurs identiques. Conclusions : En ventilation invasive, personnaliser l'assistance des modes proportionnels optimise les interactions patient-ventilateur et il est possible de cibler une zone d'effort respiratoire normale en PAV+. En VNI, les ventilateurs dédiés améliorent la synchronisation patient-ventilateur plus encore que les algorithmes VNI sur les ventilateurs de réanimation, dont l'efficacité varie grandement selon le ventilateur considéré. / During assisted mechanical ventilation, patient-ventilator interactions, which are associated with outcome, partly depend on ventilation algorithms.Objectives: : 1) during invasive mechanical ventilation, two modes offered real innovations and we wanted to assess whether the assistance could be customized depending on the patient's respiratory effort during proportional ventilatory modes: proportional assist ventilation with load-adjustable gain factors (PAV+) and neurally adjusted ventilator assist (NAVA); 2) during noninvasive ventilation (NIV): to assess whether NIV algorithms implemented on ICU and dedicated NIV ventilators decrease the incidence of patient-ventilator asynchrony.Methods: 1) In PAV+ we described a way to calculate the muscle pressure value from the values of both the gain adjusted by the clinician and the airway pressure. We then assessed the clinical feasibility of adjusting the gain with the goal of maintaining the muscle pressure within a normal range. 2) We compared titration of assistance between neurally adjusted ventilator assist (NAVA) and pressure support ventilation (PSV) based on respiratory effort indices. During NIV, we assessed the incidence of patient-ventilator asynchrony with and without the use of NIV algorithms: 1) using a bench model; 2) and in the clinical settings.Results: During PAV+, adjusting the gain with the goal of targeting a normal range of respiratory effort was feasible, simple, and most often sufficient to ventilate patients from the onset of partial ventilatory support until extubation. During NAVA, the analysis of respiratory effort indices allowed us to precise the boundaries within which the NAVA level should be adjusted and to compare patient-ventilator interactions with PSV within similar ranges of assistance. During NIV, our data stressed the heterogeneity of NIV algorithms implemented on ICU ventilators. We therefore reported that dedicated NIV ventilators allowed better patient-ventilator synchronization than ICU ventilators, even with their NIV algorithms engaged.Conclusions: During invasive mechanical ventilation, customizing the assistance during proportional ventilatory modes with the goal of targeting a normal range of respiratory effort optimizes patient-ventilator interactions and is feasible with PAV+. During NIV, dedicated NIV ventilators allow better patient-ventilator synchrony than ICU ventilators, even with their NIV algorithm engaged. ICU ventilators' NIV algorithms efficiency is however highly variable among ventilators.

Le contrôle de la ventilation procède d’une interaction complexe entre des efférences centrales à destination des groupes musculaires ventilatoires et des afférences ventilatoires provenant de mécano et de chémorécepteurs. Cette commande de la ventilation s’adapte en permanence aux besoins ventilatoires. L’activation électrique du diaphragme (EAdi) informe sur la commande ventilatoire, la charge des muscles respiratoires, la synchronie patient-ventilateur et l’efficacité de la ventilation des patients de réanimation. L’utilisation inadaptée d’un mode deventilation spontanée avec une sur ou sous-assistance peut entrainer des dysfonctions diaphragmatiques, des lésions alvéolaires et des asynchronies. La première étude a permis de cibler l’assistance du mode NAVA en fonction de l’EAdi enregistrée lors d’un échec de test de sevrage. Nous avons observé une augmentation quotidienne de cette EAdi au cours du sevrage jusqu’à l’extubation. La deuxième étude a montré que cette augmentation n’est pas associée à une modification de l’efficacité neuro-ventilatoire lors du test de sevrage, possiblement en rapport avec l’inhibition d’une sédation résiduelle. La troisième étude a montré l’importance de l’inhibition de cette sédation résiduelle par midazolam sur l’EAdi et le volume courant au début du sevrage ainsi que la corrélation qui existe entre les deux. Une dernière étude a montré l’absence d’augmentation du volume courant sous NAVA chez des patients transplantés pulmonaires aux poumons dénervés sans réflexe de Herring Breuer par rapport à un groupe contrôle. Par ailleurs le volume courant sous NAVA était corrélé à la capacité pulmonaire totale. Ces études ont montré l’intérêt du monitorage l’EAdi dans le sevrage. / The control of breathing results from a complex interaction involving differentrespiratory centers, which feed signals to a central control mechanism that, in turn, provides outputto the effector muscles. Afferent inputs arising from chemo- and mechanoreceptors, related to thephysical status of the respiratory system and to the activation of the respiratory muscles, modulatepermanently the respiratory command to adapt ventilation to the needs. Diaphragm electricalactivation provides information about respiratory drive, respiratory muscle loading, patientventilatorsynchrony and efficiency of breathing in critically ill patients. The use of inappropriatelevel of assist during spontaneous breathing with over or under assist might be harmful withdiaphragmatic dysfunction, alveolar injury and asynchrony. The first study settled NAVA modeaccording to the EAdi recorded during a failed spontaneous breathing trial (SBT). An unexpecteddaily increase of EAdi has been found during SBT until extubation. The second study did not findany increase of the neuroventilatory efficiency during weaning, possibly because of residualsedation. A third study described the inhibition of residual sedation on EAdi and tidal volume at thebeginning of the weaning, and the correlation between them. The last study did not find anyincrease of tidal volume under NAVA after lung transplantation, with denervated lung withoutHerring Breuer reflex, compared to a control group. Moreover tidal volume under NAVA wascorrelated to total lung capacity. These studies highlight the interest of EAdi monitoring duringweaning.

Thesis (MScEng)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: Patients in critical care with lung injuries need to be assisted with regards to breathing function, but current methods are not applicable for all situations. The most common method, Extracorporeal Membrane Oxygenation (ECMO) is an expensive procedure and requires trained staff to operate the equipment at all times. Lung injury may lead to the inability of the lungs to be perfused and the blood oxygenated by tracheal intubation, whereas mechanical ventilators can injure the lungs further. Especially at risk are preterm neonates, where congenital disorders or complications during birth render ECMO the only viable option. Respiratory Assist Catheters (RACs) could be used as an alternative because they do not place extra stress on the lungs, are easy to implement, cost-effective and are available for immediate use in clinical settings or in first aid situations. The development of such a device requires knowledge of possible oxygenation methods as well as the risks involved in implementing such a device. The possibility of oxygenating the blood via microbubbles by means of a RAC is promising due to the high gas transfer rates common in bubble oxygenators. It is the aim of this study to develop a prototype that could function as a RAC and to evaluate the feasibility of oxygenation by using microbubbles. The method used to design a prototype included selection of various materials and finalization of a design to be tested. The tests selected were in vivo tests and ex vivo tests using animal models to investigate the dissolution times of the microbubbles, as well as the physiological effects of an intravenously placed device. Measurements of oxygen saturation of the blood in arterial blood (SaO2), venous blood (SvO2) and pulmonary pressure allowed the oxygen transfer rates and risks involved to be evaluated, and also gave an indication regarding the formation dynamics of microbubbles in the blood. An in vitro test was also performed with the aim of determining the rate of dissolving of oxygen, and hence to give an indication regarding microbubble dissolution times. Mathematical simulations based on the dissolution rate of oxygen in venous blood confirmed the abovementioned results. The tests and simulations were analysed in order to evaluate the feasibility of intravenously oxygenating the blood using microbubbles. Approximate bubble dissolution times were an indicator of the feasibility of the concept and showed that very large bubble dissolution times renders intravenous bubble oxygenation unfeasible. These large dissolution times also lessen the possibility of implementing bubble oxygenation in an intravenous device. / AFRIKAANSE OPSOMMING: Pasiënte wat a.g.v. longbeserings in hoë-sorg behandel word het hulp nodig om asem te haal, maar bestaande metodes werk nie in alle omstandighede nie. Die mees algemene metode is ekstrakorporeale membraan suurstofverbinding (Extracorporeal Membrane Oxygenation (ECMO)), maar hierdie metode is duur en het voltyds opgeleide personeel nodig om dit te beheer. Longbeserings kan lei tot die onvermoë van die longe om bloed te ontvang en ook dat die bloed suurstof kry d.m.v. trageale intubasie. Meganiese ventilators kan die longe verder beskadig. Vroeggebore babas word blootgestel aan risiko’s veral waar oorerflike afwykings/steurnisse aanwesig is of komplikasies tydens geboorte en dus die EMCO die enigste lewensvatbare opsie maak. Kateters wat asemhaling aanhelp (Respiratory Assist Catheters (RACs)) kan as alternatief gebruik word aangesien dit nie ekstra spanning op die longe plaas nie, maklik is om te implementeer, koste-effektief is en beskikbaar is vir onmiddellike gebruik in kliniese omstandighede of in noodhulpsituasies. Die ontwikkeling van hierdie tipe toestel vereis kennis van moontlike suurstofverbindingsmetodes en ook die risiko’s verbonde aan die implementering van die toestel. Die moontlikheid om die bloed van suurstof te voorsien d.m.v. mikroborrels deur die RAC lyk belowend a.g.v. die hoë gasoordrag-koers wat algemeen is by borrel suurstofverbinders. Hierdie studie het ten doel om ʼn prototipe te ontwikkel wat kan dien as ʼn RAC en ook om die lewensvatbaarheid van suurstofverbinding met mikroborrels te bepaal. Die metode wat gebruik is om die prototipe te ontwerp sluit in die kies van verskeie materiale en die finalisering van die ontwerp wat getoets moet word. Die geselekteerde in vivo en ex vivo toetse is afgeneem deur gebruik te maak van dier-modelle om sodoende ondersoek in te stel na die oplossing van die mikroborrels en ook die fisiologiese gevolge van die toestel wat binne die aar geplaas is. Metings van die suurstofversadiging van bloed in slagaarbloed (SaO2), aarbloed (SvO2) en pulmonêre druk het toegelaat dat die koers en risiko’s verbonde aan suurstofoordrag geëvalueer word. Hierdie metings gee ook ’n aanduiding van die vormingsdinamika van die mikroborrels in die bloed. ’n In vitro toets is gedoen met die doel om die koers te bepaal van die oplossing van suurstof, en dus ’n aanduiding te gee van die tyd verbonde aan die oplossing van die mikroborrels. Wiskundige simulasies gebaseer op die oplossingskoers van suurstof in are het die bogenoemde toetse bevestig. Die toetse en simulasies is geanaliseer om die lewensvatbaarheid te bepaal om suurstof binne-aars te verskaf deur mikroborrels. Geskatte tye waarteen die borrels oplos is as aanduiding gebruik vir die lewensvatbaarheid van die konsep en ook die moontlike inwerkingstelling van die binne-aarse toestel.

Each year all over the world, Millions of patients from infants to adults are diagnosed with heart failure. A limited number of donor hearts available for these patients results in a tremendous demand of mechanical circulatory support (MCS) system, either in the form of total artificial heart (TAH) or a ventricular assist device (VAD). Physiologically MCS are expected to provide heart; a time to rest and potential recovery by unloading the ventricle, while maintaining the adequate peripheral as well as coronary circulation. Existing ventricular assist devices (VAD) have employed either displacement type pulsatile flow pumping systems or continuous flow type centrifugal/rotodynamic pumps systems. Displacement type devices produce a pulsatile outflow, which has significant benefits on vital organ function and end organ recovery. Continuous flow devices are small and can be placed within body using minimal invasive procedures, in addition they reduces infection as well as mechanical failure related complications. Despite availability of success stories for both types of pumping systems, the selection of the either of them is an ongoing debate. This thesis aims to merge the advantages of displacement pumps (pulsatile flow) and axial-flow pumps (continuous flow) into a novel left vertical assist device (LVAD), by designing a novel minimal invasive, miniature axial-flow pump producing pulsating outflow for the patients having early heart failure and myocardial infarction as a Bridge-To-Recovery (BTR) or Bridge-To-Decision (BTD) device. The design of VAD, the experimental setup and dedicated control system were developed for the in vitro evaluation of pulsatile flow. Computational fluid dynamics (CFD) had been employed for the detail investigation of pulsatile flow. In addition, CFD was also applied to optimize the pulse generation for low haemolysis levels. Outcome of the study produces comprehensive understanding for the generation of pulsatile flow using an axial flow pump. Further, it provides the means of generating a controlled pulse that can regulate flow rate for varying heart rate within low haemolysis levels.