INTRODUÇÃO: Evidências relevantes acerca dos benefícios da hipotermia terapêutica provieram da utilização de técnicas de resfriamento sistêmico. Essas técnicas, no entanto, podem causar complicações graves que poderiam ser evitadas com métodos de hipotermia encefálica seletiva. O presente estudo objetiva: 1) verificar a viabilidade da hipotermia encefálica exclusiva através de um sistema de resfriamento nasofaríngeo concomitante ao de preservação da temperatura corpórea em suínos e 2) investigar os efeitos da hipotermia encefálica exclusiva nas variáveis fisiológicas sistêmicas e encefálicas. MÉTODOS: Dez suínos híbridos foram submetidos a resfriamento nasofaríngeo durante 60 minutos e subsequente reaquecimento espontâneo. Foram obtidos dados referentes a: pressão arterial média, débito cardíaco, temperatura encefálica, pressão parcial de oxigênio do tecido encefálico (PbtO2, do inglês, pressure of brain tissue O2), velocidade do fluxo sanguíneo nas artérias encefálicas, índice de resistência e índice de pulsatilidade. RESULTADOS: O resfriamento nasofaríngeo associou-se à um decréscimo gradual da temperatura encefálica, que foi mais marcante no hemisfério cerebral esquerdo (p < 0,01). Neste hemisfério, houve redução de 1,47 ± 0,86°C nos primeiros 5 minutos (p < 0,01), 2,45 ± 1,03°C aos 10 minutos e 4,45 ± 1,36°C após 1 hora (p < 0,01). A diferença entre as temperaturas cerebral sistêmica foi 4,57 ± 0,87°C (p < 0,01). As temperaturas centrais (retal, esofágica e da artéria pulmonar), assim como a hemodinâmica encefálica e sistêmica, mantiveram-se estáveis durante o procedimento. Houve diminuição significativa da PbtO2, concomitantemente ao decréscimo da temperatura encefálica. CONCLUSÕES: A indução de hipotermia encefálica exclusiva é possível através de resfriamento nasofaríngeo associado a medidas de preservação da temperatura sistêmica. O resfriamento encefálico exclusivo não influencia as funções hemodinâmicas sistêmicas e encefálicas, contudo reduz significativamente a PbtO2 / INTRODUCTION: Relevant evidences for the use of therapeutic hypothermia derive from studies using whole body cooling methods. These methods can lead to serious complications. To avoid such complications, selective brain cooling methods were developed. The objective of this study was: 1) to verify the feasibility of exclusive brain hypothermia by means of nasopharyngeal cooling along with measures of systemic temperature preservation in an experimental swine model, and 2) to investigate the influence of the exclusive brain cooling on cerebral and systemic hemodynamics as well as on cerebral oxygenation. METHODS: Ten hybrid swine underwent nasopharyngeal cooling for 60 minutes, followed by spontaneous rewarming. A number of physiological variables were monitored: arterial blood pressure, cardiac output, temperature in the right and left cerebral hemispheres, pressure of brain tissue O2, cerebral blood flow velocities, resistance index, and pulsatility index. RESULTS: Nasopharyngeal cooling was associated with decrease in brain temperature, which was more significant in the left cerebral hemisphere (p < 0,01). There was a reduction of 1.47 ± 0.86°C in the first 5 minutes (p < 0.01), 2.45 ± 1.03°C within 10 min, and 4.45 ± 1.36°C after 1 hour (p < 0.01). The brain-core gradient was 4.57 ± 0.87°C (p < 0,001). Rectal, esophageal, and pulmonary artery temperatures, as well as brain and systemic hemodynamics, remained stable during the procedure. PbtO2 values significantly decreased following the brain cooling. CONCLUSION: Achievement of exclusive brain hypothermia is feasible by means of nasopharyngeal cooling associated with measures of systemic temperature preservation. Selective brain cooling does not influence both systemic and cerebral hemodynamics, except PbtO2, which decreased significantly

Dans le contexte industriel de la mise en forme des matériaux composites à renforts fibreux, l’outil de simulation est devenu partie intégrante de l’amélioration des procédés. Aujourd’hui, les simulations numériques de la mise en forme des renforts fibreux sont pour la plupart basées sur une approche macroscopique et des modèles de matériaux continus dont on suppose que le comportement est non linéaire élastique, donc réversible. Or on sait que sous chargement non-monotones (charges et décharges), les renforts fibreux montrent d’importantes irréversibilités, liées notamment aux glissements entre mèches et entre fibres. La première partie de ce travail consiste à caractériser l’importance des irréversibilités par des tests de charges/décharges à l’échelle macroscopique en différents modes de déformation (flexion, cisaillement, compression) réalisés sur des renforts tissés. La seconde partie consiste à chercher des modèles de comportement qui décrivent l’anélasticité en flexion et en cisaillement et à les implémenter dans un code éléments finis. Une validation de ces modèles obtenus est faite par comparaison simulation-expérimentation des essais d’identification de flexion et de cisaillement plan. Cette partie est réalisée sur le logiciel PlasFib développé par l’INSA de Lyon, un code éléments-finis explicite en grande transformation proposant une approche macroscopique semi-discrète des renforts fibreux. La troisième partie consiste à simuler différents cas de mises en forme inspirées de pièces industrielles pour mettre en évidence les zones du renfort qui subissent des chargements non monotones (en flexion et en cisaillement) lors d’une mise en forme. Cela vise également à étudier l’importance de l’utilisation des modèles irréversibles pour simuler ces mises en forme en comparant les résultats des simulations obtenus avec des modèles de comportement réversibles avec ceux obtenus pour des modèles irréversibles. / In the industrial context of shaping composite materials with fibrous reinforcements, the numerical simulation tool has become an integral part of process improvement. Today, numerical simulations of shaping fibrous reinforcements are mostly based on a macroscopic approach and continuous material models that have been assumed to be nonlinear elastic, thus reversible. However, under non-monotonous loading paths, the fibrous reinforcement shows significant irreversibility, particularly related to sliding between yarns and between fibers. First of all, we will try to characterize the importance of irreversibilities by cyclic tests (bending, in-plan shearing, compression) carried out on woven reinforcements. The second part consists in looking for behavior models that describe bending and in-plane shear irreversibilities to implement them in a finite element code. A validation of these behavior models is made by comparing simulation and experimental results of bending and in-plane shear identification tests. This part is realized on PlasFib, a software developed by INSA Lyon, based on finite element code in large deformation, proposing a macroscopic semi-discrete approach of fibrous reinforcements. The third part of the study will consist in simulating the shaping process of different industrial parts (or inspired by industrial parts). This will aim first at identifying loading cases apt to produce non-monotonous loading paths (in bending and in-plane shear) during the shaping process ; and second, at studying the importance of using irreversible models to simulate these shaping processes by comparing the results of simulations obtained with reversible behavior models with those obtained for irreversible behavior models.

Nous nous proposons d’étudier, dans cette thèse, une question essentielle et relativement peu traitée dans les recherches françaises en sciences de l’éducation, elle concerne la genèse des acquisitions des élèves et leur évolution au cours de la scolarité. En nous appuierons sur la mobilisation des données longitudinales (panel 1997) ainsi que sur la mise en œuvre d'une expérimentation musicale à l'école maternelle, nous chercherons à répondre à ces questions : Comment se structurent et évoluent les premiers apprentissages des élèves dans le contexte scolaire et socioéconomique ? En quoi les capacités cognitives des élèves ont un impact sur leurs performances scolaires ? Est-ce que des activités spécifiques peuvent avoir un effet positif sur les compétences scolaires, via un accroissement des capacités cognitives ? Des analyses implicatives menées sur les données du panel ont mis en évidence la hiérarchisation des compétences des élèves et l’importance des capacités cognitives sur leur rendement scolaire. La revue de littérature regorge d’exemples probants qui attestent qu’il est possible d’accroitre les performances scolaires des élèves en développant certaines de ces capacités cognitives, et que la musique est un outil particulièrement efficace en ce sens. Nous avons donc cherché à tester empiriquement l’impact de la musique sur les capacités cognitives et sur les performances scolaires des élèves en effectuant une recherche expérimentale. Elle repose sur une méthodologie robuste qui garanti la validité des résultats qui en sont issus. Si les résultats des analyses de différence de différences, confirmés par les modèles de réponse à l’item, sont peu concluants quant à l’impact de la musique sur les progressions des capacités cognitives, nous avons montré et vérifié via le modèle d’Heckman que le traitement expérimental a un effet sur les performances scolaires des élèves. / We propose to study in this thesis, a key issue and relatively little discussed in the French research in educational sciences, it concerns the genesis of pupil learning and their evolution during the tuition. We mobilize a longitudinal data (Panel 1997) and the results of a musical experimentation in kindergarten to answer to these questions: How are structured the first acquisitions of pupils and how is it linked to the school context and socio-economic variables? How the cognitive abilities of students affect their academic performance? Are specific activities can improve academic skills through an increase in cognitive abilities? Implicative analysis conducted on panel data has revealed a hierarchical structure of students' skills and the importance of cognitive skills on academic performance. The review of the literature demonstrates that it is possible to increase the academic performance of students by developing some of these cognitive abilities, and that music is a particularly effective tool in this sense. Therefore, we sought to empirically test the impact of music on cognitive ability and academic performance of students by our experimental research. It relies on a robust methodology which guarantees the validity of results derived from it. The result of difference in differences analyzes, confirmed by item response theory, is inconclusive for the impact of music on the progression of cognitive abilities. However, we have shown and verified via Heckman model that the experimental treatment has an effect on the academic performance of pupils.

<p>Bosiljak (Ocimum basilicum L.) pripada familiji Lamiaceae i jedna je od najrasprostranjenijih i najče&scaron;će gajenih biljaka &scaron;irom sveta. Njegova upotreba je &scaron;iroko rasprostranjena zbog bogatog sadržaja i skladnog odnosa vitamina, minerala kao i različitih fenolnih jedinjenja kao glavnih nosilaca antioksidativne aktivnosti. Poslednjih godina velika pažnja je usmerena ka fenolnim fitokomponentama kao potencijalnim promoterima zdravlja. Ciljevi ovog rada bili su ispitivanje kvalitativnih i kvantitativnih karakteristika, kao i biohemijskih aktivnosti ekstrakata bosiljka dobijenih različitim rastvaračima, kao i ispitivanje uticaja farmaceutsko-tehnolo&scaron;ke formulacije u obliku mikrovezikula ekstrakta bosiljka na glikemijski, lipidni i oksido-redukcioni status kod oglednih životinja, u odnosu na vodeni ekstrakt. In vitro ispitivanja su uključivala analizu 100 ekstrakata dobijenih različitim rastvaračima i stepenom usitnjenosti. Ukupni fenolni i flavonoidni sadržaj, kao i antioksidativna aktivnost određena je spektrofotometrijskom metodom. Takođe, kvantifikovane i kvalifikovane su fenolne komponente (fenolne kiseline i flavonoidi) primenom visokoefikasne tečne hromatografije (HPLC). In vivo ispitivanje je rađeno na 84 albino laboratorijska pacova soja Wistar. Per os su primenjivani vodeni ekstrakt bosiljka, rastvor natrijumove soli monoketoholne kiseline, njihove kombinacije, kao i ekstrakt u obliku farmaceutsko-tehnolo&scaron;ke formulacije, mikrovezikula. Posle sedmodnevnog tretmana, merene su koncentracije glukoze u krvi, a nakon žrtvovanja, u serumu su određeni parametri lipidnog statusa i antioksidativnog stresa. Ex vivo analizama procenjivani su efekti ekstrakta bosiljka na enzimske i neenzimske parametre antioksidativnog odbrambenog sistema i oksidativne modifikacije lipida. Praćen je i uticaj tretmana na akutno o&scaron;tećenje jetre usled primene paracetamola. Svi analizirani ekstrakti bosiljka su pokazali prisustvo velikog broja fenolnih jedinjenja iz klase fenolnih kiselina i flavonoida. Detektovane i kvantifikovane aktivne komponente bile su fenolne kiseline: hlorogenska, p-hidroksibenzoeva, kafena, vanilinska, ferulna, rozmarinska i cimetna, kao i apigenin, kvercetin, naringenin i rutin kao predstavnici flavonoidnih jedinjenja. Primena ekstrakta bosiljka i natrijumove soli monoketoholne kiseline, same ili u kombinaciji, a takođe i u farmaceutsko-tehnolo&scaron;koj formulaciji, pokazale su smanjenja o&scaron;tećenja tokom oksidativnog stresa, značajno antidijabetesno delovanje, povoljan uticaj na lipidni status i protektivni efekat na funkcije jetre i bubrega. Na osnovu dobijenih rezultata može se zaključiti da ekstrakt bosiljka sadrži značajnu količinu fenolnih jedinjenja odgovornih za antioksidativnu aktivnost. Vodeni ekstrakt bosiljka, sam ili u kombinaciji sa monoketoholnom kiselinom, i u obliku farmaceutsko-tehnolo&scaron;ke formulacije snižava nivo glukoze u krvi, ubrzava obnovu &beta; ćelija, ima povoljan efekat na lipidni status i ne dovodi do toksičnih promena na jetri i bubrezima kod eksperimentalnih životinja.</p> / <p>Basil (Ocimum basilicum L.) belongs to the family Lamiaceae and represents one of the most widespread and most commonly cultivated plant worldwide. Its use is widespread due to its rich content and harmonious relationship of vitamins, minerals and various phenolic compounds which are responsible for the antioxidant activity. In recent years, great attention is directed to phenolic phytocomponents as potential promoters of health. The objectives of this study were to test the qualitative and quantitative characteristics, as well as the biochemical activity of basil extracts obtained by various solvents and investigate the impact of pharmaceutical technological formulation of basil extract on glycemic, lipid and oxidation-reduction status of the aqueous extract in the experimental animals. In vitro studies have included 100 extracts obtained by various solvents and degrees of fragmentation. Total phenolic and flavonoid content, as well as antioxidant activity was determined by spectrophotometric method. Also, phenolic compounds (phenolic acids and flavonoids) were qualified and quantified using high performance liquid chromatography (HPLC). In vivo testing was performed on 84 laboratory albino Wistar rats. The aqueous extract of basil, a solution of sodium salt of monoketocholic acid, their combinations, as well as an extract in the form of the pharmaceutical technological formulation were administered per os. After seven-day-treatment, the concentrations of glucose were measured in the blood and after sacrificing of animals, the lipid and antioxidative parameters were determined in serum. Ex vivo analysis assessed the effect of the extract of basil on the parameters of enzymatic and non-enzymatic antioxidant defense system and the oxidative modification of lipids. The effect of paracetamol on acute liver injury was also monitored. All analyzed basil extracts showed the presence of the large number of phenolic compounds from the class of phenolic acids and flavonoids. Chlorogenic, p-hydroxybenzoic, caffeic, vanillic, ferulic, rosmarinic, and cinnamic acid, as well as apigenin, quercetin, naringenin and rutin were detected and quantified. The application of basil extracts and the sodium salt of monoketocholic acid, either alone or in combination, and also in pharmaceutical technological formulation of microvesicles has shown a reduction in damage during oxidative stress, then a significant antidiabetic activity, favorable effect on the lipid profile and protective effect on the liver and kidney function. Based on these results it can be concluded that basil extract contains significant amounts of phenolic compounds responsible for antioxidant activity. The aqueous extract of basil, alone or in combination with monoketocholic acid, and in the form of the pharmaceutical technological formulations lowers glucose levels in the blood, accelerates the restoration of &beta; cells, has a favorable effect on the lipid status and does not lead to toxic changes in the liver and kidneys in experimental animals.</p>

La qualité de la dérivation numérique en ligne d’un signal bruité joue un rôle primordial dans diverses applications touchant différents domaines (1D et 2D). Dans le travail présenté, nous nous sommes intéressés aux dérivateurs type "signal". Nos travaux s’inscrivent dans ce contexte et abordent des aspects théoriques et applicatifs. Du point de vue théorique, une étude de deux familles de dérivateurs a été effectuée. En premier lieu, nous avons étudié les dérivateurs de nature algébrique [travaux du projet INRIA-Non-A] et en deuxième lieu les différentiateurs modes glissants d’ordre supérieur [travaux de Levant]. Cette étude nous a permis de décrire les points forts et les points faibles de chacune de ces approches. Suite à cette étude, une nouvelle version des dérivateurs modes glissants a été proposée. Du point de vue applicatif, une première application dans le domaine 1D est présentée et qui consiste à utiliser le dérivateur proposé pour l’identification paramétrique en ligne d’un robot SCARA à deux axes. La méthode d’identification est validée expérimentalement par comparaison des résultats obtenus avec ceux donnés par d’autres méthodes (méthode en ligne et hors ligne). La deuxième application touche au domaine 2D. Dans ce cas, nous proposons l’application du différentiateur pour la détection des contours dans une image. Pour la validation des résultats, différents essais sont réalisés pour différents types de bruits. Une étude comparative avec des méthodes classiques est effectuée. Pour pouvoir tester l’efficacité du différentiateur dans des boucles de commande nous nous sommes intéressés aux systèmes électrohydrauliques. Le système physique étudié est un servo-vérin électrohydraulique à hautes performances ayant différents modes de fonctionnement. Après une succession d’hypothèses effectuées sur le modèle de simulation, des modèles de commande sont fournis. La dernière partie de ces travaux est dédiée à la synthèse de stratégie de commande via la technique du Backstepping pour le positionnement de l’axe électrohydraulique afin de tester l’efficacité l’algorithme proposé dans des boucles de commande. Comme base de comparaison, la version classique des algorithmes modes glissants est aussi utilisée. / The quality of the on-line differentiation with a noisy signal plays an important role in various applications involving different areas (1D and 2D). In the present work, we were interested particularly to differentiation method which requires a minimal knowledge on the noise and/or the input signal. Our work is registred in this context and address both aspects theoretical and applications. From the theoretical point of view, a study of two families of differentiation algorithm was performed. Firstly, we studied the algorithm based on the algebraic development [the work of the project INRIA-ALIEN] and secondly the differentiators of higher order sliding modes [work Levant] for detailed study. This study allowed us to describe the advantages and disadvantages of each approach. Following this study, a new version of sliding modes differentiator was proposed, this last one being the main theoretical contribution of this thesis. To test the efficiency of the proposed version, differents applications were carried out. The first application in 1D is shown, which consists in use the proposed differentiator for online parametric identification of a two-axis SCARA robot. The identification method is validated experimentally by comparing the results obtained with those given by other methods (method online and offline). The second application relates to the 2D domain. In this case, we propose the implementation of the differentiator for the edge detection in an image. To validate the results, various tests are carried out for different types of noise. In order to have some comparison basis, we use the filter Canny and Prewitt masks and the gradient. To test the effectiveness of the differentiator in control loops we are interested in electrohydraulic systems. For this, a model of the hydraulic and mechanical system is made. After a consideration of some assumptions on the simulation model, the control models are provided. To separate the dynamic servovalve/ actuator, a local study is performed. The last part of this work is dedicated to the synthesis of control strategy through the backstepping technique for the positioning of the electro-hydraulic axis in order to test the effectiveness of the proposed algorithm in the control loop. As a basis for comparison, the classic version of sliding mode algorithm is also used.

Introdução: A estratégia protetora de ventilação mecânica para a Síndrome do Desconforto Respiratório Agudo (SDRA), que associa o uso de baixo volume corrente com PEEP mais elevada, é uma intervenção eficaz para reduzir a morbimortalidade desta síndrome. Existe um consenso sobre o ajuste do volume corrente, mas o método de escolher a PEEP ainda é controverso. Dos diversos modos de escolher a PEEP, a titulação decrescente, após uma manobra de recrutamento alveolar, é um método com base fisiológica bem aceito. A escolha da PEEP é feita com base na complacência do sistema respiratório ou métodos de imagem que avaliam o colapso pulmonar. Esta titulação geralmente é feita de modo lento (4-10 minutos por queda de PEEP) o que a torna difícil na prática clínica e aumenta o risco para o paciente. Além disso, os critérios para escolha do valor da PEEP que mantém a estabilidade pulmonar ao longo do tempo ainda são incertos. Objetivos: 1) comparar, em modelo suíno de SDRA grave, usando a Tomografia de Impedância Elétrica (TIE) e a Tomografia Computadorizada (TC), o ajuste de PEEP por titulação decrescente de forma convencional (32 minutos) e rápida (6 minutos); e 2) avaliar a estabilidade pulmonar e hemodinâmica (complacência do sistema respiratório, shunt, PaO2 e débito cardíaco) durante 1 hora de ventilação mecânica com 3 níveis de PEEP definidos pela TIE: PEEP inferior à 1% de colapso de tecido pulmonar (PEEP TIT); inferior à 1% de colapso de tecido pulmonar +2cm H2O (PEEP TIT+2) e inferior à 1% de colapso de tecido pulmonar - 2cmH2O (PEEP TIT -2). Método: Vinte e cinco animais foram estudados, sendo que 6 também realizaram TC e 11 animais foram acompanhados ao longo do tempo. Resultados: Não foi observada diferença na porcentagem de colapso encontrado pelos dois métodos de imagem (TC e TIE), tanto na titulação rápida (p=0,89) como na lenta (p=0,86). Houve uma boa concordância entre as titulações rápida e lenta realizadas pela TIE, com diferença entre as titulações lenta e rápida de -0,6 (± 1,2) cmH2O. A PaCO2 foi significantemente maior (p=0,01) na titulação lenta quando comparado com a rápida. No seguimento por 1 hora, a estratégia PEEP TIT-2 determinou menores valores de complacência (p < 0,001), menor PaO2 (p=0,001) e maior porcentagem de shunt (p < 0,01) quando comparado com as estratégias PEEP TIT e PEEP TIT+2. Conclusões: a titulação rápida teve boa concordância com titulação lenta e determinou menos hipercapnia; 2) a PEEP ótima escolhida por titulação rápida utilizando TIE (colapso recrutável inferior a 1%) conseguiu manter boa estabilidade pulmonar e oxigenação durante 1 hora de monitorização; 3) não houve diferença entre o colapso recrutável estimado pelo TIE e pela TC dinâmica / Introduction: The protective strategy of mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS), which combines low tidal volume with higher PEEP, is an effective intervention to reduce the morbimortality of this syndrome. There is a consensus about setting tidal volume, but the method of choosing PEEP is still controversial. Decremental PEEP titration, following an alveolar recruitment maneuver, is a well-accepted method with physiological basis. The choice of PEEP is based on respiratory system complacency or imaging methods that assess lung collapse. This titration is usually done slowly (4-10 minutes in each step) which makes its execution difficult in clinical practice and increases the risk for the patient. In addition, the criteria for choosing the value of PEEP that maintains pulmonary stability over time are still uncertain. Objectives: 1) to compare, in a severe ARDS model in pigs, using Electrical Impedance Tomography (EIT) and Computed Tomography (CT), the decremental PEEP titration in a conventional maneuver (slow, 32 minutes) and fast (6 minutes); and 2) to evaluate the pulmonary stability and hemodynamics (respiratory system compliance, shunt, PaO2 and cardiac output) during 1 hour of mechanical ventilation with 3 PEEP values defined by EIT: PEEP with less than 1% lung tissue collapse (PEEP TIT); less than 1% collapse of lung tissue + 2cm H2O (PEEP TIT + 2) and less than 1% collapse of lung tissue - 2cmH2O (PEEP TIT - 2). Methods: Twenty-five animals were studied, 6 of which also performed CT and 11 animals were monitored over time. Results: No difference was observed in the percentage of collapse found by the two imaging methods (CT and EIT), both in fast (p = 0.89) and slow (p = 0.86) titrations. There was a good concordance between the fast and slow titrations performed by EIT, with a difference between the slow and fast titrations of -0.6 (± 1.2) cmH2O. PaCO2 was significantly higher (p = 0.01) in slow titration than in fast titration. At the 1-hour follow-up, the PEEP TIT-2 strategy determined lower values of compliance (p < 0.001), lower PaO2 (p = 0.001) and higher shunt (p < 0,01) when compared with PEEP TIT and PEEP TIT +2 strategies. Conclusions: 1) fast titration had good agreement with slow titration and causes less hypercapnia; 2) optimum PEEP chose by fast titration using EIT (recruitable-collapse lower than 1%) was able to maintain good lung function and oxygenation during 1 hour of monitoring; 3) there was no difference between the recruitable collapse estimated by EIT and by dynamic CT

Ce travail de recherche s’appuie sur l’analyse ex post de la conception d’un dispositif de formation. Il est destiné à des conseillers agricoles, confrontés aux bouleversements de leur métier. Les exigences de l’agriculture performante économiquement et écologiquement, modifient l’exercice du métier de conseil agricole. Les pratiques de conseil sont perturbées par la mobilisation de l’agronomie pour inciter à réduire les intrants. Il s’agit de se doter d’un cadre théorique qui permette d’analyser les situations de conseil de conseillers, conjointement avec une méthode pour accompagner la réflexion, dans l’interaction conseillers/formateur. La didactique professionnelle et la sociologie de l’action sont convoquées pour appréhender la situation sociale de développement et la situation de formation comme moyen de la formation. Dans les dialectiques connaissances pour l’action, connaissances théoriques, le cadre de l’expérimentation a permis de saisir la faisabilité du conseil, l’accès aux possibles de l’activité de conseil, la coordination des actants pour construire l’action. Il en résulte, un dispositif didactique et coordonné qui garantit un cadre de travail construisant chemin faisant ce que les protagonistes cherchent à faire ensemble, une approche qui ouvre la voie à l’appréhension du social par la didactique professionnelle, l’émergence du métier. / This research work is based on the ex post analysis of the design of a training approach. It is targeted at agricultural advisors facing major changes in their job. The requirements induced by an economically and environmentally performing agriculture modify the job of advisor. The established practices of counselling are disrupted by the agronomy’s engagement to encourage the reduction of inputs. The objective is to design a theoretical frame, allowing to analyze the advisors’ counselling situations, supported by a methodology to back up the reflection and with interactions advisors / trainers. Professional didactic and sociology of action are summoned to appreciate the social situation of development and the training situation as means of training. In the relationships between knowledge for action, theoretical knowledge, the experimentation framework allowed to seize the feasibility of counselling, the access to the potential of the counselling activity and the coordination of the stakeholders to build the action. This leads to a coordinated learning approach with a framework creating along the way what the protagonists are seeking to do together; an approach opening the path to understanding the social component by professional learning; the job emergence.

Introdução: A estratégia protetora de ventilação mecânica para a Síndrome do Desconforto Respiratório Agudo (SDRA), que associa o uso de baixo volume corrente com PEEP mais elevada, é uma intervenção eficaz para reduzir a morbimortalidade desta síndrome. Existe um consenso sobre o ajuste do volume corrente, mas o método de escolher a PEEP ainda é controverso. Dos diversos modos de escolher a PEEP, a titulação decrescente, após uma manobra de recrutamento alveolar, é um método com base fisiológica bem aceito. A escolha da PEEP é feita com base na complacência do sistema respiratório ou métodos de imagem que avaliam o colapso pulmonar. Esta titulação geralmente é feita de modo lento (4-10 minutos por queda de PEEP) o que a torna difícil na prática clínica e aumenta o risco para o paciente. Além disso, os critérios para escolha do valor da PEEP que mantém a estabilidade pulmonar ao longo do tempo ainda são incertos. Objetivos: 1) comparar, em modelo suíno de SDRA grave, usando a Tomografia de Impedância Elétrica (TIE) e a Tomografia Computadorizada (TC), o ajuste de PEEP por titulação decrescente de forma convencional (32 minutos) e rápida (6 minutos); e 2) avaliar a estabilidade pulmonar e hemodinâmica (complacência do sistema respiratório, shunt, PaO2 e débito cardíaco) durante 1 hora de ventilação mecânica com 3 níveis de PEEP definidos pela TIE: PEEP inferior à 1% de colapso de tecido pulmonar (PEEP TIT); inferior à 1% de colapso de tecido pulmonar +2cm H2O (PEEP TIT+2) e inferior à 1% de colapso de tecido pulmonar - 2cmH2O (PEEP TIT -2). Método: Vinte e cinco animais foram estudados, sendo que 6 também realizaram TC e 11 animais foram acompanhados ao longo do tempo. Resultados: Não foi observada diferença na porcentagem de colapso encontrado pelos dois métodos de imagem (TC e TIE), tanto na titulação rápida (p=0,89) como na lenta (p=0,86). Houve uma boa concordância entre as titulações rápida e lenta realizadas pela TIE, com diferença entre as titulações lenta e rápida de -0,6 (± 1,2) cmH2O. A PaCO2 foi significantemente maior (p=0,01) na titulação lenta quando comparado com a rápida. No seguimento por 1 hora, a estratégia PEEP TIT-2 determinou menores valores de complacência (p < 0,001), menor PaO2 (p=0,001) e maior porcentagem de shunt (p < 0,01) quando comparado com as estratégias PEEP TIT e PEEP TIT+2. Conclusões: a titulação rápida teve boa concordância com titulação lenta e determinou menos hipercapnia; 2) a PEEP ótima escolhida por titulação rápida utilizando TIE (colapso recrutável inferior a 1%) conseguiu manter boa estabilidade pulmonar e oxigenação durante 1 hora de monitorização; 3) não houve diferença entre o colapso recrutável estimado pelo TIE e pela TC dinâmica / Introduction: The protective strategy of mechanical ventilation for Acute Respiratory Distress Syndrome (ARDS), which combines low tidal volume with higher PEEP, is an effective intervention to reduce the morbimortality of this syndrome. There is a consensus about setting tidal volume, but the method of choosing PEEP is still controversial. Decremental PEEP titration, following an alveolar recruitment maneuver, is a well-accepted method with physiological basis. The choice of PEEP is based on respiratory system complacency or imaging methods that assess lung collapse. This titration is usually done slowly (4-10 minutes in each step) which makes its execution difficult in clinical practice and increases the risk for the patient. In addition, the criteria for choosing the value of PEEP that maintains pulmonary stability over time are still uncertain. Objectives: 1) to compare, in a severe ARDS model in pigs, using Electrical Impedance Tomography (EIT) and Computed Tomography (CT), the decremental PEEP titration in a conventional maneuver (slow, 32 minutes) and fast (6 minutes); and 2) to evaluate the pulmonary stability and hemodynamics (respiratory system compliance, shunt, PaO2 and cardiac output) during 1 hour of mechanical ventilation with 3 PEEP values defined by EIT: PEEP with less than 1% lung tissue collapse (PEEP TIT); less than 1% collapse of lung tissue + 2cm H2O (PEEP TIT + 2) and less than 1% collapse of lung tissue - 2cmH2O (PEEP TIT - 2). Methods: Twenty-five animals were studied, 6 of which also performed CT and 11 animals were monitored over time. Results: No difference was observed in the percentage of collapse found by the two imaging methods (CT and EIT), both in fast (p = 0.89) and slow (p = 0.86) titrations. There was a good concordance between the fast and slow titrations performed by EIT, with a difference between the slow and fast titrations of -0.6 (± 1.2) cmH2O. PaCO2 was significantly higher (p = 0.01) in slow titration than in fast titration. At the 1-hour follow-up, the PEEP TIT-2 strategy determined lower values of compliance (p < 0.001), lower PaO2 (p = 0.001) and higher shunt (p < 0,01) when compared with PEEP TIT and PEEP TIT +2 strategies. Conclusions: 1) fast titration had good agreement with slow titration and causes less hypercapnia; 2) optimum PEEP chose by fast titration using EIT (recruitable-collapse lower than 1%) was able to maintain good lung function and oxygenation during 1 hour of monitoring; 3) there was no difference between the recruitable collapse estimated by EIT and by dynamic CT

Introdução: A síndrome do desconforto respiratório agudo (SDRA) tem como parte do seu tratamento uma ventilação mecânica adequada. A manobra de recrutamento alveolar (MRA) faz parte de um grupo de estratégias empregadas nos quadros moderados e graves. A MRA consiste na aplicação de um aumento de pressão transitório e controlado nas vias aéreas no intuito de abrir alvéolos previamente colapsados. A Tomografia de Impedância Elétrica (TIE) é capaz de avaliar o potencial de recrutamento alveolar (PRA) a beira leito. Objetivos:1) Comparar o PRA calculado pela TIE (através do ganho de complacência regional) com a TC. 2) Avaliar o \"deslocamento vertical de volume\" como índice de recrutamento alveolar.3) Estimar precocemente o PRA, através das manobras de recrutamento de rastreio propostas, utilizando a TIE. Método: Avaliamos o PRA em um modelo experimental de SDRA. Utilizamos 15 suínos da raça Landrace. Os animais foram sedados e intubados, em seguida, submetidos ao modelo experimental de SDRA desenvolvido na Faculdade de Medicina da Universidade de São Paulo (LIM-09). Ao término da lesão, um grupo de 7 animais recebeu uma sequência randomizada de manobras de recrutamento de rastreio propostas (Pressões inspiratórias de 30, 35 e 40 cmH2O) seguidas da manobra de recrutamento máxima (Pressão inspiratória de 60 cmH2O). Os animais foram monitorados com TIE e Tomografia computadorizada por raio X (TC) durante todas as manobras de recrutamento. Outro grupo de 8 animais ,submetidos a mesma lesão e com medidas de TC e TIE, foi retirado do banco de dados do LIM-09 e também analisados. Utilizamos o programa IBM® SPSS® Statistics 9.0 e 20.0.Resultados:1) PRA calculado pela TIE atráves do ganho de complacência regional corrigido para hiperdistensão, comparado com TC, apresentou um R2=0,76. 2) PRA calculado pelo ganho de complacência regional corrigido para hiperdistensão combinado com o deslocamento vertical apresentou R2 = 0,91 comparado a TC .3) As manobras de rastreio não conseguiram predizer quantitativamente o PRA mas auxiliariam na correção da hiperdistensão. Conclusões: A TIE é capaz de avaliar o recrutamento alveolar a beira leito. O deslocamento vertical combinado com o ganho de complacência regional corrigida para hiperdistensão representam de forma semelhante a TC o comportamento pulmonar durante uma MRA. A aplicação de uma manobra de recrutamento de rastreio pode ser útil para uma manobra de recrutamento máxima mais segura / Introduction: The acute respiratory distress syndrome (ARDS) treatment demands a proper mechanical ventilation strategy. The alveolar recruitment maneuver (ARM) is an intervention applied in moderate and severe cases of ARDS. ARM is a transitory and controlled increase in mechanical ventilator pressure delivered to the lungs aiming to open previously collapsed alveoli. The electrical impedance tomography (EIT) is a valuable tool at bedside; it is able to monitor and to help during an ARM performance through the estimation of the alveolar recruitment potential (ARP). Objectives: 1) To compare the ARP with the EIT as a regional compliance improvement quantification adjusted for lung hyperdistention with CT. 2) To evaluate the \"volume vertical displacement\" at the same pressure as alveolar recruitment index using EIT and CT. 3) To estimate earlier the ARP using the EIT through a screening recruitment maneuver. Methods: We evaluated the ARP in an experimental model of ARDS. We studied 15 Landrace race pigs. Subjects were sedated, intubated and submitted to the ARDS experimental model developed at Medical investigation laboratory n ° 09, University of São Paulo. In the end of the lung injury, a group of 7 pigs received a randomized sequence of screening recruitment maneuvers (inspiratory pressures of 30, 35 and 40 cmH2O) followed by a maximum recruitment maneuver (inspiratory pressure of 60 cmH2O).EIT and x-ray computed tomography (CT) monitored the steps of each recruitment maneuver. Another group of 8 pigs, submitted to the same lesion and with measures of EIT and CT, were extracted from our data bank. Analysis was performed at IBM® SPSS® Statistics 20.0. Results: 1) ARP calculated by EIT (regional compliance improvement quantification) reached a R2=0,76 when compared to CT. 2) The combination of regional compliance improvement and volume vertical displacement obtained R2 = 0,91 when compared to CT 3) The screening recruitment maneuvers were not able to predict quantitatively the ARP, but they helped in the lung hyperdistension adjustment. Conclusions: EIT is able to evaluate the ARP at bedside. The combination of regional compliance improvement and volume vertical displacement give information similar to CT about the lung behavior during a ARM. The application of a recruitment screening maneuver might be useful for more safe ARM

INTRODUÇÃO: O desenvolvimento de colapso pulmonar (atelectasia) durante anestesia geral com ventilação mecânica é frequente, podendo determinar hipoxemia e contribuir para desenvolvimento de outras complicações pós-operatórias, como infecção e síndrome do desconforto respiratório agudo (SDRA). O uso de fração inspirada de oxigênio (FIO2) baixa e de pressão expiratória final positiva (PEEP) podem reduzir a quantidade de pulmão atelectasiado. Existem poucos dados experimentais sobre a cinética do desenvolvimento da atelectasia no intraoperatório em diferentes ajustes de FIO2 e PEEP no decorrer do tempo. A Tomografia de impedância elétrica (TIE) do tórax permite uma análise contínua e não invasiva da função pulmonar, bem como da quantificação do colapso e pode ser usada no intraoperatório. OBJETIVOS: a) avaliar, em animais com pulmões sadios durante anestesia geral, o efeito do uso de uma PEEP individualizada escolhida através da TIE (\"PEEP titulada\"), na formação de colapso; b) analisar a magnitude e a cinética de desenvolvimento do colapso pulmonar no decorrer do período de uma hora em dois valores de FIO2 (0,4 e 1) e dois valores de PEEP (3 cmH2O e valor da PEEP titulada) através da TIE e Tomografia computadorizada (TC); c) analisar mecânica, ventilação regional e aeração pela TIE e troca gasosa nos diferentes períodos do estudo. MÉTODOS: Nove animais (suínos) com pulmão normal foram submetidos à manobra de titulação da PEEP para escolha da PEEP que determina colapso pulmonar mínimo (colapso menor que 3% determinado pela TIE, denominada \"PEEP titulada\") e posteriormente ventilados com volume corrente de 6ml/Kg em quatro ajustes, em sequência randomizada, por um período de 1 hora: FIO2 0,4 e PEEP 3, FIO2 0,4 e PEEP titulada, FIO2 1 e PEEP 3 e FIO2 1 e PEEP titulada. O colapso, ventilação regional e aeração foram medidos continuamente, através da TIE assim como dados da mecânica. Mensuramos troca gasosa e aeração pulmonar pela TC em 3 momentos em cada período do estudo (baseline, 5 e 50 minutos). RESULTADOS: A PEEP titulada foi de 11,6 ±1,4 cm H2O. Houve colapso progressivo no decorrer do tempo nos 4 grupos estudados tendo sido maior na PEEP 3 que na PEEP titulada. A medida do colapso pela TIE não foi influenciada pela FIO2 utilizada, ao contrário da mensuração pela TC na qual o colapso foi maior na FIO2 de 1. Houve queda da complacência pulmonar e aumento da pressão de distensão no decorrer do tempo, maiores na PEEP 3, sem influência da FIO2. Na região dorsal, a TIE evidenciou redução da ventilação (delta Z) na PEEP 3, sem influência da FIO2, e, também, redução da aeração (mínimo Z) que foi maior na PEEP 3 e na FIO2 de 1. Houve queda da relação PaO2/FIO2 e aumento do shunt e mistura venosa na PEEP 3. Não houve alterações hemodinâmicas clinicamente relevantes durante o estudo. CONCLUSÕES: Houve colapso progressivo no decorrer do tempo, sendo maior na PEEP 3 que na PEEP titulada. O colapso aferido pela TC foi maior na FIO2 de 1 do que na 0,4 para uma mesma PEEP, diferente da TIE cuja estimativa de colapso não foi diferente. Paralelamente houve queda da complacência pulmonar, aumento da pressão de distensão e redução da ventilação dorsal, maiores na PEEP 3 e sem influência da FIO2. A queda da aeração estimada pela TIE foi maior na PEEP 3, sendo que nas duas PEEP a aeração foi menor na FIO2 de 1 / INTRODUCTION: The development of pulmonary collapse (atelectasis) during general anesthesia with mechanical ventilation is frequent, which can determine hypoxemia and contribute to the development of other postoperative complications, such as infection and acute respiratory distress syndrome (ARDS). The use of low fraction of inspired oxygen (FIO2) and positive end expiratory pressure (PEEP) may reduce the amount of collapsed lung. There are few experimental data on the kinetics of intraoperative atelectasis development in different FIO2 and PEEP adjustments over time. Electrical impedance tomography (EIT) of the thorax allows a continuous and noninvasive analysis of pulmonary function as well as the quantification of pulmonary atelectasis and can be used intraoperatively. OBJECTIVES: a) to evaluate, in animals with healthy lungs during general anesthesia, the effect of the use of an individualized PEEP chosen through EIT (titrated PEEP), in the formation of collapse; b) to analyze the magnitude and development kinetics of pulmonary collapse during the one-hour period in two values of FIO2 (0.4 and 1) and two PEEP values (3 cmH2O and titrated PEEP value) through EIT and computed tomography (CT); c) to analyze mechanics, regional ventilation and aeration by EIT and gas exchange in the different periods of the study. METHODS: Nine animals (swine) with normal lung were submitted to a PEEP titration maneuver to select PEEP that determines minimal pulmonary collapse (collapse of less than 3% determined by EIT, called \"titrated PEEP\") and then ventilated with a tidal volume of 6ml / kg in four adjustments, in a randomized sequence, for a period of 1 hour: FIO2 0.4 and PEEP 3, FIO2 0.4 and titrated PEEP, FIO2 1 and PEEP 3 and FIO2 1 and titrated PEEP. The collapse, regional ventilation and aeration were measured continuously through EIT as well as mechanics data. We also measured gas exchange and aeration by CT at 3 times in each study period (baseline, 5 e 50 minutes). RESULTS: The titrated PEEP was 11.6 ±1.4 cm H2O. There was a progressive collapse over time in the 4 groups studied, having been higher in PEEP 3 than in titrated PEEP. The measurement of EIT collapse was not influenced by the FIO2 used, as opposed to the CT measurement in which the collapse was greater in the FIO2 1. There was a decrease in pulmonary compliance and an increase in drive pressure over time, higher in PEEP 3, without influence of FIO2. In the dorsal region, EIT showed a decrease in ventilation, as measured by delta Z, in PEEP 3, with no influence of FIO2; there was also reduction of aeration, measured by the minimum Z, higher in PEEP 3 and FIO2 of 1. There was a decrease in the PaO2 / FIO2 ratio and increased in shunt and venous admixture in PEEP 3. There was no clinically relevant change in hemodynamics during the study. CONCLUSIONS: There was a greater collapse in PEEP 3 than in titrated PEEP over time. Collapse measured by CT was higher in FIO2 of 1 than 0.4 for the same PEEP, different from EIT estimates of collapse which was not different. Beside the collapse, there were decrease in compliance, increase in driving pressure and reduction of dorsal ventilation, higher in PEEP 3 without FIO2 influence. The decrease of aeration estimated by EIT was higher in PEEP 3 and for both PEEP values aeration was lower with FIO2 of 1