A necessidade de intubação e uso de ventilação mecânica (VM) na prematuridade está relacionada à chamada lesão pulmonar induzida pela ventilação (VILI) e consequente displasia broncopulmonar (DBP). Estudos com animais e também em humanos mostraram que breves períodos de VM são suficientes para a liberação de interleucinas pró-inflamatórias. Outras formas de VM que regulam o volume-corrente evitando o volutrauma e as ventilações não invasivas como a pressão positiva contínua em via aérea por pronga nasal (CPAPn) parecem medidas protetoras ou menos lesivas para VILI. Esses efeitos protetores do CPAPn não foram ainda estudados em humanos. Objetivo: avaliar os níveis plasmáticos da interleucina (IL)-1β, IL-6, IL-8, IL-10 e fator de necrose tumoral (TNF)-α em recém-nascidos tão logo instituído CPAPn e duas horas após. Secundariamente, avaliação dessa resposta inflamatória em pacientes que necessitaram de VM. Metodologia: estudo de coorte prospectivo, incluindo recém-nascidos admitidos com idade gestacional (IG) de 28-35 semanas e necessidade de assistência ventilatória, excluindo malformações, infecção congênita, sepse, surfactante profilático e suporte ventilatório em sala de parto. Amostras de sangue coletadas nesses dois momentos. Realizada descrição das variáveis em medianas e interquartis (p25-p75), empregado Teste de Wilcoxon. Resultados: 43 recém-nascidos, médias de peso 1883,5±580g e IG 32±2,4semanas, 23 (53%) receberam CPAPn como primeira modalidade ventilatória. Pré-termos após duas horas de VM apresentaram níveis significativamente maiores de IL-6, TNF-α e IL-8. Já os níveis de IL-6 reduziram significativamente após duas horas de CPAPn. Em 15 dos 22 (68%) neonatos cujas mães receberam corticoide pré-natal, as medianas das citocinas foram menores no início do uso do CPAPn, mas esse efeito não se sustentou duas horas após. O uso de surfactante pelos prematuros em VM não alterou a resposta inflamatória em comparação aos que não necessitaram do fármaco. Conclusão: demonstramos que os RN em CPAPn apresentaram mínima liberação de citocinas pro-inflamatórias e essa modalidade pode ter um papel protetor - nesse estudo potencializado pelo uso de corticoide ante natal. Por outro lado, VM promove significativa resposta inflamatória, estimulando-se CPAPn como estratégia ventilatória inicial protetora ao prematuro maior de 28 semanas de IG com desconforto respiratório moderado. Ainda assim, serão necessários mais estudos para determinar o papel de outras formas de ventilação não invasiva e outras formas de VM consideradas protetoras na prevenção da VILI. Essa nova compreensão dos mecanismos de lesão envolvendo resposta inflamatória mediada pelas citocinas possibilitará o desenvolvimento de novas estratégias no cuidado dos recém-nascidos prematuros. / The need for intubation and mechanical ventilation (MV) in preterm infants is related to ventilator-induced lung injury (VILI) and subsequent bronchopulmonary dysplasia (BPD). Studies in animals and in humans have shown that short periods of MV are enough for the release of pro-inflammatory interleukins. Other forms of MV that regulate tidal volume avoiding volutrauma and non- invasive ventilation such as continuous positive airway pressure by nasal prongs (nCPAP) seem protective measures against VILI. These protective effects of nCPAP have not been studied in humans. Objective: To evaluate the plasma levels of interleukin (IL) - 1β , IL - 6 , IL - 8 , IL - 10 and tumor necrosis factor (TNF) - α in preterm infants as soon as established nCPAP and two hours after. Secondarily, to evaluate this inflammatory response in patients who required MV. Methods: Prospective cohort including newborns admitted with gestational age (GA) of 28-35 weeks and requiring ventilation support, excluding malformations, congenital infections, sepsis, previous surfactant use and ventilatory support need in the delivery room. Blood samples were collected at those two moments. Cytokines were described as medians and interquartile ranges (p25 - p75), and Wilcoxon test was performed. Results: 43 newborns, medium weight 1883.5 ± 580g and gestational age of 32 ± 2.4 weeks, 23 (53 %) received nCPAP as the first ventilatory mode. Preterm two hours after MV had significantly higher levels of IL - 6, TNF - α and IL - 8. The levels of IL - 6 decreased significantly two hours after nCPAP. In 15 of 22 (68 %) neonates whose mothers received antenatal corticosteroids, the median of cytokines were lower at the onset of the nCPAP, but this effect was not sustained after two hours. The use of surfactant in preterm infants in MV did not alter the inflammatory response compared to those who did not need the drug. Conclusion: we demonstrated that nCPAP presents minimal release of pro-inflammatory cytokines and may have a protective role - in this study enhanced by the use of antenatal corticosteroids. Still, MV promotes significant inflammatory response, thus stimulating nCPAP as initial less harmful ventilatory strategy to preterm greater than 28 weeks of GA with moderate respiratory discomfort. Therefore, further studies are needed to determine the role of other forms of non-invasive ventilation and other forms of MV considered protective in preventing VILI. This new understanding of injury mechanisms involving inflammatory response mediated by cytokines allows the development of new strategies in the care of premature infants.

The scope of this dissertation focuses on issues related to the quality of life of children suffering with spinal muscular atrophy (SMA) and their carers and the associated social impact on families affected by this progressive and incurable disease. It describes ethical aspects of help to families with SMA and serious decisions in relation to the need to connect to artificial ventilation. Spinal Muscular Atrophy - SMA is a motoneuron disease i.e. disease of neurons, which are responsible for conscious movements of muscles e.g. running, head movement and swallowing. The prevalence is approximately 1 newborn for 6000 live births and approximately 1 person of 40 people is the carrier of the disease. SMA affects all the bone muscles i.e. proximal muscles are often affected the most. Everyone affected is in some point in life, depending on stage and type, reliant on mechanical or electrical wheelchair, in many cases also on artificial ventilation and permanent 24hr care. Families affected by this illness accept the fact of this progressive and incurable illness differently, this dissertation reflects upon such different perceptions on quality of life of the affected children, the carers. It forms a contribution in building a foundation for organising multi-discipline teams of experts with sole purpose of therapeutical interventions, to support the child and his/hers family. The World Health Organization (WHO) defines palliative care as "improving quality of life of patients facing life-threatening illnesses, and their families, through the prevention and relief of suffering by early identification and treatment of pain and other problems, whether physical, psychological, social or spiritual." Palliative care prepares families for these situations and should be provided along with whatever treatment options families choose. This dissertation is a comprehensive information base to support children affected by SMA and their families in early care in Czech Republic and in the process of inclusive educational integration into mainstream society.

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No. of bitstreams: 1 barbosa_so_dr_bot.pdf: 1518184 bytes, checksum: 6d5b1e7635afb78dfefe1890eea01151 (MD5) Previous issue date: 2018-02-27 / Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP) / A Síndrome do Desconforto Respiratório Agudo (SDRA) caracteriza-se por processo inflamatório que leva à quebra da barreira alvéolo-capilar com desenvolvimento de edema intersticial e alveolar, diminuição da complacência pulmonar, hipertensão pulmonar, desequilíbrio da relação ventilação/perfusão e hipoxemia refratária à administração de oxigênio. Apesar do progresso no entendimento de sua fisiopatologia e consequente avanço em estratégias terapêuticas de pacientes com SDRA, a mortalidade permanece elevada. Entre os mecanismos que levam a síndrome, várias evidências sugerem que pacientes portadores de SDRA estão expostos a elevado grau de estresse oxidativo (EO) induzido por ampla variedade de eventos. Por essa razão é fundamental a compreensão do papel do EO tanto na instalação como na perpetuação do processo infamatório que ocorre na doença. No entanto, apesar do uso de antioxidantes ter mostrado algum benefício na evolução da doença, ainda não há evidência clínica para sua utilização rotineira na prática. O licopeno é um carotenoide sem atividade provitamina A encontrado principalmente no tomate e nas frutas vermelhas. Em decorrência de seu grande número de duplas ligações conjugadas, o licopeno é considerado um dos melhores antioxidantes entre os carotenoides. Além disso, é um dos mais potentes antioxidantes encontrados no organismo humano, apresentando potência antioxidante 100 vezes maior do que a vitamina E e a vitamina C. A ventilação mecânica convencional protetora (VMC) constitui um dos principais pilares do tratamento da SDRA, sendo capaz de modificar a evolução da doença e reduzir a mortalidade. Baseado nos efeitos protetores da ventilação oscilatória de alta frequência (VOAF) sobre a SDRA, anteriormente descritos pelo grupo, bem como o potencial papel antioxidante e antiinflamatório do licopeno, nossa hipótese é que esse carotenoide exerce efeito protetor adicional em modelo experimental de SDRA. O objetivo do estudo foi investigar os efeitos da suplementação com licopeno sobre o EO pulmonar, por meio da capacidade antioxidante total (TAP) e dano oxidativo do DNA (teste do Cometa), em modelo experimental de lesão pulmonar induzida em coelhos ventilados com VMC e VOAF, comparando-os com grupo controle. Também foram avaliadas a histologia pulmonar e a inflamação pela contagem de células de neutrófilos no lavado broncoalveolar. Cinquenta e cinco coelhos foram instrumentados com traqueostomia, acessos vasculares e ventilados mecanicamente. Os animais suplementados receberam 10mg/Kg de licopeno durante 21 dias antes do experimento. A lesão pulmonar foi induzida por infusão traqueal de salina aquecida (30mL/Kg, 38°C). Foram formados os seguintes grupos experimentais: animais sadios foram submetidos a eutanásia para compor o grupo baseline sem suplementação: GBL; n=5 e baseline suplementado com licopeno: GBLL; n=5, animais sadios submetidos à VM Protetora, sem suplementação denominado grupo controle GC; n=5, animais submetidos à indução da lesão pulmonar e tratamento com ventilação mecânica e suplementados com licopeno GVMCL; n=10 e sem suplementação GVMC; n=10, com LP submetidos à VOAF e suplementados com licopeno GVAFL; n=10 e sem suplementação GVAF; n=10. Após a confirmação da lesão pulmonar, as gasometrias foram realizadas a cada 30 minutos pelas 4 horas de duração do protocolo experimental. O nível de significância foi de 5%. Comparando os momentos, antes e depois da lesão pulmonar em cada grupo, houve piora significante da oxigenação e também diminuição da complacência pulmonar estática em todos os grupos. Após 4 horas, os grupos tratados com VOAF, com e sem licopeno, e o grupo sob VMC protetora com licopeno, apresentaram melhora significante em relação ao grupo VMC protetora sem suplementação, apresentando relação de PaO2/FiO2 semelhante aos momentos antes da indução da lesão pulmonar e em relação ao GC. A contagem de neutrófilos no lavado broncoalveolar mostrou que os grupos GVMCL e GVAFL, apresentaram valores significantemente menores em comparação com os animais sem suplementação. GC, GVAFL e GVMCL apresentaram escore de lesão histológica significantemente menor quando comparados com os grupos sem suplementação. Quanto ao TAP no tecido pulmonar, não houve diferença estatística entre os grupos. O dano do DNA nos linfócitos, comparando os animais sob VMC protetora, foi significantemente mais baixo nos animais suplementados com licopeno. Este estudo demonstra que independentemente do modo ventilatório, a suplementação prévia com licopeno melhora a oxigenação, reduz a lesão inflamatória bem como a lesão histopatológica nos animais, assemelhando-se aos benefícios propostos pela VOAF, e minimiza o dano no DNA nos animais sob VMC protetora com suplementação em relação aos animais sob mesma ventilação. / Acute Respiratory Distress Syndrome (ARDS) is characterized by inflammatory process that leads to the breakdown of the alveolar-capillary barrier with the development of interstitial and alveolar edema, decreased pulmonary compliance, pulmonary hypertension, impaired ventilation and perfusion, and hypoxemia refractory to administration of oxygen. Despite better understanding in pathophysiology and consequent advancement in therapeutic strategies for ARDS patients, mortality remains high. Although the exact mechanism leading to ARDS is unknown, several evidences suggest that patients with the syndrome are exposed to a high degree of oxidative stress. For this reason it is important to understand the role of oxidative stress in both, initiation and progress of inflammatory process that occurs in the disease. However, although the use of antioxidants has shown some benefit in ARDS evolution, there is still no clinical evidence for its use in practice routine. Lycopene is a carotenoid with no provitamin A activity found mainly in tomatoes and red fruits. Due to its large number of double conjugated bonds, lycopene is considered one of the best antioxidants among carotenoids. In addition, it is one of the most potent antioxidants found in the human body, with antioxidant potency 100 times higher than vitamin E and vitamin C. Conventional mechanical ventilation (CMV) is the main ARDS treatment, capable of modifying disease evolution and reducing mortality. Based on the protective effects of high frequency oscillatory ventilation (HFOV) on ARDS, previously described by our group, as well as the potential antioxidant and antiinflammatory role of lycopene, our hypothesis is that this carotenoid has additional protective effect in ARDS model. The aim of this study was to investigate the effects of lycopene supplementation on pulmonary oxidative damage, analyzing total antioxidant performance (TAP) and oxidative DNA damage (Comet Assay), in an experimental induced lung injury model in rabbits, ventilated by CMV and HFOV compared to control group. Pulmonary histology and neutrophil cell counts were also evaluated. Fifty-five rabbits were instrumented with tracheostomy, vascular accesses and mechanically ventilated. Supplemented animals received 10mg/ kg of lycopene for 21 days prior to the experiment. Lung injury was induced by tracheal infusion of warm saline (30mL/ kg, 38°C). The following experimental groups were: healthy animals submitted to euthanasia to compose the baseline group without supplementation: GBL; n = 5 and baseline supplemented with lycopene: GBLL; n = 5, healthy animals submitted to Protective CMV, without supplementation, denominated GC control group; n = 5, animals submitted to lung injury induction and mechanical ventilation treatment and supplemented with lycopene GVMCL; n = 10 and without supplementation GVMC; n = 10, animals with LP submitted to HFOV and supplemented with lycopene GVAFL; n = 10 and without supplementation GVAF; n = 10. After confirming lung injury induction, blood gases were performed every 30 minutes during the 4 hours of the experimental protocol. The level of significance was 5%. Comparing the moments before and after the pulmonary injury induction in each group, there was a significant worsening of oxygenation and decrease in static lung compliance in all groups after injury induction. After 4 hours, groups treated with HFOV, with and without lycopene supplementation, and group with lycopene supplementation and submitted protective CMV, showed a significant improvement compared to Protective CMV group without supplementation, showing PaO2/FiO2 ratio similar to the moments before the pulmonary induction and CG. Neutrophil count in bronchoalveolar lavage showed that GVMCL and GVAFL groups presented significantly lower comparing with animals without supplementation. GC, GVAFL and GVMCL had a significantly lower histological injury score compared to groups without supplementation. TAP in lung tissue showed no statistical difference among groups. DNA damage on lymphocytes comparing animals submitted to protective CMV was significantly lower in animals supplemented with lycopene. This study demonstrates that independent of the ventilatory mode, prior lycopene supplementation improves oxygenation, reduced inflammatory injury, as well as histopathological injury score in this lung injury animal model. Both HFOV groups, and animals submitted to protective CMV and supplemented with lycopene showed reduced DNA-free damage compared to animals under de same ventilation without supplementation. / FAPESP: 2014/15683-9

A necessidade de intubação e uso de ventilação mecânica (VM) na prematuridade está relacionada à chamada lesão pulmonar induzida pela ventilação (VILI) e consequente displasia broncopulmonar (DBP). Estudos com animais e também em humanos mostraram que breves períodos de VM são suficientes para a liberação de interleucinas pró-inflamatórias. Outras formas de VM que regulam o volume-corrente evitando o volutrauma e as ventilações não invasivas como a pressão positiva contínua em via aérea por pronga nasal (CPAPn) parecem medidas protetoras ou menos lesivas para VILI. Esses efeitos protetores do CPAPn não foram ainda estudados em humanos. Objetivo: avaliar os níveis plasmáticos da interleucina (IL)-1β, IL-6, IL-8, IL-10 e fator de necrose tumoral (TNF)-α em recém-nascidos tão logo instituído CPAPn e duas horas após. Secundariamente, avaliação dessa resposta inflamatória em pacientes que necessitaram de VM. Metodologia: estudo de coorte prospectivo, incluindo recém-nascidos admitidos com idade gestacional (IG) de 28-35 semanas e necessidade de assistência ventilatória, excluindo malformações, infecção congênita, sepse, surfactante profilático e suporte ventilatório em sala de parto. Amostras de sangue coletadas nesses dois momentos. Realizada descrição das variáveis em medianas e interquartis (p25-p75), empregado Teste de Wilcoxon. Resultados: 43 recém-nascidos, médias de peso 1883,5±580g e IG 32±2,4semanas, 23 (53%) receberam CPAPn como primeira modalidade ventilatória. Pré-termos após duas horas de VM apresentaram níveis significativamente maiores de IL-6, TNF-α e IL-8. Já os níveis de IL-6 reduziram significativamente após duas horas de CPAPn. Em 15 dos 22 (68%) neonatos cujas mães receberam corticoide pré-natal, as medianas das citocinas foram menores no início do uso do CPAPn, mas esse efeito não se sustentou duas horas após. O uso de surfactante pelos prematuros em VM não alterou a resposta inflamatória em comparação aos que não necessitaram do fármaco. Conclusão: demonstramos que os RN em CPAPn apresentaram mínima liberação de citocinas pro-inflamatórias e essa modalidade pode ter um papel protetor - nesse estudo potencializado pelo uso de corticoide ante natal. Por outro lado, VM promove significativa resposta inflamatória, estimulando-se CPAPn como estratégia ventilatória inicial protetora ao prematuro maior de 28 semanas de IG com desconforto respiratório moderado. Ainda assim, serão necessários mais estudos para determinar o papel de outras formas de ventilação não invasiva e outras formas de VM consideradas protetoras na prevenção da VILI. Essa nova compreensão dos mecanismos de lesão envolvendo resposta inflamatória mediada pelas citocinas possibilitará o desenvolvimento de novas estratégias no cuidado dos recém-nascidos prematuros. / The need for intubation and mechanical ventilation (MV) in preterm infants is related to ventilator-induced lung injury (VILI) and subsequent bronchopulmonary dysplasia (BPD). Studies in animals and in humans have shown that short periods of MV are enough for the release of pro-inflammatory interleukins. Other forms of MV that regulate tidal volume avoiding volutrauma and non- invasive ventilation such as continuous positive airway pressure by nasal prongs (nCPAP) seem protective measures against VILI. These protective effects of nCPAP have not been studied in humans. Objective: To evaluate the plasma levels of interleukin (IL) - 1β , IL - 6 , IL - 8 , IL - 10 and tumor necrosis factor (TNF) - α in preterm infants as soon as established nCPAP and two hours after. Secondarily, to evaluate this inflammatory response in patients who required MV. Methods: Prospective cohort including newborns admitted with gestational age (GA) of 28-35 weeks and requiring ventilation support, excluding malformations, congenital infections, sepsis, previous surfactant use and ventilatory support need in the delivery room. Blood samples were collected at those two moments. Cytokines were described as medians and interquartile ranges (p25 - p75), and Wilcoxon test was performed. Results: 43 newborns, medium weight 1883.5 ± 580g and gestational age of 32 ± 2.4 weeks, 23 (53 %) received nCPAP as the first ventilatory mode. Preterm two hours after MV had significantly higher levels of IL - 6, TNF - α and IL - 8. The levels of IL - 6 decreased significantly two hours after nCPAP. In 15 of 22 (68 %) neonates whose mothers received antenatal corticosteroids, the median of cytokines were lower at the onset of the nCPAP, but this effect was not sustained after two hours. The use of surfactant in preterm infants in MV did not alter the inflammatory response compared to those who did not need the drug. Conclusion: we demonstrated that nCPAP presents minimal release of pro-inflammatory cytokines and may have a protective role - in this study enhanced by the use of antenatal corticosteroids. Still, MV promotes significant inflammatory response, thus stimulating nCPAP as initial less harmful ventilatory strategy to preterm greater than 28 weeks of GA with moderate respiratory discomfort. Therefore, further studies are needed to determine the role of other forms of non-invasive ventilation and other forms of MV considered protective in preventing VILI. This new understanding of injury mechanisms involving inflammatory response mediated by cytokines allows the development of new strategies in the care of premature infants.

A necessidade de intubação e uso de ventilação mecânica (VM) na prematuridade está relacionada à chamada lesão pulmonar induzida pela ventilação (VILI) e consequente displasia broncopulmonar (DBP). Estudos com animais e também em humanos mostraram que breves períodos de VM são suficientes para a liberação de interleucinas pró-inflamatórias. Outras formas de VM que regulam o volume-corrente evitando o volutrauma e as ventilações não invasivas como a pressão positiva contínua em via aérea por pronga nasal (CPAPn) parecem medidas protetoras ou menos lesivas para VILI. Esses efeitos protetores do CPAPn não foram ainda estudados em humanos. Objetivo: avaliar os níveis plasmáticos da interleucina (IL)-1β, IL-6, IL-8, IL-10 e fator de necrose tumoral (TNF)-α em recém-nascidos tão logo instituído CPAPn e duas horas após. Secundariamente, avaliação dessa resposta inflamatória em pacientes que necessitaram de VM. Metodologia: estudo de coorte prospectivo, incluindo recém-nascidos admitidos com idade gestacional (IG) de 28-35 semanas e necessidade de assistência ventilatória, excluindo malformações, infecção congênita, sepse, surfactante profilático e suporte ventilatório em sala de parto. Amostras de sangue coletadas nesses dois momentos. Realizada descrição das variáveis em medianas e interquartis (p25-p75), empregado Teste de Wilcoxon. Resultados: 43 recém-nascidos, médias de peso 1883,5±580g e IG 32±2,4semanas, 23 (53%) receberam CPAPn como primeira modalidade ventilatória. Pré-termos após duas horas de VM apresentaram níveis significativamente maiores de IL-6, TNF-α e IL-8. Já os níveis de IL-6 reduziram significativamente após duas horas de CPAPn. Em 15 dos 22 (68%) neonatos cujas mães receberam corticoide pré-natal, as medianas das citocinas foram menores no início do uso do CPAPn, mas esse efeito não se sustentou duas horas após. O uso de surfactante pelos prematuros em VM não alterou a resposta inflamatória em comparação aos que não necessitaram do fármaco. Conclusão: demonstramos que os RN em CPAPn apresentaram mínima liberação de citocinas pro-inflamatórias e essa modalidade pode ter um papel protetor - nesse estudo potencializado pelo uso de corticoide ante natal. Por outro lado, VM promove significativa resposta inflamatória, estimulando-se CPAPn como estratégia ventilatória inicial protetora ao prematuro maior de 28 semanas de IG com desconforto respiratório moderado. Ainda assim, serão necessários mais estudos para determinar o papel de outras formas de ventilação não invasiva e outras formas de VM consideradas protetoras na prevenção da VILI. Essa nova compreensão dos mecanismos de lesão envolvendo resposta inflamatória mediada pelas citocinas possibilitará o desenvolvimento de novas estratégias no cuidado dos recém-nascidos prematuros. / The need for intubation and mechanical ventilation (MV) in preterm infants is related to ventilator-induced lung injury (VILI) and subsequent bronchopulmonary dysplasia (BPD). Studies in animals and in humans have shown that short periods of MV are enough for the release of pro-inflammatory interleukins. Other forms of MV that regulate tidal volume avoiding volutrauma and non- invasive ventilation such as continuous positive airway pressure by nasal prongs (nCPAP) seem protective measures against VILI. These protective effects of nCPAP have not been studied in humans. Objective: To evaluate the plasma levels of interleukin (IL) - 1β , IL - 6 , IL - 8 , IL - 10 and tumor necrosis factor (TNF) - α in preterm infants as soon as established nCPAP and two hours after. Secondarily, to evaluate this inflammatory response in patients who required MV. Methods: Prospective cohort including newborns admitted with gestational age (GA) of 28-35 weeks and requiring ventilation support, excluding malformations, congenital infections, sepsis, previous surfactant use and ventilatory support need in the delivery room. Blood samples were collected at those two moments. Cytokines were described as medians and interquartile ranges (p25 - p75), and Wilcoxon test was performed. Results: 43 newborns, medium weight 1883.5 ± 580g and gestational age of 32 ± 2.4 weeks, 23 (53 %) received nCPAP as the first ventilatory mode. Preterm two hours after MV had significantly higher levels of IL - 6, TNF - α and IL - 8. The levels of IL - 6 decreased significantly two hours after nCPAP. In 15 of 22 (68 %) neonates whose mothers received antenatal corticosteroids, the median of cytokines were lower at the onset of the nCPAP, but this effect was not sustained after two hours. The use of surfactant in preterm infants in MV did not alter the inflammatory response compared to those who did not need the drug. Conclusion: we demonstrated that nCPAP presents minimal release of pro-inflammatory cytokines and may have a protective role - in this study enhanced by the use of antenatal corticosteroids. Still, MV promotes significant inflammatory response, thus stimulating nCPAP as initial less harmful ventilatory strategy to preterm greater than 28 weeks of GA with moderate respiratory discomfort. Therefore, further studies are needed to determine the role of other forms of non-invasive ventilation and other forms of MV considered protective in preventing VILI. This new understanding of injury mechanisms involving inflammatory response mediated by cytokines allows the development of new strategies in the care of premature infants.

Le syndrome de détresse respiratoire aiguë (SDRA) présente un taux de mortalité élevé, près de 40%, dans des unités de soins intensifs. Il est défini comme un ensemble de manifestations cliniques, radiologiques et physiologiques qui traduisent une intense inflammation pulmonaire et une hyperperméabilité pulmonaire, correspondant aux différentes agressions aiguës du poumon. Le prise en charge des patients atteints du SDRA nécessite une ventilation assistée qui, en cas de mauvaise adaptation des paramètres de ventilation, notamment, pression et volume, peut aggraver l'état du patient. Le réglage de ces paramètres est basé sur l'analyse de l'aération pulmonaire en réponse à la ventilation assistée. Cette analyse peut être faite sur des images tomodensitométriques (CT en anglais) après y avoir segmenté le parenchyme pulmonaire. Néanmoins, cette segmentation est entravée par l'augmentation de la densité du parenchyme, qui réduit le contraste entre le poumon et les structures voisines. Cette thèse cherche à fournir des outils de traitement d'images qui permettent aux experts l'analyse de l'aération pulmonaire dans des images CT acquises dans le cadre d'un projet sur le SDRA utilisant un modèle animal / Acute Respiratory Distress Syndrome (ARDS) is a life threatening disease presenting a high mortality of about 40% in intensive care units. It is the consequence of different pulmonary aggressions generating hypoxemia and pulmonary edema, which are radiologically expressed as infiltrations observable as opaque regions in the lung. The treatment of ARDS requires mechanical ventilation, which may deteriorate the state of the patient if the ventilation parameters, namely volume and pressure, are not correctly adjusted. To adjust the parameter settings to each individual case, lung aeration - in response to ventilation - needs to be assessed. This assessment can be done using computed tomography (CT) images. However, it requires the segmentation of the lung-parenchymal tissue, which is a challenging task in ARDS images due the opacities that hinder the image contrast. In this thesis we aim to provide the required tools for the experts to analyze the aeration in the images acquired within an ARDS project using an animal model

Étude de déterminants de la dysfonction vasculaire pulmonaire au cours du syndrome de détresse respiratoire aigue. La physiopathologie du syndrome de détresse respiratoire aigue (Acute Respiratory Distress Syndrome, ARDS) inclut une dysfonction vasculaire pulmonaire, résultant de phénomènes de thrombose, hyperperméabilité endothéliale, dysrégulation de la vasomotricité et remodelage. La ventilation en pression positive est un facteur aggravant. Il en résulte une augmentation des résistances vasculaires pulmonaires, à l'origine d'une hypertension pulmonaire et à risque de cœur pulmonaire aigu, associés à un pronostic péjoratif au cours de l'ARDS. Mais les déterminants de cette dysfonction vasculaire pulmonaire demeurent largement méconnus. Un modèle murin d'agression pulmonaire aigue two hit a été développé, associant une instillation orotrachéale de lipopolysaccharide bactérien à une ventilation mécanique protectrice, avec explorations physiologiques respiratoires et hémodynamiques invasives. Trois déterminants potentiels de la dysfonction vasculaire pulmonaire ont été étudiés. Dans le premier travail, nous avons établi que l'utilisation de manœuvres de recrutement alvéolaire, consistant en l'application transitoire et répétée de hauts niveaux de pression positive, limitait la dégradation de la mécanique ventilatoire mais induisait une hypertension pulmonaire. Une analyse transcriptomique pulmonaire a montré une dysrégulation d'un grand nombre de gènes impliqués dans les principales fonctions endothéliales. Dans le deuxième travail, une déficience en interleukine-6 a été montrée associée à une inflammation et un œdème pulmonaires majorés. Une élévation des résistances pulmonaires totales était aussi observée, prévenue par l'injection d'interleukine-6 recombinante et au moins partiellement attribuable à une dysrégulation de la vasomotricité pulmonaire impliquant la voie des nitric oxide synthases. Dans le troisième travail, nous avons comparé des souris adultes jeunes et d'âge mature et illustré une gravité âge-dépendante, caractérisée par une inflammation systémique et pulmonaire et une fuite alvéolocapillaire accrues, ainsi qu'un dosage bronchoalvéolaire d'angiopoiétine 2 élevé, suggérant une atteinte endothéliale sévère. Nos résultats pourraient contribuer à l'identification de nouvelles voies thérapeutiques ciblant la microvascularisation pulmonaire au cours de l'ARDS. Mots clés: syndrome de détresse respiratoire aigue, ventilation mécanique, hypertension pulmonaire, dysfonction vasculaire pulmonaire, vieillissement, interleukine-6, manœuvre de recrutement. / Study of factors determining the pulmonary vascular dysfunction during acute respiratory distress syndrome.The pathophysiology of the acute respiratory distress syndrome (ARDS) includes a pulmonary vascular dysfunction, which is attributable to thrombosis, endothelial hyperpermeability, dysregulation of the pulmonary vasomotor tone and remodeling. Positive pressure ventilation is an exacerbating factor. The result is an increase in the pulmonary vascular resistances, which lead to an acute pulmonary hypertension and may cause acute cor pulmonale, both associated with an altered prognosis during ARDS. But the factors determining the pulmonary vascular dysfunction are poorly known. A murine model of two hit acute lung injury, combining an orotracheal aspiration of bacterial lipopolysaccharide to a protective mechanical ventilation, with physiological respiratory and invasive hemodynamic monitoring. Three factors which might determine pulmonary vascular dysfunction were studied. In the first work, we established that the use of alveolar recruitment maneuvers, consisting in a transient and repetitive application of high positive pressure level, minimized the alteration of lung mechanics but induced a pulmonary hypertension. A transcriptomic lung analysis showed a dysregulation of many genes involved in main endothelial functions. In the second work, a interleukin-6 deficiency was shown to be associated with higher pulmonary inflammation and edema. An increase in total pulmonary resistances was also observed, but prevented with a human recombinant interleukin-6 treatment and at least partially attributed to a nitric oxide synthase-dependent dysregulation of the pulmonary vasoreactivity. In the third work, we compared young adult and mature adult mice and we observed an age-dependent severity, including a higher systemic and pulmonary inflammation, a higher alveolocapillary leak and a higher bronchoalveolar angiopoietin 2, suggestive for a severe endothelial injury. Our results might contribute to identify new therapeutic pathways targeting pulmonary microvessels during ARDS.Key words: acute respiratory distress syndrome, mechanical ventilation, pulmonary hypertension, pulmonary vascular dysfunction, aging, interleukin-6, recruitment maneuvers.

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.

Background: General anesthesia usually requires mechanical ventilation, which is traditionally accomplished with constant tidal volumes in volume- or pressure-controlled modes. Experimental studies suggest that the use of variable tidal volumes (variable ventilation) recruits lung tissue, improves pulmonary function and reduces systemic inflammatory response. However, it is currently not known whether patients undergoing open abdominal surgery might benefit from intraoperative variable ventilation. Methods/Design: The PROtective VARiable ventilation trial ('PROVAR') is a single center, randomized controlled trial enrolling 50 patients who are planning for open abdominal surgery expected to last longer than 3 hours. PROVAR compares conventional (non-variable) lung protective ventilation (CV) with variable lung protective ventilation (VV) regarding pulmonary function and inflammatory response. The primary endpoint of the study is the forced vital capacity on the first postoperative day. Secondary endpoints include further lung function tests, plasma cytokine levels, spatial distribution of ventilation assessed by means of electrical impedance tomography and postoperative pulmonary complications. Discussion: We hypothesize that VV improves lung function and reduces systemic inflammatory response compared to CV in patients receiving mechanical ventilation during general anesthesia for open abdominal surgery longer than 3 hours. PROVAR is the first randomized controlled trial aiming at intra- and postoperative effects of VV on lung function. This study may help to define the role of VV during general anesthesia requiring mechanical ventilation.

The diploma thesis deals with the analysis of problems of unevenly stratified air flow in air handling units and subsequent optimization with respect to speed ratios, energy efficiency and legislative requirements. Methods of solving the problem are theoretical and experimental, while the theoretical part deals with air distribution by means of air-conditioning fans with a focus on their aerodynamics, pressure conditions and other requirements, which are an integral part of properly designed equipment. In the experimental part of the thesis was applied a proposal of an innovative technical approach to a specific model of air conditioning assembly, which was implemented in the laboratories of the Institute of Building Services.