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.

In title 12, 22, 11 are in subscript. / Thesis (PhD)--Stellenbosch University, 2002. / ENGLISH ABSTRACT: The aim of this study was to test a synthetic protein-free surfactant preparation, LPM-l, with the same chemical composition as commercially available Exosurf (Glaxo Wellcome), but containing in addition, a sugar, trehalose (TRE). Towards this end, a study was designed to firstly test the hypothesis that the true difference in acute physiological effects between a mixture of oppe, tyloxapol, hexadecanol and trehalose (LPM-l), and Exosurf, (Oppe, tyloxapol and hexadecanol) is zero, in a surfactantdeficient animal model. A second study addressed the physiological effects of oppe, hexadecanol, tyloxapol and trehalose (LPM-l) compared to treatment with trehalose (TRE) or saline, in order to determine (1) the contribution of TRE to the mixture of oppe, hexadecanol and tyloxapol, and (2) to assess the effect of the LPM-l surfactant replacement on the epithelial lining fluid composition by means of analysing bronchoalveolar lavage fluid. Thirdly, the effects of TRE and / or calcium were studied on the surface properties of oppe suspensions, by in vitro analysis using the ring detachment method of Du Nouy The in vivo research comprised of two studies, performed in randomised controlled fashion. In the first study, 24 New Zealand White adult rabbits were randomised into 4 groups, while in the second study, 15 animals were randomised into 3 groups. In the first in vivo study, three synthetic surfactants, LPM-l, Exosurf and LPM-2, and a saline group were tested. LPM-l is a new formulation that consists ofa mixture of Df'PC, TRE, hexadecanol and tyloxapol. LPM-2 is a formulation with a composition equivalent to that of commercially available Exosurf, prepared on site. In both studies animals were subjected to repeated lavage with large volumes of warm saline (25 ml/kg) in order to establish surfactant deficiency and acute lung injury. Five minutes after the last lavage, vehicle, i.e. surfactants LPM-l, Exosurf, or LPM-2, or saline, in the first in vivo study, and LPM-l, TRE or saline in the second in vivo study, was instilled, and the course of the animals followed over the next 3 hours. Ventilator settings were standardized before and after lavage. The effects of surfactant treatment on gas exchange (arterial Pa02, oxygenation index (Ol), arterial-alveolar oxygen (a/A) ratio), percentage calculated shunt, and total dynamic respiratory compliance (CRSdyn), and histopathological changes were compared with changes in saline treated controls. Arterial blood gases in 100% oxygen and CRSdynwere measured before and after lavage, at 15 minute intervals for the first 30 min, then at 60, 90, 120, and 180 min after vehicle instillation. Oxygenation improved to a similar extent after LPM-l and Exosurf instillation, surpassing that of LPM-2 or saline. Overall, intratracheal instillation of both Exosurf and LPM-l, rapidly improved the gas exchange and reduced the intrapulmonary shunt, but did not restore the lung to its pre-lavage condition. From the 2nd in vivo study it was evident that trehalose-only, was inefficient as a lung surfactant, failing to improve oxygenation indices or the calculated percentage shunt, or influencing respiratory compliance. The addition of the sugar, trehalose (TRE), to the on-site 'Exosurf mixture (LPM-2) brought the activity of the resultant LPM-l to the same level as that of commercial Exosurf, but failed to raise the activity above that of Exosurf. These physiological improvements were sustained for up to 3 hours. Saline-treated animals had no improvement in gas exchange despite management with variable PIP (to maintain a tidal volume of -1 0 ml / kg) and constant PEEP of 5 cm H20. In-vitro results, obtained by the Ou Nouy tensiometer, showed higher mean ordinate surface tension values for the OPPC-only and DPPC + TRE mixtures, and the slopes of their respective graphs smaller in magnitude than those of the other formulations, suggesting that these formulations had less surface tension-lowering capability than the other surfactants. At 20°C (20 mg / ml DPPC-surfactants) the mean ordinate values of OPPC and OPPC + TRE, 70.13 and 69.47 dyne / cm, respectively, were not significantly different from each other. The mean ordinate values of LPM-l and the formulation containing OPPC + TRE + tyloxapol + CaCh were lower, but similar, as were the values of LPM-2 (on-site Exosurf) and LPM-2 + CaCho Thus, three internally homogeneous subgroups could be identified which differed significantly, namely: DPPC and DPPC + TRE, LPM-2 and LPM-2 + CaCh, and DPPC + TRE + tyloxapol + CaCh and LPM-l. Similar conclusions apply to the ordinate values of the surfactants at 37°C, and to the mean slope values at 20°C, with the exception that the subgroups, LPM-2 and LPM-2 + CaCh, and LPM-l and OPPC + TRE + tyloxapol + CaCh are not so clearly separated. A similar analysis of mean slope values was performed. Here too a significant difference between substances was found, OPPC alone or in combination with TRE, again being significantly different from the other surfactants. The most prominent light microscopy findings of the lungs of animals included general lymphatic dilatation, congestion and lung polymorphonuclear infiltration, with no difference between study groups. Hyaline membranes were present in all surfactant groups, but significantly more so in the saline treated group. In the first in vivo study, the presence of neutrophils in the lung interstitiwn as well as alveoli, was a common finding in all of the study groups towards the end of the study protocol. A significant increase in the BAL-fluid neutrophil count occurred in all animals, concurrent with a significant decrease in the BAL macrophage count. No significant change occurred in the peripheral neutrophil count during the 3-hour study, suggesting recruitment of neutrophils from storage pools. Treatment with synthetic surfactant (LPM -1) did not have a significant effect on modifying the inflammatory response, since there was no significant difference in the BAL-derived cell counts between the LPM-1 and -saline groups. Epithelial damage was a consistent finding in all groups. The damage was more evident by electron microscopy examination and included hydropic changes, most readily observed in the mitochondria. The airspaces of study subjects showed the presence of oedema fluid. This luminal oedema appeared to be more prominent in the control group and LPM-2 (on site 'Exosurf') group. Organellar debris, probably originating from lysis of epithelial cells, was present, despite treatment with synthetic surfactant. The electron microscopical appearance of the epithelial-lined substance ("hyaline membranes") in the present study showed a marked variability within groups as well as within the same case. The majority of cases showed a mix of membrane types with both granular and fibrillar materials present within the same membrane. In some cases there were layering of the membranes into distinct bands. The instillation of LPM-l resulted in the formation of a slightly different type of epithelial lining fluid after lavage, when compared to the prelavage composition. The most pronounced changes occurred within the fatty acids, whilst the phosphatidylcholine values remained unchanged. Palmitic acid concentrations (C16:0) increased significantly, suggesting enrichment of the epithelial lining fluid after instillation of LPM-l. This increase in C16:0 was concurrent with significant decreases in the percentage C16:1, C18:0, and C18:2. In contrast to previous studies, we describe higher levels for phosphatidyldimethylethanolarnine (PEA). An explanation may be that the lipid identified as PEA, was in fact partly phosphatidylglycerol (PG)-a lipid whose accurate identification was precluded for technical reasons. After surfactant instillation, the PC/SM ratio, a reflection of the lecithin / sphingomyelin (LIS), decreased significantly in the TRE-group between the first and final lavage, but remained statistically unchanged in the animals treated with LPM-l or saline. The change in ratio was mainly accounted for by a decrease in BAL-fluid PC content together with a rise in SM content. A poor correlation existed between the BAL-derived PC/SM ratio and indices reflecting oxygenation status (a/A ratio, Ol), as well as the CRSdynat the time of the final lavage. In conclusion, the primary hypothesis was accepted, LPM-l performed similarly to Exosurf in vivo, improving oxygenation, but not CRSdyn.None was clearly superior to the other. Some questions remain. The reason why LPM-l (LPM-2 + TRE) did not behave in a superior manner, in vivo, to Exosurf, is partly unclear. This finding was somewhat surprising since the chemical composition of Exosurf and LPM-2 did not differ, and the addition of TRE to LPM-2 (on-site Exosurf), did improve the in vivo activity of the resultant LPM-l, above that of LPM-2. A possible explanation for observed differences in performance include methodological issues, i.e. the preparation of the on-site formulations, especially that of LPM-2 (on-site Exosurf), may differ from the way in which true commercial Exosurf is prepared. / AFRIKAANSE OPSOMMING: Die doel van die studie was om 'n sintetiese proteïn vrye surfaktant te ontwikkel en die produk te vergelyk met 'n kunsmatige surfaktant reeds in kliniese gebruik. Die bekende uit die literatuur en die onbekende van die produk wat evalueer sou word, lei op tot die samestelling van die nul hipotese van die PhD naamlik dat geen verskil in longfunksie sou gewys word tussen die toetsproduk en reeds gebruikte kommersiële surfaktant nie. Die hipotese was dat 'n suiker (trehalose), in kombinasie met Dipalmitoiel fosfatidielcholine (DPPC), gaswisseling en longfunksies sal verbeter vir 'n long met 'n lae surfaktant konsentrasie. Vir die studie is jong volwasse wit New Zealand konyne gebruik en is hulle met 'n gestandaardiseerde en menslike manier gebruik in eksperimentele werk. Die diere is onder intraveneuse narkose geplaas en verskillende kardiovaskulêre en pulmonologiese aspekte is gemeet. Die long surfaktant is uitgewas deur middel van fisiologiese soutoplossing wat tot liggaam temperatuur verhit is en daarna is die diere prospektief gerandomiseer tot eksperimentele groepe. Met vooraf bepaalde tydsintervalle is die fisiologiese metings herhaal en was die metings toegespits daarop om longmeganiese funksie en gasoordrag vermoë te evalueer. Lig mikroskopiese en elektron mikroskopiese studies is ook op die longe gedoen en verder is brongoalveolêre vloeistof ook ontleed. Die groepe met ondersoek was: I. oppe, heksadekanol, tyloxapol en trehalose (LPM-I). 2. oppe, heksadekanol, tyloxapol (LPM-2 :. LPM-I sonder trehalose). Hierdie is 'n proteïnvrye surfaktant plaaslik berei ( dieselfde samestelling as Exosurf). 3. Exosurf®. (Kommersiële preperaat reeds in gebruik). Hierdie is 'n proteïnvrye sintetiese surfaktant. 4. Trehalose, 'n non-reduserende disakklaried van glukose. Addisioneel is daar ook in vitro studies gedoen waann die oppervlakte spanmngs aktiwiteite van die verskillende surfaktant oplossings vergelyk is. Die statistiese analise is gedoen in samewerking met Prof. J. Maritz wat 'n unieke metode ontwikkel en gepubliseer het om herhalende veranderlikes op 'n statisties verantwoordbare manier te ontleed. In die eerste van die studies, is LPM-I, Exosurf®, fisiologiese soutoplossing en 'n plaaslik bereide "Exosurf" (LPM-2), met 'n chemiese samestelling identies aan dié van kommersiële Exosurf®, evalueer. In 'n tweede studie is die fisologiese effekte van LPM-I vergelyk met trehalose of fisiologiese soutoplossing om die volgende te ondersoek: 1) Die bydrae van trehalose tot 'n mengsel van oppe, heksadekanol en tyloxapol (LPM-2). 2) Die gevolg van LPM-l surfaktant toediening op die konyn se brongo-alveolêre vloeistof samestelling. 'n Derde, in vitro studie, het die oppervlaktespannings-effekte van trehalose en of kalsiumbyvoegings tot DPPC-oplossings gemeet deur middel van die ring metode van Du Nouy, In die eerste in vivo studie verbeter oksigenasie en persentasie longaftakking tot dieselfde mate na LPM-l en Exosurf® toediening en word die hipotese van die proefskrif bevestig. In die breë gesien, is die tydsprofiele van LPM-l en Exosurf® ten opsigte van oksigenasie en persentasie longaftakking statisties betekenisvol beter en van 'n sneller aard, as die tydsprofiele van dieselfde indekse na die toediening van fisiologiese soutoplossing of LPM-2. Die tydsprofiel van dinamiese longvervormbaarheid, na die toediening van LPM-I of Exosurf®, is dieselfde, maar betekenisvol beter as die vervormbaarheid na toediening van LPM-2 of fisiologiese soutoplossing. Alhoewel die oksigenasie indekse in die geval van LPM-l en Exosurf® betekenisvol verbeter oor die studietydperk, vind volkome herstel tot die basislynwaardes (voor spoeling) nie plaas nie. Bykomend, geen van die surfaktante het na toediening enige noemenswaardige verbetering in longvervormbaarheid tot gevolg gehad nie. Die rede vir die swakker vertoning van LPM-2 en Exosurf is onbekend en sal in opvolg studie ondersoek word. In die tweede in vivo studie is dit duidelik dat trehalose op sy eie, 'n oneffektiewe surfaktant is aangesien die preperaat na toediening geen verbetering teweegbring ten opsigte van oksigenasie indekse, persentasie longaftakking, of long-dinamiese vervormbaarheid nie. Die toevoeging van trehalose tot LPM-2, om LPM-l te lewer, neem wel die aktiwiteit van LPM-l tot dieselfde in vivo vlak as dié van kommersiële Exosurf®, maar slaag nie daarim om 'n hoër fisiologiese in vivo aktiwiteit as dié produk te bereik nie. Die diere wat met fisiologiese soutoplossing behandel is toon geen verbetering in enige fisiologiese parameter nie. Die in vitro resultate wat verkry is deur die Du Nouy tensiometer toon hoër gemiddelde ordinaat oppervlaktespannings waardes vir 'n formule wat slegs uit DPPC bestaan, asook vir 'n mengsel van DPPC + trehalose. Die helling van die grafieke van hierdie oplossings is ook kleiner as die van die ander formulas wat daarop dui dat DPPC op sigself, en DPPC + trehalose, weinig vermoë het om oppervlaktespanning te verminder. Daarteenoor verlaag die volgende oplossings die oppervlaktespanning ten opsigte van gedistilleerde water betekenisvol en wel in In konsentrasie afhanklike manier by beide 21°C en 3rc: LMP-I-, LPM-2-, DPPC + trehalose + tyloxapol + CaCf2-, en LPM-2 + CaCf2. Die prominentste ligmikroskopiese bevindinge van die longe van die diere sluit in: Algemene limfvat dilatasie, stuwing, en long neutrofiel infiltrasie. Betreffende hierdie histologiese bevindinge is daar geen verskille aangetoon tussen die groepe nie. Hialienmembrane was teenwoordig in al die groepe, maar betekenisvol meer in die groep wat fisiologiese soutoplossing ontvang as vervangingsterapie. In die tweede in vivo studie is daar 'n betekenisvolle styging in die neutrofiel- en daling in makrofaagtelling, van die brongoalveolêre vloeistof spoeling in al drie die groep aangetoon. Terselfdertyd vind geen noemenswaardige daling in die perifêre (sistematiese) neutrofieltelling plaas nie. Hierdie bevindinge dui daarop dat die brongoalveolêre selveranderinge toegeskryf kan word aan verwerwing van neutrofiele vanuit 'n longstoringspoel eerder as rekrutering vanuit die sistemiese sirkulatoriese poel. Surfaktant (LPM-l), behandeling het geen betekenisvolle vermindering in long inflammasie teweeggebring nie. Epiteelskade was 'n algemene ligmikroskopiese bevinding in al die groepe. Die samestelling van die brongoalveolêre vloeistof verander na installering van LPM-I. Die prominentste verandering word waargeneem in die vetsuur samestelling terwyl die DPPC waardes onveranderd bly. Die vetsuur, palmitiensuur (palmitic acid), (CI6:0), verhoog betekenisvol na toediening van LPM-l. Daarteenoor verminder die konsentrasie van C16:1, C18:0 en C18:2. In kontras met vorige studies, beskryf die huidige studie hoër konsentrasies van fosfatidieletanolamien, moontlik as gevolg van tegniese verskille in die metingsmetodes. 'n Betekenisvolle verlaging in die fosfatidielcholine:sfingomiëlien (PC/SM) verhouding word waargeneem tussen die eerste en die finale longspoeling van die trehalose-groep, terwyl dit onveranderd bly in die diere wat LPM-1 of fisiologiese soutoplossing ontvang.

Les enjeux médicaux et le contexte socio-économique des maladies respiratoires ont une importance majeure à l'échelle mondiale. Parmi les procédures mini-invasives classiques de traitement des maladies respiratoires, l’aérosolthérapie se distingue par sa capacité d’administrer des médicaments pour les pathologies locales, directement dans les voies respiratoires, comme les sinus ou l’arbre trachéaux-bronchique. Dans ce contexte, l’utilisation de nanoparticules à visée pulmonaire est objet de grandes avancées en aérosolthérapie car les aérosols nanométriques ont la capacité de contourner les obstacles dans les voies aériennes supérieures et se déposer dans le poumon profond, renforçant ainsi la performance thérapeutique et diagnostique de ces aérosols. Afin de contribuer à l’évolution des traitements par aérosolthérapie cette thèse s’est orientée vers le développement des nouvelles techniques de génération d’aérosols nanométriques et submicroniques, capables de cibler des régions spécifiques de l'appareil respiratoire d'un patient. La problématique majeure à être confrontée dans ce contexte est donc l’adaptation de la taille des particules de l’aérosol afin de promouvoir un dépôt ciblé chez le patient. Pour cela il est d’abord nécessaire d’avoir une large gamme de tailles d’aérosols, de micronique à nanométrique, puis déterminer la relation entre la taille des particules et leur site de dépôt dans les voies respiratoires. De ce fait, les objectifs principaux de cette thèse sont la caractérisation métrologique et l’évaluation des performances des aérosols nanométriques en termes de cartographie de dépôt. Les résultats obtenus ont démontré qu’il est possible de générer efficacement des aérosols submicroniques et nanométriques soit solides soit liquides. Les aérosols contenant une plus grande quantité de nanoparticules ont montré un dépôt plus important dans les poumons, ce qui contribue au développement des techniques d'administration de médicaments par aérosolthérapies ainsi que pour des études toxicologiques. / Medical and socio-economic issues of respiratory diseases have a major importance in world medicine. Among the conventional minimally invasive procedures in the treatment of respiratory diseases, the aerosoltherapy distinguishes itself by its ability to deliver medication directly into the respiratory tract, such as the sinuses or the tracheal-bronchial tree. In this context, the use of nanoparticles to target the lungs is object of great advances in aerosoltherapy as nanometric aerosols have the ability to overcome obstacles in the upper airways and deposit in the deep lung, increasing the therapeutic and diagnostic performance of these aerosols. In order to contribute with the advance of aerosoltherapy treatments this thesis is directed towards the development of new techniques of generation of nanometric and submicronic aerosols, able to target specific regions of the respiratory system of a patient. The major problem within this context is the adjustment of the aerosol’s particle size in order to promote a targeted deposition in a patient. Therefore, it is firstly necessary to have a wide range of aerosols sizes, from micronic to nanometric, and then it is needed to determine the relationship between particle size and deposition site in the respiratory tract. As a result, the main objectives of this thesis are the metrological characterization of nanometric aerosols and the evaluation of its performance in terms of its deposition in the respiratory tract. The achieved results have demonstrated that is possible to efficiently generate submicronic and nanometric aerosols, either with solid or liquid particles. Aerosols containing a higher amount of nanoparticles showed a larger deposit in the lungs that may contribute to the advancement of aerosoltherapy techniques as well as for toxicological studies.

Chronic respiratory diseases (CRDs) include chronic diseases involving the airways and other structures of the lung. In the current circumstance of Vietnam, people are exposed to numerous risk factors of CRD, such as heavy smoking, high frequency of pulmonary tuberculosis, chronic helminthiasis, allergic factors, migration and urbanization (the last associated with traffic-related pollution). The phenotype diagnoses should take into account the risk factors of each individual besides the clinical features, while the differential diagnoses mostly depend on the available techniques in each healthcare center. Our aim was to improve the differential diagnoses of the 3 most frequent CRDs: chronic obstructive pulmonary disease (COPD), asthma and COPD – asthma overlap syndrome (ACOS), in Vietnam. In the first part, we evaluated the prevalence of the allergen sensitization among patients with CRD, in regard to the urban and rural area in the South of Vietnam. House dust mites and cockroach droppings were the most frequent sensitizer. Compared with participants born in the urban setting, those born in the rural environment were less frequently sensitized and this protective effect disappeared in the case of migration from rural to urban areas. In the second part, we evaluated skin prick test as a method to screen dust mite sensitization in CRD in southern Vietnam. The data suggested that, in the present circumstance, skin prick test can be used to screen mite sensitization. In the third part, we evaluated the risk of mite sensitization in the native and migrant population, in regard to several environmental factors. Consistently with the hygiene hypothesis, compared to urban, exposure to high endotoxin concentration in rural was a protective factor against allergic sensitization. We reported for the first time that this effect was reversible among the migrants from rural to urban setting in association with lower endotoxin exposure. In the fourth part, we have defined asthma, COPD and ACOS based on clinical symptoms, cumulative smoking and airway expiratory flow with reversibility, on one side, and the age-related of the different phenotypes, on the other side. We hypothesized that the cumulative exposure to noxious particles should increase the age-related prevalence of COPD, while due to the immunosenescence process, the prevalence of IgE-mediated asthma should decrease with age, and ACOS prevalence being not related to age due to the combined mechanisms.  In conclusion, we showed in the South of Vietnam that:1) mites and cockroach allergens were the most frequent sensitizer in chronic respiratory diseases;2) the skin prick test to mite has been validated to screen mite sensitization;3) associated with a reduced level of endotoxin level, migration from rural to the urban setting was a risk factor of mite sensitization in chronic respiratory diseases;4) based on the clinical symptoms, spirometric values, and cumulative smoking, the diagnosis of asthma, COPD and ACOS have been made and their prevalence were 25, 42 and 33%, respectively. / Doctorat en Sciences biomédicales et pharmaceutiques (Médecine) / info:eu-repo/semantics/nonPublished

Orientador: Sandra Elisa Contir Pitton / Banca: Ari Menardi Junior / Banca: Lucy Marion Calderini Philadelpho Machado / Resumo: O trabalho científico em questão buscou de um modo claro, unir todas as nuances relevantes ao tema proposto, mesclando Geografia, Medicina e Direito, numa redação coesa e enriquecida com dados estatísticos e muita discussão teórica. Inicialmente, discutiu-se questões preliminares da Geografia da Saúde, pontuando observações terminológicas e metodológicas, consagrando assim uma ruptura institucional com antigas formas de produção científica. Num segundo plano, destacou-se a qualidade de vida como de difícil constatação qualitativa ou quantitativa, verificando-se a saúde como um de seus indicadores de grande importância. Neste contexto, procurou-se nos dados coletados, sublimar as doenças mais corriqueiras, com influência internacional, que tivessem vínculos com atitudes omissivas ou comissivas de Estados independentes e de notoriedade indispensável à boa qualidade de vida, ou com a própria sobrevivência humana. Emergiu a questão do ar como objeto de estudo, levantando cientificamente a circulação das massas de ar e, por conseguinte, o caminhar das impurezas aéreas, causadoras e catalisadoras das doenças respiratórias. Isto posto, verificou-se que o tema possuía grande inserção na questão da soberania de Estados independentes, tendo sido de suma importância discorrer sobre a gênese do Estado moderno e assim, discutir nas considerações finais, sobre as necessidades institucionais para que se garanta a soberania, respeitando o planeta como um grande Sistema. / Abstract: This scientific work aimed at clearly putting together all the relevant nuances considering the proposed issue, mixing up Geography, Medicine and Laws, in a cohesive writing enriched by statistical data and lots of oral discussion. At the beginning the preliminary questions like the Geography of Health were discussed, pointing out terminological and methodological observations, therefore obtaining an institutional breakup with the old forms of scientific production. In a second phase, the quality of life was shown to be of difficult qualitative and quantitative verification, health being one of its most important indicators. In such context, we tried to point out from the collected data, the most common deceases with international influences, which had to do with negligent or wrong attitudes by independent states and of high significance to the quality of life or to human survival. Then the issue of the air as an object of study arose, scientifically studying the circulation of masses of air and therefore the trips of air impurities, which cause respiratory deceases. Afterwards we could realize both that the issue was of great value towards the question of the sovereignty of independent states and that the discussion on the genesis of the modern state was highly important, which led us to the final considerations about the institutional needs for the sovereignty to be guaranteed, respecting the planet as a great System. / Mestre

INTRODUÇÃO: O Estado de São Paulo é o maior produtor de cana-de-açúcar dentre os demais estados da federação, alcançando uma área de 5.768.184 hectares (ha) cultivada no ano de 2013. Diversos estudos desenvolvidos recentemente no Brasil apontam para os impactos negativos à saúde humana no processo de colheita por meio da queima da cana-de-açúcar. Em 2007, foi assinado o Protocolo de Cooperação (Protocolo do Etanol Verde) entre o setor sucroalcooleiro e o governo estadual visando à antecipação das metas de redução de queima de cana-de-açúcar por meio do processo de mecanização da colheita. Diante deste cenário, faz-se necessária uma análise sobre os impactos à saúde humana neste período de implantação de práticas sustentáveis. OBJETIVO: Este trabalho tem como objetivo avaliar o impacto da produção canavieira, após a assinatura do Protocolo Etanol Verde (2007), em alguns municípios do noroeste paulista por meio da análise das evoluções dos métodos de colheita da cana-de-açúcar possíveis associações com as doenças do aparelho respiratório. METODOLOGIA: . A área de estudo foi definida por meio de técnicas de análise espacial utilizando o software ARCGIS 10.1 com criação de shapefile de incidência de internações por doenças do aparelho respiratório por município e calculado o Índice Local de Moran, possibilitando a identificação dos municípios com maiores incidências e que formam aglomerados espaciais (clusters). Foram consolidados dados secundários de internações por doenças respiratórias em todos os municípios do Estado de São Paulo entre os anos de 2008 e 2012, levando em consideração o mês mais seco do ano (julho) para composição da incidência. Concomitantemente, os aspectos socioeconômicos e físicos relevantes foram caracterizados na área de estudo. Em seguida, foi realizada a análise espacial da distribuição dos métodos de colheita de cana-de-açúcar nos 25 municípios selecionados e foram definidas variáveis de risco associadas à distribuição espacial da colheita e que potencializam o impacto na saúde respiratória da população, levando-se em consideração o decreto 47.700, SMA - SAA 004/08 e outras referências. A partir dos dados levantados, correlações foram calculadas entre as variáveis,(Regressões lineares e correlação de Pearson, p<ou=0,05) RESULTADOS: A maioria das variáveis analisadas apresentaram significância estatísica quando correlacionadas com a variável incidência de internações por doença do aparelho respiratório (p<0,05) . A força das correlações (r), entretanto, variou entre os municípios. Os municípios com as maiores incidências de internação apresentaram os valores (r) mais próximo de 1 ou -1. Identificou-se através da ferramenta de geoprocessamento near analysis diversas áreas de queima a menos de 01 km das sedes municipais. CONCLUSÃO: Levando em consideração os impactos da produção de cana-de-açúcar sobre a saúde respiratória nos municípios do Noroeste Paulista, pode-se constatar que houve uma tendência diminuição das taxas de internação no período 2008 - 2012, entretanto as incidências de julho de 2009 e 2011 apresentaram aumento. Poucos municípios atingiram as metas propostas pelo Protocolo de Cooperação, alguns deles chegaram a ter áreas de queima em distâncias muito próximas à sede urbana, ainda que não comprovado neste estudo a causa e o efeito desta ação. Pequenos municípios tendem a sofrer mais com a colheita não mecanizada em função da falta de mecanismos de fiscalização e recurso humano dentre outras questões apontadas no estudo. Além disso, os aspectos socioeconômicos contribuem significativamente para o agravo da situação, em especial os associados à deficiência dos serviços voltados a atenção básica destes municípios. / INTRODUCTION: The State of São Paulo is the largest producer of sugarcane among the other states of the country, reaching an area of 5,768,184 hectares (ha) planted in 2013 Several recent studies developed in Brazil point to. negative impacts on human health in the process of picking through the burning of cane sugar impacts. In 2007, the Protocol of Cooperation (Green Ethanol Protocol) was signed between the sugar and alcohol sector and the state government seeking to advance the goals of reducing the burning of cane sugar by the process of mechanical harvesting. Given this scenario, it is necessary to analyze the impacts to human health in this period of implementation of sustainable practices. OBJECTIVE: This study aims to evaluate the impact of sugarcane production, after signing the Protocol Ethanol Green (2007), in some municipalities in the northwest region by analyzing the evolution of methods of harvesting cane sugar, on diseases the respiratory system. METHODOLOGY:. The study area was defined by spatial analysis using ArcGIS 10.1 software to create shapefile incidence of hospitalizations for respiratory diseases by county and calculated the Local Moran Index, allowing the identification of municipalities with higher incidences and forming spatial clusters (clusters). Secondary data on admissions for respiratory diseases were consolidated in all counties of the State of São Paulo between 2008 and 2012, taking into account the driest month of the year (July) for composition of incidence. Concomitantly, the relevant socioeconomic and physical aspects were characterized in the study area. Then, the spatial distribution analysis of methods of harvesting sugar cane in 25 selected municipalities was performed and risk variables associated with the spatial distribution of harvest were defined and potentiate the impact on the respiratory health of the population, taking into consideration the decree 47.700, SMA - SAA - 004/08 and other references. From the data collected, correlations were calculated between the variables (linear regressions and Pearson\'s correlation, p <or = 0.05) RESULTS. When correlated to the incidence of hospitalizations by respiratory diseases, the majority of variables presented statistical significance (p<0,05). However, the strength og correlations (r) varied widely among the municipality. Municipalities with the highest hospitalization incidences presented r values close to 1 or -1. Besides, many burning areas were identified at less of 1km from municipality centers by the geoprocessing tool near analysis. CONCLUSION: Taking together the sugarcane production impacts on the respiratory health at the Paulista Northwest municipalities, we can observe a decrease of hospitalization rates between the years of 2008 and 2012, nevertheless incidences at July 2009 and July 2011 increased. A minority of municipalities reached the purposed goals by the Protocol of Cooperation, with some still presenting burning areas very close to the urban center, even if not proved by this study the cause and effect of this action. Small municipalities trend to suffer more with the non automatized harvesting by the lack of surveillance mechanisms and human resources among other issues highlighted by this study. Besides, socioeconomic aspects count to a significant harm of the analyzed condition, especially those associated to the basic health care services deficiency.

O conhecimento antecipado das condições meteorológicas poderá ajudar a sociedade a evitar prejuízos e desperdícios de recursos humanos e materiais. Portanto, o objetivo deste estudo foi obter a partir de uma análise estatística um modelo capaz de predizer internações a partir dos dados de poluição do ar e índices biometeorológicos. Para isso, foram utilizados dados diários de 1997 a 2000, referentes à cidade de São Paulo. Os dados de internações por doenças respiratórias foram divididos em três categorias: AVAS (Afecções Vias Aéreas Superiores), AVAI (Afecções das Vias Aéreas Inferiores) e IP (Influenza e Pneumonia), estes dados foram obtidos junto ao Ministério da Saúde. Os dados referentes à poluição foram obtidos junto à CETESB (Companhia de Tecnologia de Saneamento Ambiental) e os dados meteorológicos foram obtidos da estação meteorológica do Parque Estadual das Fontes do Ipiranga. Os índices de conforto térmico foram descritos com base em variáveis meteorológicas. Através de uma metodologia estatística de Regressão de Poisson e Análise de Componentes Principais (ACP), encontraram-se modelos estatísticos capazes de prever em média internações por doenças respiratórias. Esses modelos foram nomeados MBCS (Modelo Brasileiro de Clima e Saúde). A ACP foi utilizada a fim de corroborar a modelagem de regressão. Os resultados encontrados mostraram associação entre AVAS e SO2, CO (ambos sem defasagem) e com o índice biometeorológico TEv4 (com defasagem de 4 dias). Os resultados chamam atenção para o SO2 que, mesmo muito abaixo do padrão de qualidade do ar recomendado, ainda provoca acréscimos nas internações. Para as AVAI, os resultados mostram associações entre os poluentes MP10, O3 (ambos sem defasagem) e TEv4 (com 3 dias defasamento). Com relação à IP, as variáveis que se mostraram relacionadas foram MP10 (sem defasagem) e TEv4 (com 3 dias defasagem). Para verificar o skill do modelo, utilizou-se o ano de 2001. Os modelos apresentaram erro médio de 15% para AVAS, 30% para AVAI e 44% para IP com relação à previsão das internações. No que diz respeito a ACP, esta concorda com o que foi encontrado na modelagem de Poisson. Porém para AVAI e IP, os escores dos poluentes e dos índices deverão ser usados separadamente. Estes resultados mostram que o MBCS poderá ser utilizado para previsão de internação, contribuindo para políticas públicas e os meios de comunicação, ajudando nas tomadas de decisões e evitando desperdícios econômicos e humanos. / The meteorological condition knowledge can provide society prejudice prevention regarding human and material resources. Therefore, the aim of this study the statistical modeling in order to prevent internment of morbidity based on air pollution and meteorological variability. The whole 1997 to 2000 at the city of São Paulo. The morbidity data was divided in to three categories: AVAS (upper respiratory airway diseases), AVAI (lower respiratory airway diseases) and IP (Influenza and Pneumonia). These data were obtained from Brazilian Heath Ministry. Air pollution data were obtained from CETESB (Environmental agency) and meteorological data from Parque Estadual das Fontes do Ipiranga. Thermal comfort indexes were also used based on meteorological variables. Poisson regression models as well as Principal Component (PC) models were used in order to evaluate the data through statistical methodology. These models were nominated MBCS (Brazilian Climate and Health Model). Scores from PC statistical analysis were also used in order to compare to multiple regression models. As the first results, AVAS modeling presents association with SO2, CO (both without time lag) and the TEv4- a biometeorological index (with 4 days time lag). SO2 presents interesting result due to the fact that it is below the recommended standard, but it still causes AVAS morbidity. Concerning AVAI results, the variables which explain the morbidity were the pollutants MP10, O3 (both without lag) and TEv4 (with 3 days lag). Regarding to the skill of the models, AVAS model presents a 15% average error; AVAI model, 30% and IP model, 44%, during year of 2001. PC analysis corroborated the Poisson models. Regarding PC more weight for AVAS was pollutants. Already AVAI and IP more weight was biometeorological indexes and meteorological variables. The risk results used scores was similar to the MMRP. However for AVAI and IP, the scores of the pollutants and scores of the indexes should be used individually. These results indicate these models can be used as a forecasting internment program, contributing on the public and media decisions, avoiding economical and human unnecessary wastes.

O Vírus Respiratório Sincicial humano (hRSV human Respiratory Syncytial Virus) está entre os principais causadores de doenças do trato respiratório. O hRSV pertence à família Paramyxoviridae. Os sintomas da infecção podem variar de simples estado gripal a doença respiratória grave, e eventualmente levar a óbito. Atualmente não há vacina licenciada ou droga eficaz contra esse vírus. Anteriormente foram obtidos, em nosso laboratório, vetores com genes otimizados. Com essas ferramentas a proteína M foi produzida e purificada tendo sido possível obter anticorpos policlonais específicos e eficientes na sua detecção. Com esses anticorpos confirmamos a interação da proteína M com as proteínas celulares tropomiosina e nucleofosmina. Também foi demonstrado por imunofluorescência e por western blotting que a proteína M quando expressa fora do contexto de infecção apresenta localização nuclear e citoplasmática. Foram feitos testes de imunização com a proteína M purificada ou com um vetor eucariótico que a expressa (DNA). A imunização com proteína M resultou apenas em resposta humoral, enquanto com a vacina de DNA obtivemos apenas resposta celular. Nenhum desses imunógenos, entretanto, foi capaz de conferir proteção contra hRSV. / The human Respiratory Syncytial Virus (hRSV) is among the main causes of respiratory tract diseases, hRSV belongs to the Paramyxoviridae family. The symptoms of the infection can range from simple flulike state to severe respiratory disease eventually leading to death. Currently there is no licensed vaccine or effective drug against this virus. Vectors with genes optimized for of the hRSV Matrix protein (M) expression in bacteria and in eukaryotic cells were previously obtained in our lab. With these tools the M protein was produced and purified. Specific and efficient polyclonal antibodies could then be obtained and used for its detection. Using these antibodies we confirmed M interaction with cellular proteins tropomyosin and nucleophosmin. It was also demonstrated by immunofluorescence and western blotting that protein M when expressed out of viral infection context, presents cytoplasmic and nuclear localization. Immunization tests were made with the purified M protein or with a eukaryotic vector that expresses it (DNA). Immunization with M protein resulted only in humoral response, while with the DNA vaccine only cellular response was obtained. None of these antigens, however, was able to confer protection against hRSV.

Esta tese analisou o efeito da poluição atmosférica nas doenças respiratórias em crianças de 0 (zero) a 6 (seis) anos de idade incompletos residentes em Campinas, Cubatão, Santos, São José dos Campos, São José do Rio Preto e Santo André, caracterizados por seus diferentes perfis de emissão de poluentes do ar, no período de janeiro de 2011 a dezembro de 2014. As concentrações dos poluentes (PM10, NO2, SO2 e O3) foram extraídas de relatórios da CETESB. Foram usados modelos de defasagem com distribuição polinomial, além de uma metarregressão para o PM10, identificando um padrão de efeito deste poluente, independentemente de sua composição. O NO2 e o SO2 não apresentaram concentrações fora dos padrões de qualidade do ar em nenhum dos municípios. O O3 se apresentou em concentrações acima dos padrões de qualidade do ar em diversos dias no período estudado, em todos os municípios, trazendo grande preocupação com relação aos agravos à saúde oriundos deste poluente. O efeito do interquartil (13,81?g/m3) na concentração de PM10 na saúde respiratória das crianças em Campinas foi um aumento de 10,45% (IC95%: 6,39-14,51) dos casos de internação, com efeito já no dia 0; em Cubatão o aumento das internações foi de 14,49% (IC95%: 5,56-23,42); em São José dos Campos o aumento foi de 8,64% (IC95%: 2,41-14,86) nos casos de internações, com uma elevação nestes dados a partir do dia 1; em São José do Rio Preto, no dia da exposição à elevação de concentração de PM10 o aumento de internações nas crianças já foi de 5,75% (IC95%: 1,26-10,25), maior que a somatória dos eventos em uma semana; Santo André, teve um incremento nas internações a partir do dia 1, com uma somatória de 7,30% (IC95%: 1,34-13,25) após seis dias de exposição. Santos não possui significância no efeito adverso em nenhum dos dias após o dia de exposição, nem na somatória dos eventos, mesmo com uma elevação apresentada na ordem de 4,81%. Confirma-se o padrão de efeito, independente do perfil de emissão do PM10 com efeito adverso estatisticamente significante nos dias 0 e 1, respectivamente com 1,84% (IC95%: 1,78-1,89) e 1,03% (IC95%: 1,00-1,07) de aumento nos casos de internações nas crianças expostas / This thesis analyzed the effect of atmospheric pollution on respiratory diseases in children from 0 (zero) to 6 (six) years of age incomplete residing in Campinas, Cubatão, Santos, São José dos Campos, São José do Rio Preto and Santo André, characterized by their different emission profiles of air pollutants in the period from January 2011 to December 2014. The concentrations of pollutants (PM10, NO2, SO2 and O3) were extracted from CETESB reports. Lag models with polynomial distribution were used, in addition to a metarregression for PM10, identifying a pattern of effect of this pollutant, regardless of its composition. NO2 and SO2 did not present concentrations outside the air quality standards in any of the municipalities. O3 was present in concentrations above air quality standards in several days during the study period, in all municipalities, bringing great concern regarding health problems arising from this pollutant. The effect of interquartile (13,81?g/m3) on the concentration of PM10 in the respiratory health of children in Campinas was an increase of 10.45% (95%CI: 6,39-14,51) of the cases of hospitalization, with effect already on day 0; in Cubatão, the increase in hospitalizations was 14.49% (95%CI: 5.56-23,42); in São José dos Campos the increase was 8.64% (95%CI: 2,41-14,86) in cases of hospitalizations, with an elevation in these data from day 1; in São José do Rio Preto, on the day of exposure to the elevation of PM10 concentration, the increase in hospitalizations in children was 5.75% (95%CI: 1.26-10,25), higher than the sum of the events in one week; Santo André, had an increase in hospitalizations from day 1, with a summation of 7.30% (95%CI: 1.34-13,25) after six days of exposure. Santos does not have any significance in the adverse effect in any of the days after the day of exposure, nor in the summation of the events, even with an elevation presented in the order of 4.81%. The effect pattern is confirmed regardless of the PM10 emission profile with a statistically significant adverse effect on days 0 and 1, respectively with 1.84% (95%CI: 1.78-1,89) and 1.03% (95%CI: 1.00-1.07) of increase in cases of hospitalizations in children exposed

INTRODUÇÃO: O Estado de São Paulo é o maior produtor de cana-de-açúcar dentre os demais estados da federação, alcançando uma área de 5.768.184 hectares (ha) cultivada no ano de 2013. Diversos estudos desenvolvidos recentemente no Brasil apontam para os impactos negativos à saúde humana no processo de colheita por meio da queima da cana-de-açúcar. Em 2007, foi assinado o Protocolo de Cooperação (Protocolo do Etanol Verde) entre o setor sucroalcooleiro e o governo estadual visando à antecipação das metas de redução de queima de cana-de-açúcar por meio do processo de mecanização da colheita. Diante deste cenário, faz-se necessária uma análise sobre os impactos à saúde humana neste período de implantação de práticas sustentáveis. OBJETIVO: Este trabalho tem como objetivo avaliar o impacto da produção canavieira, após a assinatura do Protocolo Etanol Verde (2007), em alguns municípios do noroeste paulista por meio da análise das evoluções dos métodos de colheita da cana-de-açúcar possíveis associações com as doenças do aparelho respiratório. METODOLOGIA: . A área de estudo foi definida por meio de técnicas de análise espacial utilizando o software ARCGIS 10.1 com criação de shapefile de incidência de internações por doenças do aparelho respiratório por município e calculado o Índice Local de Moran, possibilitando a identificação dos municípios com maiores incidências e que formam aglomerados espaciais (clusters). Foram consolidados dados secundários de internações por doenças respiratórias em todos os municípios do Estado de São Paulo entre os anos de 2008 e 2012, levando em consideração o mês mais seco do ano (julho) para composição da incidência. Concomitantemente, os aspectos socioeconômicos e físicos relevantes foram caracterizados na área de estudo. Em seguida, foi realizada a análise espacial da distribuição dos métodos de colheita de cana-de-açúcar nos 25 municípios selecionados e foram definidas variáveis de risco associadas à distribuição espacial da colheita e que potencializam o impacto na saúde respiratória da população, levando-se em consideração o decreto 47.700, SMA - SAA 004/08 e outras referências. A partir dos dados levantados, correlações foram calculadas entre as variáveis,(Regressões lineares e correlação de Pearson, p<ou=0,05) RESULTADOS: A maioria das variáveis analisadas apresentaram significância estatísica quando correlacionadas com a variável incidência de internações por doença do aparelho respiratório (p<0,05) . A força das correlações (r), entretanto, variou entre os municípios. Os municípios com as maiores incidências de internação apresentaram os valores (r) mais próximo de 1 ou -1. Identificou-se através da ferramenta de geoprocessamento near analysis diversas áreas de queima a menos de 01 km das sedes municipais. CONCLUSÃO: Levando em consideração os impactos da produção de cana-de-açúcar sobre a saúde respiratória nos municípios do Noroeste Paulista, pode-se constatar que houve uma tendência diminuição das taxas de internação no período 2008 - 2012, entretanto as incidências de julho de 2009 e 2011 apresentaram aumento. Poucos municípios atingiram as metas propostas pelo Protocolo de Cooperação, alguns deles chegaram a ter áreas de queima em distâncias muito próximas à sede urbana, ainda que não comprovado neste estudo a causa e o efeito desta ação. Pequenos municípios tendem a sofrer mais com a colheita não mecanizada em função da falta de mecanismos de fiscalização e recurso humano dentre outras questões apontadas no estudo. Além disso, os aspectos socioeconômicos contribuem significativamente para o agravo da situação, em especial os associados à deficiência dos serviços voltados a atenção básica destes municípios. / INTRODUCTION: The State of São Paulo is the largest producer of sugarcane among the other states of the country, reaching an area of 5,768,184 hectares (ha) planted in 2013 Several recent studies developed in Brazil point to. negative impacts on human health in the process of picking through the burning of cane sugar impacts. In 2007, the Protocol of Cooperation (Green Ethanol Protocol) was signed between the sugar and alcohol sector and the state government seeking to advance the goals of reducing the burning of cane sugar by the process of mechanical harvesting. Given this scenario, it is necessary to analyze the impacts to human health in this period of implementation of sustainable practices. OBJECTIVE: This study aims to evaluate the impact of sugarcane production, after signing the Protocol Ethanol Green (2007), in some municipalities in the northwest region by analyzing the evolution of methods of harvesting cane sugar, on diseases the respiratory system. METHODOLOGY:. The study area was defined by spatial analysis using ArcGIS 10.1 software to create shapefile incidence of hospitalizations for respiratory diseases by county and calculated the Local Moran Index, allowing the identification of municipalities with higher incidences and forming spatial clusters (clusters). Secondary data on admissions for respiratory diseases were consolidated in all counties of the State of São Paulo between 2008 and 2012, taking into account the driest month of the year (July) for composition of incidence. Concomitantly, the relevant socioeconomic and physical aspects were characterized in the study area. Then, the spatial distribution analysis of methods of harvesting sugar cane in 25 selected municipalities was performed and risk variables associated with the spatial distribution of harvest were defined and potentiate the impact on the respiratory health of the population, taking into consideration the decree 47.700, SMA - SAA - 004/08 and other references. From the data collected, correlations were calculated between the variables (linear regressions and Pearson\'s correlation, p <or = 0.05) RESULTS. When correlated to the incidence of hospitalizations by respiratory diseases, the majority of variables presented statistical significance (p<0,05). However, the strength og correlations (r) varied widely among the municipality. Municipalities with the highest hospitalization incidences presented r values close to 1 or -1. Besides, many burning areas were identified at less of 1km from municipality centers by the geoprocessing tool near analysis. CONCLUSION: Taking together the sugarcane production impacts on the respiratory health at the Paulista Northwest municipalities, we can observe a decrease of hospitalization rates between the years of 2008 and 2012, nevertheless incidences at July 2009 and July 2011 increased. A minority of municipalities reached the purposed goals by the Protocol of Cooperation, with some still presenting burning areas very close to the urban center, even if not proved by this study the cause and effect of this action. Small municipalities trend to suffer more with the non automatized harvesting by the lack of surveillance mechanisms and human resources among other issues highlighted by this study. Besides, socioeconomic aspects count to a significant harm of the analyzed condition, especially those associated to the basic health care services deficiency.