Bilevel vs ICU Ventilators Providing Noninvasive Ventilation: Effect of System Leaks A COPD Lung Model Comparison

Background: Noninvasive positive-pressure ventilation (NPPV) modes are currently available on bilevel and ICU ventilators. However, little data comparing the performance of the NPPV modes on these ventilators are available. Methods: In an experimental bench study, the ability of nine ICU ventilators to function in the presence of leaks was compared with a bilevel ventilator using the IngMar ASL5000 lung simulator (IngMar Medical; Pittsburgh, PA) set at a compliance of 60 mL/cm H(2)O, an inspiratory resistance of 10 cm H(2)O/L/s, an expiratory resistance of 20 cm H(2)O/L/s, and a respiratory rate of 15 breaths/min. All of the ventilators were set at 12 cm H(2)O pressure support and 5 cm H(2)O positive end-expiratory pressure. The data were collected at baseline and at three customized leaks. Main results: At baseline, all of the ventilators were able to deliver adequate tidal volumes, to maintain airway pressure, and to synchronize with the simulator, without missed efforts or auto-triggering. As the leak was increased, all of the ventilators (except the Vision [Respironics; Murrysville, PA] and Servo I [Maquet; Solna, Sweden]) needed adjustment of sensitivity or cycling criteria to maintain adequate ventilation, and some transitioned to backup ventilation. Significant differences in triggering and cycling were observed between the Servo I and the Vision ventilators. Conclusions: The Vision and Servo I were the only ventilators that required no adjustments as they adapted to increasing leaks. There were differences in performance between these two ventilators, although the clinical significance of these differences is unclear. Clinicians should be aware that in the presence of leaks, most ICU ventilators require adjustments to maintain an adequate tidal volume. (CHEST 2009; 136:448-456)

Oxygen therapy, continuous positive airway pressure, or noninvasive bilevel positive pressure ventilation in the treatment of acute cardiogenic pulmonary edema

OBJECTIVE: To compare the effects of 3 types of noninvasive respiratory support systems in the treatment of acute pulmonary edema: oxygen therapy (O2), continuous positive airway pressure, and bilevel positive pressure ventilation. METHODS: We studied prospectively 26 patients with acute pulmonary edema, who were randomized into 1 of 3 types of respiratory support groups. Age was 69±7 years. Ten patients were treated with oxygen, 9 with continuous positive airway pressure, and 7 with noninvasive bilevel positive pressure ventilation. All patients received medicamentous therapy according to the Advanced Cardiac Life Support protocol. Our primary aim was to assess the need for orotracheal intubation. We also assessed the following: heart and respiration rates, blood pressure, PaO2, PaCO2, and pH at begining, and at 10 and 60 minutes after starting the protocol. RESULTS: At 10 minutes, the patients in the bilevel positive pressure ventilation group had the highest PaO2 and the lowest respiration rates; the patients in the O2 group had the highest PaCO2 and the lowest pH (p<0.05). Four patients in the O2 group, 3 patients in the continuous positive pressure group, and none in the bilevel positive pressure ventilation group were intubated (p<0.05). CONCLUSION: Noninvasive bilevel positive pressure ventilation was effective in the treatment of acute cardiogenic pulmonary edema, accelerated the recovery of vital signs and blood gas data, and avoided intubation.

Let's talk: public evaluation of large projects: variational inequialities, bilevel programming and complementarity. a survey

Large projects evaluation rises well known difficulties because -by definition- they modify the current price system; their public evaluation presents additional difficulties because they modify too existing shadow prices without the project. This paper analyzes -first- the basic methodologies applied until late 80s., based on the integration of projects in optimization models or, alternatively, based on iterative procedures with information exchange between two organizational levels. New methodologies applied afterwards are based on variational inequalities, bilevel programming and linear or nonlinear complementarity. Their foundations and different applications related with project evaluation are explored. As a matter of fact, these new tools are closely related among them and can treat more complex cases involving -for example- the reaction of agents to policies or the existence of multiple agents in an environment characterized by common functions representing demands or constraints on polluting emissions.

Monitoring of noninvasive ventilation by built-in software of home bilevel ventilators: a bench study.

BACKGROUND: Current bilevel positive-pressure ventilators for home noninvasive ventilation (NIV) provide physicians with software that records items important for patient monitoring, such as compliance, tidal volume (Vt), and leaks. However, to our knowledge, the validity of this information has not yet been independently assessed. METHODS: Testing was done for seven home ventilators on a bench model adapted to simulate NIV and generate unintentional leaks (ie, other than of the mask exhalation valve). Five levels of leaks were simulated using a computer-driven solenoid valve (0-60 L/min) at different levels of inspiratory pressure (15 and 25 cm H(2)O) and at a fixed expiratory pressure (5 cm H(2)O), for a total of 10 conditions. Bench data were compared with results retrieved from ventilator software for leaks and Vt. RESULTS: For assessing leaks, three of the devices tested were highly reliable, with a small bias (0.3-0.9 L/min), narrow limits of agreement (LA), and high correlations (R(2), 0.993-0.997) when comparing ventilator software and bench results; conversely, for four ventilators, bias ranged from -6.0 L/min to -25.9 L/min, exceeding -10 L/min for two devices, with wide LA and lower correlations (R(2), 0.70-0.98). Bias for leaks increased markedly with the importance of leaks in three devices. Vt was underestimated by all devices, and bias (range, 66-236 mL) increased with higher insufflation pressures. Only two devices had a bias < 100 mL, with all testing conditions considered. CONCLUSIONS: Physicians monitoring patients who use home ventilation must be aware of differences in the estimation of leaks and Vt by ventilator software. Also, leaks are reported in different ways according to the device used.

A Bilevel Approach to Transmission Expansion Planning Within a Market Environment

We present a bilevel model for transmission expansion planning within a market environment, where producers and consumers trade freely electric energy through a pool. The target of the transmission planner, modeled through the upper-level problem, is to minimize network investment cost while facilitating energy trading. This upper-level problem is constrained by a collection of lower-level market clearing problems representing pool trading, and whose individual objective functions correspond to social welfare. Using the duality theory the proposed bilevel model is recast as a mixed-integer linear programming problem, which is solvable using branch-and-cut solvers. Detailed results from an illustrative example and a case study are presented and discussed. Finally, some relevant conclusions are drawn.

Bilevel approach for optimal location and contract pricing of distributed generation in radial distribution systems using mixed-integer linear programming

In this study, a novel approach for the optimal location and contract pricing of distributed generation (DG) is presented. Such an approach is designed for a market environment in which the distribution company (DisCo) can buy energy either from the wholesale energy market or from the DG units within its network. The location and contract pricing of DG is determined by the interaction between the DisCo and the owner of the distributed generators. The DisCo intends to minimise the payments incurred in meeting the expected demand, whereas the owner of the DG intends to maximise the profits obtained from the energy sold to the DisCo. This two-agent relationship is modelled in a bilevel scheme. The upper-level optimisation is for determining the allocation and contract prices of the DG units, whereas the lower-level optimisation is for modelling the reaction of the DisCo. The bilevel programming problem is turned into an equivalent single-level mixed-integer linear optimisation problem using duality properties, which is then solved using commercially available software. Results show the robustness and efficiency of the proposed model compared with other existing models. As regards to contract pricing, the proposed approach allowed to find better solutions than those reported in previous works. © The Institution of Engineering and Technology 2013.

Differential block coding of bilevel images

Abstract- In this correspondence, a simple one-dimensional (1-D) differencing operation is applied to bilevel images prior to block coding to produce a sparse binary image that can be encoded efficiently using any of a number of well-known techniques. The difference image can be encoded more efficiently than the original bilevel image whenever the average run length of black pixels in the original image is greater than two. Compression is achieved because the correlation between adjacent pixels is reduced compared with the original image. The encoding/decoding operations are described and compression performance is presented for a set of standard bilevel images.

A RANDOMIZED TRIAL OF BILEVEL POSITIVE AIRWAY PRESSURE DEVICE AND HIGH FLOW OXYGEN FOR PERSISTENT DYSPNEA IN

Background: Dyspnea is a common and distressing symptom among patients with advanced cancer. The role of bilevel positive airway pressure (BIPAP) and Vapotherm in the relief of dyspnea have not been well defined. We aimed to determine and to compare the efficacy of BIPAP and VapoTherm for cancer related dyspnea. Methods: In this randomized, open-label, crossover study, we randomly assigned advanced cancer patients with persistent dyspnea >=3/10 to either Vapotherm for 2 hours followed by BiPAP for 2 hours, or BiPAP followed by Vaptherm. A variable washout period was instituted between interventions. The primary end point was change in numeric rating scale before and after each intervention. We planned to enroll 50 patients in total. Results: Among the 803 patients screened over the last 8 months, 62 (26%) were eligible, and 16 (2%) were enrolled so far. Five patients completed the entire study successfully, 4 discontinued the study prematurely due to prolonged relief of dyspnea, and 7 dropped out for various reasons, including inability to tolerate BiPAP (N=3), anxiety (N=2), fatigue (N=1) and pain requiring opioids (N=1). The median baseline numeric rating score for dyspnea was 7/10 (interquartile range (IQR) 5-8), and the median baseline Borg score was 4/10 (3-7). Interim analysis revealed that BiPAP was associated with a median change in numeric rating score of -3 (N=10, IQR -6.3 to -1, p=0.007) and modified Borg score of -1 (N=10, IQR -3 to 0.3, p=0.058), while Vapotherm was associated with a median change in numeric rating score of -2 (N=9, IQR -3 to -1, p=0.011) and modified Borg score of -2.5 (N=8, IQR -5.5 to -0.1, p=0.051). Among the 5 individuals who completed the entire study, 2 preferred Vapotherm, 2 favored BiPAP, and 1 liked both. The respiratory rate decreased and the oxygen saturation improved with both interventions. No significant toxicities were observed. Conclusions: We were successfully able to enroll patients onto this clinic trial. Our preliminary results suggest that BiPAP and Vapotherm are highly efficacious in providing relief for patients with persistent refractory dyspnea. A direct comparison of the two interventions will be done upon study completion. Further research is necessary to confirm our findings.

Hierarchical Forest Management Planning: A Bilevel Wood Supply Modelling Approach

Le processus de planification forestière hiérarchique présentement en place sur les terres publiques risque d’échouer à deux niveaux. Au niveau supérieur, le processus en place ne fournit pas une preuve suffisante de la durabilité du niveau de récolte actuel. À un niveau inférieur, le processus en place n’appuie pas la réalisation du plein potentiel de création de valeur de la ressource forestière, contraignant parfois inutilement la planification à court terme de la récolte. Ces échecs sont attribuables à certaines hypothèses implicites au modèle d’optimisation de la possibilité forestière, ce qui pourrait expliquer pourquoi ce problème n’est pas bien documenté dans la littérature. Nous utilisons la théorie de l’agence pour modéliser le processus de planification forestière hiérarchique sur les terres publiques. Nous développons un cadre de simulation itératif en deux étapes pour estimer l’effet à long terme de l’interaction entre l’État et le consommateur de fibre, nous permettant ainsi d’établir certaines conditions pouvant mener à des ruptures de stock. Nous proposons ensuite une formulation améliorée du modèle d’optimisation de la possibilité forestière. La formulation classique du modèle d’optimisation de la possibilité forestière (c.-à-d., maximisation du rendement soutenu en fibre) ne considère pas que le consommateur de fibre industriel souhaite maximiser son profit, mais suppose plutôt la consommation totale de l’offre de fibre à chaque période, peu importe le potentiel de création de valeur de celle-ci. Nous étendons la formulation classique du modèle d’optimisation de la possibilité forestière afin de permettre l’anticipation du comportement du consommateur de fibre, augmentant ainsi la probabilité que l’offre de fibre soit entièrement consommée, rétablissant ainsi la validité de l’hypothèse de consommation totale de l’offre de fibre implicite au modèle d’optimisation. Nous modélisons la relation principal-agent entre le gouvernement et l’industrie à l’aide d’une formulation biniveau du modèle optimisation, où le niveau supérieur représente le processus de détermination de la possibilité forestière (responsabilité du gouvernement), et le niveau inférieur représente le processus de consommation de la fibre (responsabilité de l’industrie). Nous montrons que la formulation biniveau peux atténuer le risque de ruptures de stock, améliorant ainsi la crédibilité du processus de planification forestière hiérarchique. Ensemble, le modèle biniveau d’optimisation de la possibilité forestière et la méthodologie que nous avons développée pour résoudre celui-ci à l’optimalité, représentent une alternative aux méthodes actuellement utilisées. Notre modèle biniveau et le cadre de simulation itérative représentent un pas vers l’avant en matière de technologie de planification forestière axée sur la création de valeur. L’intégration explicite d’objectifs et de contraintes industrielles au processus de planification forestière, dès la détermination de la possibilité forestière, devrait favoriser une collaboration accrue entre les instances gouvernementales et industrielles, permettant ainsi d’exploiter le plein potentiel de création de valeur de la ressource forestière.

Effect of PaCO(2) variation on standard base excess value in critically ill patients

Purpose: The aim of this study was to investigate the impact of acute PaCO(2) temporal variation on the standard base excess (SBE) value in critically ill patients. Methods: A total of 265 patients were prospectively observed; 158 were allocated to the modeling group, and 107 were allocated to the validation group. Two models were developed in the modeling group (one including and one excluding PaCO(2) as a variable determinant of SBE), and both were tested in the validation group. Results: In the modeling group, the mathematical model including SIDai, SIG, L-lactate, albumin, phosphate, and PaCO(2) had a predictive superiority in comparison with the model without PaCO(2) (R(2) = 0.978 and 0.916, respectively). In the validation group, the results were confirmed with significant F change statistics (R(2) change = 0.059, P < .001) between the model with and without PaCO(2). A high correlation (R = 0.99, P < .001) and agreement (bias = -0.25 mEq/L, limits of agreement 95% = -0.72 to 0.22 mEq/L) were found between the model-predicted SBE value and the SBE calculated using the Van Slyke equation. Conclusions: Acute PaCO(2), temporal variation is related to SBE changes in critically ill patients. (C) 2009 Elsevier Inc. All rights reserved.

Ventilação não invasiva com altas pressões pode ser mais eficaz do que com baixas pressões no tratamento da atelectasia pós-operatória de cirurgia cardíaca?

Mestrado em Fisioterapia

Otimização com restrições de complementaridade: algoritmos e aplicações

Tese de Doutoramento em Engenharia Industrial e de Sistemas (PDEIS)

Tarification logit dans un réseau

Le problème de tarification qui nous intéresse ici consiste à maximiser le revenu généré par les usagers d'un réseau de transport. Pour se rendre à leurs destinations, les usagers font un choix de route et utilisent des arcs sur lesquels nous imposons des tarifs. Chaque route est caractérisée (aux yeux de l'usager) par sa "désutilité", une mesure de longueur généralisée tenant compte à la fois des tarifs et des autres coûts associés à son utilisation. Ce problème a surtout été abordé sous une modélisation déterministe de la demande selon laquelle seules des routes de désutilité minimale se voient attribuer une mesure positive de flot. Le modèle déterministe se prête bien à une résolution globale, mais pèche par manque de réalisme. Nous considérons ici une extension probabiliste de ce modèle, selon laquelle les usagers d'un réseau sont alloués aux routes d'après un modèle de choix discret logit. Bien que le problème de tarification qui en résulte est non linéaire et non convexe, il conserve néanmoins une forte composante combinatoire que nous exploitons à des fins algorithmiques. Notre contribution se répartit en trois articles. Dans le premier, nous abordons le problème d'un point de vue théorique pour le cas avec une paire origine-destination. Nous développons une analyse de premier ordre qui exploite les propriétés analytiques de l'affectation logit et démontrons la validité de règles de simplification de la topologie du réseau qui permettent de réduire la dimension du problème sans en modifier la solution. Nous établissons ensuite l'unimodalité du problème pour une vaste gamme de topologies et nous généralisons certains de nos résultats au problème de la tarification d'une ligne de produits. Dans le deuxième article, nous abordons le problème d'un point de vue numérique pour le cas avec plusieurs paires origine-destination. Nous développons des algorithmes qui exploitent l'information locale et la parenté des formulations probabilistes et déterministes. Un des résultats de notre analyse est l'obtention de bornes sur l'erreur commise par les modèles combinatoires dans l'approximation du revenu logit. Nos essais numériques montrent qu'une approximation combinatoire rudimentaire permet souvent d'identifier des solutions quasi-optimales. Dans le troisième article, nous considérons l'extension du problème à une demande hétérogène. L'affectation de la demande y est donnée par un modèle de choix discret logit mixte où la sensibilité au prix d'un usager est aléatoire. Sous cette modélisation, l'expression du revenu n'est pas analytique et ne peut être évaluée de façon exacte. Cependant, nous démontrons que l'utilisation d'approximations non linéaires et combinatoires permet d'identifier des solutions quasi-optimales. Finalement, nous en profitons pour illustrer la richesse du modèle, par le biais d'une interprétation économique, et examinons plus particulièrement la contribution au revenu des différents groupes d'usagers.

Ventilação mecânica não-invasiva no pós-operatório de cirurgia cardíaca: atualização da literatura

Este estudo objetivou atualizar os conhecimentos em relação à utilização da ventilação mecânica não-invasiva (VMNI) no pós-operatório de cirurgia cardíaca e identificar se há indícios da superioridade de uma forma de modalidade de VMNI em relação à outra. Foi realizada revisão da literatura entre 2006 a 2011, a partir das bases de dados PubMed, SciELO e Lilacs, utilizando os descritores respiração artificial, pressão positiva contínua nas vias aéreas, ventilação com pressão positiva intermitente e cirurgia cardíaca, e seus correspondentes na língua inglesa, os quais foram pesquisados em cruzamentos. A partir dos critérios adotados, foram selecionados nove artigos, dos quais seis demonstraram aplicações de VMNI, por meio de modalidades como pressão positiva contínua nas vias aéreas, pressão positiva com dois níveis pressóricos e respiração com pressão positiva intermitente, no pós-operatório de cirurgia cardíaca, e, três realizaram comparações entre as diferentes modalidades. As modalidades de VMNI descritas na literatura foram utilizadas com resultados satisfatórios. Estudos que comparam diferentes modalidades são escassos, contudo alguns demonstraram superioridade de uma modalidade de VMNI, como é o caso da respiração com pressão positiva intermitente na reversão da hipoxemia e da pressão positiva com dois níveis pressóricos na melhora da oxigenação, da frequência respiratória e frequência cardíaca desses pacientes, em comparação a outras modalidades.

Optimal Contract Pricing of Distributed Generation in Distribution Networks

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)