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|The Mountain-Prairie Region
U.S. Fish and Wildlife Service
134 Union Boulevard
Lakewood, Colorado 80228
September 26, 2006
Contact: Valerie Fellows 202.208.5634
Colorado to Receive $159,450 Grant
Interior Secretary Dirk Kempthorne today announced more than $67 million in grants to 27 states to support conservation planning and acquisition of vital habitat for threatened and endangered fish, wildlife and plants. The grants, awarded through the Cooperative Endangered Species Conservation Fund, will benefit species ranging from orchids to bull trout that are found across the United States.
"These grants are incredibly important tools to conserve threatened and endangered species," said Secretary of Interior Dirk Kempthorne. "Our ability to successfully conserve habitat for imperiled species depends on long-term partnerships and voluntary landowner participation. These grants provide the means for States to work with landowners and communities to conserve habitat and foster conservation stewardship efforts for future generations."
Authorized by Section 6 of the Endangered Species Act, the grants enable States to work with private landowners, conservation groups and other agencies to initiate conservation planning efforts and acquire and protect habitat to support the conservation of threatened and endangered species.
The cooperative endangered species fund this year provides $7.5 million through the Habitat Conservation Planning Assistance Grants Program, $46 million through the Habitat Conservation Plan Land Acquisition Grants Program and $13.9 million through the Recovery Land Acquisition Grants Program. The three programs were established to help reduce potential conflicts between the conservation of threatened and endangered species and land development and use.
The Colorado Natural Areas Program will receive $159,450 to purchase a ranch in Montrose, Colorado, in cooperation with The Nature Conservancy. The parcel, which is adjacent to a preserve on BLM land, contains the largest and most viable population of the endangered clay-loving wild buckwheat. The magnitude and imminence of the threat of development, associated increase in off-road vehicle use, and an approved new highway have increased the urgency of acquiring this 43-acre private land parcel.
Under the Habitat Conservation Plan Land Acquisition Program, the Service provides grants to States or Territories for land acquisition associated with approved HCPs. The grants are targeted to help landowners who want to undertake proactive conservation work on their lands to conserve imperiled species. HCPs are agreements between a landowner and the Service, allowing a landowner to undertake otherwise lawful activities on their property that may result in the death, injury or harassment of a listed species, when that landowner agrees to conservation measures designed to minimize and mitigate the impact of those actions. HCPs may also be developed by a county or state to cover certain activities of all landowners within their own jurisdiction and may address multiple species. There are more than 650 HCPs currently in effect covering 600 separate species on approximately 41 million acres.
The HCP Planning Assistance Program provides grants to States and Territories to support the development of HCPs through funding of baseline surveys and inventories, document preparation, outreach, and similar planning activities.
The Recovery Land Acquisition Grants Program provides funds to states and territories to acquire habitat for endangered and threatened species with approved recovery plans. Habitat acquisition to secure long term protection is often an essential element of a comprehensive recovery effort for a listed species.
For a complete list of the 2006 grant awards for these programs (Catalog of Federal Domestic Assistance Number 15.615), see the Service's Endangered Species Grants home page at http://endangered.fws.gov/grants/section6/index.html.
The U.S. Fish and Wildlife Service is the principal Federal agency responsible for conserving, protecting and enhancing fish, wildlife and plants and their habitats for the continuing benefit of the American people. The Service manages the 95-million-acre National Wildlife Refuge System which encompasses 545 national wildlife refuges, thousands of small wetlands and other special management areas. It also operates 69 national fish hatcheries, 63 fishery resource offices and 81 ecological services field stations. The agency enforces Federal wildlife laws, administers the Endangered Species Act, manages migratory bird populations, restores nationally significant fisheries, conserves and restores wildlife habitat such as wetlands, and helps foreign and Native American tribal governments with their conservation efforts. It also oversees the Federal Aid program that distributes hundreds of millions of dollars in excise taxes on fishing and hunting equipment to state fish and wildlife agencies.


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|Property type
|Minimum Stay
|30 nights
Book this ROOM now for July and August 2017.
Views of the woods on three sides and glimpses of Hog Creek across the street. Fantastic outdoor shower complete with foot sprayer! Five minute drive to private bay beach (use our beach pass); fifteen minute drive to ocean beaches. Bring your bikes. Ask us about well-trained, 110% housebroken pets. (Rental Registry #16-765)
We rent by the month in July and August.
I was pleasantly surprised by this rental . I rented for the month of July 2015. The house was very well maintained & clean as a whistle. My family includes a 6 year old granddaughter & she loved it. We could easily walk to the private bay beach. We also took advantage of the very short drive to the ocean beaches. A big plus was the large outdoor shower so we could leave the sand outside.
There are many restaurants nearby as well as any number of take out places. There is a grill at the house that my son -in -law was happy to fire up!
The sleeping arrangements were perfect. All bedding looked new. The master bedroom is downstairs so the rest of the family could do whatever they wanted & I got to relax in my own little oasis complete with bath.
I have already booked my return stay!
My family and I have stayed in this amazing vacation rental before and keep returning to it because it's just.... well, perfect! It's just a few minutes drive from the chic celebrity-strewn town of East Hampton and also from a fabulous beach. My teenage daughters (who normally don't want to holiday with 'mum and dad' -- adore the privacy offered by the separate (if you want it to be), downstairs 'studio' (I call it that because it's the largest bedroom I've ever seen... and is en-suite). Upstairs, the spacious layout of the airy sitting room (with its lovely fireplace and wrap around terrace), along with the bedrooms and family bathroom -- make this the IDEAL place to spend a couple of weeks without getting on each others' nerves! (We loved having bbq's outside; and our youngest ones adored the very smart and functional outdoor shower). I am almost reluctant to recommend this gorgeous house; very much tempted to keep it our own personal secret. But fairness wins the day. I, and my whole family recommend this amazing vacation rental highly. It's just a little slice of heaven on earth.
I rented Ms. Scanlon's house in the lovely Clearwater Beach section of East Hampton, NY while working on my book "Roger Maris: Baseball's Reluctant Hero." It was the perfect environment: peaceful, pretty, easy walk to the beach, a friendly and accommodating landlord, easy distance to restaurants, shops, movies, etc. The book turned out well, and part of that was because of the inviting house and its surroundings.
I spent the most idyllic month this past October at this little bit of paradise in East Hampton. We enjoyed the fabulous woodlands views from the open and airy living room a with its romantic wood-burning fireplace that welcomed us after a bracing walk on the nearby beach. The house itself was impeccably clean and provided every amenity we could possibly need including internet access and satellite/cable TV. The owner couldn't have been more accommodating and efficient. We shall definitely return to this very special place and highly recommend it to others.
The house is located in a very nice and quiet area at a very short distance (less than 3 minutes driving) from a private bay beach with lifeguard, where you can see little school of fishes while standing on the shore, fabulous for kids! The house is a comfortable size, nicely ventilated. We enjoyed the wrap-around porch: we barbequed and ate "al fresco" every night. This house has all the comforts a family would need with a nice big kitchen and you're only about 15 minutes from the Village of East Hampton.
Stayed at the house this spring. It's a special house. I love the deck,
and the house is light and airy. The house is a real cut-above the usual
summer rental. I had a great time! The owner was terrific. Actually left us
a bottle of champagne in the refrigerator.
I am an author and publisher.
What makes this rental a cut above the rest? It's a year-round home, lovingly cared for and completely equipped. It's a quick walk or bike to private marina and bay beach. Ten to 15-minutes to town and beaches of Amagansett and East Hampton. One mile to The Maidstone Deli for The Sunday New York Times!
It has rave reviews.
House is surrounded on three sides by a wildlife preserve. In the winter months you can see Hog Creek from the living room and deck.
The deck on the second floor wraps around the living room. You might think it is not safe for children, but there is a fine mesh along the railing from top to bottom that keeps children perfectly safe and contained, no matter what age -- toddler to teen.
Pool? No. We never wanted one. We like going to the beach, AND we never wanted to worry about unattended children having an accident. The woods works for us.
|Refundable damage deposit
|Cleaning Per Week
|Tax Rate
We check references. Guests sign a two-page, plain-English seasonal lease. Let's talk about the electric bill if you are long-term.

subset: commoncrawl


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AfriGeneas Genealogy and History Forum Archive 2
Looking for smiths in Bogalusa, LA
I am trying to locate family of Norman Smith. He is my daughters grandfather. He died in 1980 I belive. My daughters father knows nothing about him except that he was a black panther. I really need help. I don't even know where he is buried. He has children in Chicago, so he may be from there. Can someone please help. I don't know where to start.


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Very good condition 1965 Guild Starfire III in a cherry red finish. Light buckle rash on the back of the body as well as light checking on the back of the neck and headstock. No repairs.
Bank checks & wires (wire fee $15), Money orders. Visa/MC (US only) shipping & billing address must match on credit cards. All checks and credit cards must be drawn on US banks. NO COD's, personal checks or Wester Union. We do not underinsure guitars shipped internationally and must show the full purchase price on invoices.
We usually use UPS. Customer pays shipping upfront. 24 hour approval on US purchases. Customer is responsible for shipping and insurance both ways if the item is returned. We only ship small amplifiers and there is no warranty.
24 Hour approval on US shipments. Full no hassle refund less shipping costs for guitars received back in same condition as sent. Customer ships guitar back fully insured at own expense. No refunds on layaways or amps.


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Weather Underground Forecast for Monday, October 07, 2013.
A cold front is expected to move over the eastern third of the country on Monday, bringing showers and thunderstorms to the Eastern Seaboard, while the majority of the Southwest will experience dry conditions.
Washington, Oregon, northern Nevada, and eastern Montana can expect rainy weather throughout the day on Monday as a cold front boundary moves over the region. Temperatures will drop 5 to 10 degrees behind the front, which may spur snow showers at high elevations in the northern Cascades. The Southwest and Great Basin will likely avoid precipitation on Monday as a ridge of high pressure builds over the four corners.
A cold front boundary extending from the Florida panhandle to New York will bring showers and thunderstorms to a large portion of the East Coast. Showers will persist in the upper Midwest, although wet weather should die down by the late afternoon. The central Midwest will experience drier conditions on Monday as the cold front moves further east, but temperatures will likely be 5 to 10 degrees cooler due to the cold air mass behind the front. The strongest thunderstorms associated with this extensive cold front will move through the Mid-Atlantic states as remnants of Tropical Storm Karen will continue to interact with this system. Gusty winds can also be expected along the coast. The Northeast will experience moderate showers and thunderstorms as a low pressure system ushers moisture in from Canada.
Temperatures in the Lower 48 states Sunday have ranged from a morning low of 17 degrees at Gunnison, Colo. to a high of 93 degrees at North Island, Calif.


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|1,200 sq. ft.
|Property type
|Minimum Stay
|1 - 5 nights
Located in the heart of Palisades Village on a quite trip lined street. You can enjoy our charming, spacious and bright 2 Bedroom TOP FLOOR Duplex in the heart of Pacific Palisades. Great Location, walk to Palisades Village, quiet and private, this is the one. Charming Upper Duplex. Sit and enjoy watching the birds land in the trees outside your picture perfect windows. Gorgeous designer perfect Upper 2 bedroom & 1 bathroom Duplex. Sleeps 5 guests. Top of the line King size bed in the master bedroom, Queen in the guest bedroom, custom designed sofa sleeper plus desk in the living room. Many More photos upon request.
Rates based on 30 night minimum stay.
Amazing Location in the heart of charming Pacific Palisades Village. Walk to shops right outside your door. Short stroll to the breathtaking Palisades Bluffs, where you will enjoy the most spectacular views and Sunsets. Just a 7 minute short drive along Pacific Coast Highway and you will be in the heart of Santa Monica by the world famous Pier and The 3rd Street Mall.
Enjoy all new furnishings, in this bright and airy apt. Flat screen TV's in both living room and Master Bedroom. Wireless internet throughout. Very Private peaceful and quiet. Relax on your own private patio. This property is a real retreat. Own Washer/Dryer/ All new appliances including dishwasher. 2 car Parking. Complete Home just bring your toothbrush. Come relax and have fun.
Walk just one block to beautiful Temescal Canyon Park and hike to the top to see the waterfall. Come enjoy the Farmers Market every Sunday. Dine with the myriad of restaurants steps away from your door in Pacific Palisades Village. Walk down the block and enjoy the local live theater at Pierson Playhouse. Visit us on July 4th with our quaint parade and enjoy the fireworks at the Palisades High School without getting in your car. Take a drive to Santa Monica's famous Third Street Promenade just 7 minutes away and watch the street performers or see a film. If you want a work out rent a bike and ride from the Palisades all the way to Venice Beach and watch the athletes at Muscle Beach. Go sailing off the coast of Marina Del Rey and catch a glimpse of a dolphin or a whale. Go to Will Rogers for a horse back riding trip or or catch a polo match. Come to the Riviera Country Club for the world famous Northern Trust Open. Spend the day among the rich in Beverly Hills famous Rodeo Drive and pick up a bobble at Cartier to take home as a souvenir.
Drive to Will Rogers Beach and read a book or catch a wave in our beautiful Pacific Ocean. Visit the stunning Getty Villa Museum and catch a show in their beautiful amphitheater. Spend the day at the Getty Museum and drink up the art and have a bite to eat. Go downtown to the Mark Taper, Ahmanson or Dorothy Chandler Pavillion for a wonderful show. Go to Culver City and enjoy a show at the Kirk Douglas Theater. Disneyland and Universal are about 45 minutes to one hour away.
This apt has been totally remodeled. Located upstairs, there are 2 bedrooms with luxurious I Sleep Organic European mattresses, fine linens and 1 bath totally remodeled. The kitchen includes stainless steel appliances and a washer & dryer. Very quiet, quaint atmosphere down a sidewalk street.
REG Rates Offered at $275 per night
Cleaning fee FROM $175.DEPENDS ON LENGTH OF STAY Check in fee from $49
Rates based on 30 night minimum stay
Call Jeri for last minute specials
We accept all major credit cards.
Call Jeri and book now
Keywords: Malibu, Santa Monica, Pacific Palisades, beach, hiking, horse trails, restaurants, Los Angeles, Westwood, Brentwood, UCLA, Ocean,
In the film industry in Los Angeles for many years and stay at home mom .
Jeri Weiss purchased this apartment in 2005
I bought this property because in Los Angeles their is no place like Pacific Palisades. We call it Mayberry because although we are part of a big city, Pacific Palisades is unique and has a small town feeling. It is very safe here and the people are very friendly. The saying goes, 'If your rich you live in Beverly Hills, if your famous you live in Malibu and if you're lucky you live in Pacific Palisades.'
This is the top floor of a duplex. Lot of charm and character in this Cape Cod style property. Walk to the bluffs every night to enjoy the sunset over the ocean with the locals.
The Palisades Treehouse was everything we could have hoped for in a rental...clean, well appointed with the necessities, perfect location, quiet, one block to town, cute decor, comfortable beds and more. I would highly recommend this property, although I hesitate because that just means it will be harder to book! No but seriuosly, the owner and managers do a wonderful job of making their guests comfortable. THANK YOU, and we can't wait to return!
We enjoyed staying at the cute Palisades Treehouse! Great location with walkable amenities. We appreciate the ease of check in and out and the house had everything we needed.
The pull out sofa needs to be replaced as it is barely sleepable.
We stayed here 2 years ago in March of 2015 and loved it! The whole process of the rental was easy and effortless. We had plenty of space for 4 people and loved being able to walk to restaurants and shopping. The only negative was no air conditioning and we sure could have used it the first two nights. We would love to stay here again some day soon.
While the home is in a great location and clean if you like to do a little cooking during your stay bring your own condiments and while there were pots and pans I was surprised to find not even a salt shaker or cookie sheet the cabinets were barren. A minor thing for people who eat all there meals out but not for people that don't. There is no air conditioner as well so a few days were very hot however there are fans.
My family and I absolutely loved it!!!! It was a very pleasurable experience to stay in this lovely tree house. Everything we needed was there for us. The beach was super close, so close my husband jogged to it in the mornings. Lots of shops and restaurants around. The kids absolutely loved it. They loved how it had games for them to play and could sit out on the back patio. Cant wait to go back next year.
Walk to the village. Close to beach, Will Rogers, Santa Monica Beach, Malibu, walk to restaurants, July 4th parade, Christmas parade, farmers market, church, synagogue, self realization church, 10 minutes to Westwood, Village & Brentwood
|Cleaning Fee
|Pet Fee
|Damage Insurance
Rates are subject to change
Cleaning fees from $175 based on length of stay
Check in fee from $49 - providing check in is prior to 7pm


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Charlize Theron's Malibu Dreamhouse Goes Into Escrow
Shelterpop posts photos of Charlize Theron's 2,095 square foot beach house, which reportedly has a buyer who's forking out "just under $7 million" for the property. Plus, Jane Pratt prepares to launch her new site for women — xoJane.com — next week, according to Women's Wear Daily, and The New York Times reviews Andrea Wulf's new book about the Founding Fathers and their passion for gardening. More news and links below.
• Dear Charlize Theron: Are You Sure You Want to Sell This House? | Shelterpop
• Kisses and Hugs From Jane Pratt | Women's Wear Daily
• Book Review: The Founding Fathers and Their Gardens | New York Times
• Designers: Apply for an Ideas that Matter Grant | Sappi
• The Top 500 Design Firms | Engineering News Record


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Raincode's solution to migrate PACBASE systems has been tested more than any other in the field, both in terms of number of sites it has been applied to, and in the total volume of code it has processed.
Still, it is not carved in stone. The migration toolset still evolves, to recognize COBOL quirks (some dare call them extensions) we never encountered before, or to support new features, new patterns, new transformations required by our customers.
But then comes the question, how do we validate the changes? How do we ensure that the migrated code still works as the original one, that functional equivalence remains guaranteed release after release? The migration machinery is a sophisticated piece of software, and it requires more than superficial testing here and there. We would not want to go to our prospects and customers, telling them that we are going to change their source code if we are not entirely confident that the functional equivalence is guaranteed.
Our quality control procedures aim at providing us with this confidence. It is based on a common strategy when it comes to software engineering, namely divide and conquer.
But before we proceed, we must first explain more about how the migration toolset is structured.
It is divided in two main components:
- The Raincode engine is our COBOL parsing and analysis facility. It deals with everything that has to do with recognizing COBOL programs, and supports transformations and queries on these programs. It recognizes numerous COBOL dialects, including SQL, CICS and DL/I extensions. It is a generic tool we use for a number of purposes, out of which PACBASE migration is just an example.
- On top of the Raincode engine, the COBOL restructuring facility actually transforms the code to make it more maintainable, more readable etc.
This clear separation in two layers is the cornerstone of our testing strategy, based on a simple premise: we never change both components simultaneously. We always change one of the components, and test the result extensively before considering changing the other.
How does this work in practice?
We keep a large portfolio made of several thousands of PACBASE-generated COBOL programs, together with the resulting code after restructuring. When changing only the engine, since the logic of the restructuring is not altered, we can ensure that the new engine produces the same restructured COBOL program logic to the character level. Failing that, the new version of the Raincode engine has an obvious change of behaviour.
When the restructuring facility evolves, we restructure a number of thoroughly crafted test programs that exercise the various transformations supported by the migration facility, run them and ensure that their execution remains consistent with the previous release of the restructuring facility.
Differences in the resulting COBOL programs are also inspected manually, to ensure that they are in line with the changes that have just been made to the restructuring facility.
This layered approach to regression testing has yielded excellent results. Differences of behaviour are detected as early as possible in the process, rather than relying on customer testing to ensure that the restructured programs do indeed behave as they did before.
After all, this is a volume business, and requiring extensive ad hoc testing would defeat the purpose altogether.
As always, comments are very welcome!
That's all for now…


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Blade Runner DVD – New Special Editions Fall 2006 and 2007
I've been into Blade Runner since it came out in 1982. I remember the color full page ad I cutRead more
I've been into Blade Runner since it came out in 1982. I remember the color full page ad I cutRead more
In an episode of Martian Successor Nadesico Akito Tenkawa, the series' heartthrob cook and Aestivalis pilot, is admiring the handiworkRead more
When I was an adolescent I would tag along with my mother while she ran her errands. As she shoppedRead more
The Divining Pendant (Major Spoilers Ahead!) It is a wonder that I am still alive. Throughout most of my childhoodRead more
I would always come home from my fellow ninja's house with grass stains on my back. My gai would getRead more
Back in the mid-eighties, my home town only had one, short-lived toy store. It was a typical store for theRead more
In past Fanatical Visions I have taken cheap shots at otaku who practice the art form of cosplay. I apologizeRead more
1987. I was a freshman in highschool, and my best friend's best friend had connections. Not normal highschool connections, likeRead more


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Peregrine's Christmas Adventure
The Longest Bedtime Story Ever Written!
Peregrine's Christmas Adventure is the first of three books in, The Pottontot Chronicles. It is a bedtime MINI-SERIES!
Twelve nights of fun and adventure take the young child and the reader on an exciting journey, with Peregrine Pottontot and his best friend, Teddy as they seek to discover what is making that strange and wonderful sound. Each of the 12 chapters begin with a full color, full page illustration and end with a "good-night" verse.
Please visit Help Page for Questions
regarding ISBN / ISBN-10 / ISBN10, ISBN-13 / ISBN13, EAN / EAN-13, and Amazon
Home | ISBN Directory | Affiliate
Program | Contact
Copyright © 2003-2014 AllDiscountBooks.net All rights reserved.


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CSCMI Who we are:
AWANA Clubs International, after a long history of building up Christian leaders of tomorrow through their scholarship camps, decided in 2006 that it would no longer directly oversee these camp ministries. Instead they proposed that a grassroots organization of interested churches and AWANA Clubs create an independent camp experience for those Clubs that wish to continue a camp ministry. In this way each state or region would create its own organization to create and oversee this annual event for it's clubbers. At that time many groups of AWANA leaders, parents and other dedicated people all over the country decided to continue their camp ministries and formed their own organizations to assure that this vital ministry would continue for their AWANA clubbers. These individuals worked very hard with their AWANA clubs and churches to make sure that this week at camp each summer remained what it had always been: a great time to reward clubbers who work hard to complete their AWANA books each year, to challenge clubbers to seek God's will for their lives, and to equip them with the tools they need to be effective witnesses for Him in every area of their lives. In April of 2009 Richard Yandle hosted a meeting of all the camps that were continuing to provide the AWANA camp experience for various clubs across the nation. It was Richards hope that an association of clubs could be formed for the purpose of establishing a formal ministry partnership between AWANA Clubs International and these camps so that we could mutually support one another's ministries. It was at this time that Christian Scholars Camp Ministries Inc. expanded their mission statement and became the umbrella organization for the creation of this ministry partnership. At this meeting many of the camps that were represented joined this organization to form an independent association of Camps to provide, in the tradition of AWANA Camps, a Christian Camp Experience to AWANA Club International Clubbers. The Mission Statement for this association is:
As sovereign providers of Christian Camp Programs, we enter into an association for the purposes of:
- Providing a continuity of the Prior AWANA Camp experience to AWANA Clubs that wish to continue to provide a camp experience for their Clubbers.
- For mutual sharing of knowledge and resources to coduct high impact camps.
- For accountability, program continuity and promotion of camp ministries.
As independently owned and operated programs we will endeavor to be safe, affordable, fun and effective in providing campers with a very profound experience with Jesus Christ that campers will never forget and that will have a lasting effect on their Christian walk.
If you currently opperate a camp for AWANA clubbers or have an interest in starting a camp ministry you can get more information on how to become a member or associate of CSCMI by contacting Bill Mitchell at 909-260-8804 or by email email@example.com.


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We Believe You Are Important, How Can We Help?
Real-time ATP surface hygiene test which gives an objective indication of cleanliness in seconds. With its unique liquid stable enzyme, the test offers superior levels of repeatability. This aspect of its performance and its incredible simplicity means customers throughout the world have put…
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Revista Brasileira de Anestesiologia
Print version ISSN 0034-7094On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.56 no.3 Campinas May/June 2006
Importance of pleural pressure for the evaluation of respiratory mechanics*
La importancia de la presión pleural en la evaluación de la mecánica respiratoria
Cláudia Regina Fernandes, TSA
Doutora em Medicina pela Universidade de São Paulo; Chefe do Serviço de Anestesiologia do HUWC/UFC; Responsável pelo CET/SBA HUWC/UFC
OBJECTIVES: Pleural pressure has to be known for the partitioning of respiratory
system mechanical measurements into their lung and chest wall components. This
review aimed at discussing alternative methods to obtain pleural pressure to
calculate pulmonary mechanics, at reporting peculiarities of the esophageal
balloon method for obtaining indirect pleural pressure, peculiarities of esophageal
pressure measurement in sedated or anesthetized patients, at discussing direct
pleural pressure and its correlation with esophageal pressure, in addition to
reporting on the impact of PEEP on pleural and esophageal pressures.
CONTENTS: Esophageal pressure variation reflects pleural pressure variation and may be used as alternative to direct pleural pressure in the study of lungs and chest wall mechanics. Esophageal pressure may be obtained with a delicate balloon placed inside the esophagus. Method and technique were observed and validated in humans and animals in different conditions and body positions. PEEP is a consolidated method for patients under mechanically controlled ventilation, however there are controversies about the close correlation between esophageal and pleural pressure in patients ventilated with PEEP, which may result in wrong respiratory mechanics calculation based on the esophageal pressure.
CONCLUSIONS: The esophageal balloon is the most common method to obtain indirect pleural pressure. In sedated or anesthetized patients without major respiratory compliance changes, esophageal pressure variation corresponds to pleural pressure variation when PEEP is applied.
Key Words: PHYSIOLOGY, Pulmonar: pleural cavity, respiratory mechanics; VENTILATION: positive end expiratory pressure.
Y OBJETIVOS: Para la partición de las medidas de mecánica
del sistema respiratorio en sus componentes pulmón y pared torácica,
se hace necesario el conocimiento de la presión pleural. La finalidad
de esta revisión fue la de discutir sobre las medidas alternativas para
la obtención de la presión pleural para el cálculo de la
mecánica pulmonar, relatar las peculiaridades del método del globo
esofágico para la obtención indirecta de la presión pleural,
las particularidades de la obtención de la medida de la presión
esofágica en pacientes sedados o anestesiados, discurrir sobre la medida
directa de la presión pleural y su correlación con la presión
esofágica, como también relatar sobre el reflejo de la PEEP en
las presiones pleural y esofágica.
CONTENIDO: La variación de la presión intra esofágica refleja la variación de la presión intrapleural, pudiendo ser usada como medida alternativa a la presión pleural directa, en el estudio de la mecánica de los componentes pulmón y pared del sistema respiratorio. La medida de la presión esofágica puede ser realizada a través de un delicado globo posicionado en el interior del esófago. El método y la técnica fueron observados y validados en seres humanos y animales en diferentes condiciones y posturas corporales. El empleo de la PEEP en pacientes bajo ventilación controlada mecánica está consolidado, sin embargo existen controversias de la correlación próxima entre la presión esofágica y la presión pleural en pacientes ventilados con PEEP, lo que puede resultar en errores de cálculo de mecánica respiratoria considerando la presión esofágica.
CONCLUSIONES: El método del globo esofágico es el más utilizado para la obtención de la medida indirecta de la presión pleural. En pacientes sedados o anestesiados sin importantes alteraciones de la complacencia respiratoria, la variación de la presión esofágica corresponde a la variación de la presión pleural cuando se aplica a PEEP.
Pleural pressure (Ppl) has to be known for the partitioning of respiratory system mechanics measurements into its lungs and chest wall components. However, the access to pleural cavity to obtain direct measurement has disadvantages for being invasive and for the risk of pneumothorax. So, alternatives were sought, such as esophageal pressure (Pes). It is known for more than one century that intra-esophageal pressure variation reflects pleural pressure variation 1 and may be used as alternative to direct pleural pressure to study lungs and chest wall mechanics and to evaluate respiratory work during assisted or spontaneous ventilation.
Esophageal pressure measurement through a delicate balloon placed in the esophagus was firstly described more than 50 years ago 2. Since then, several human and animal studies were conducted comparing esophageal and pleural pressures to try to validate the method 3,4. Other studies were performed to validate the esophageal balloon technique 5,6.
PEEP in patients under mechanically controlled ventilation is consolidated both for anesthesia and intensive care. It is mandatory in the treatment of respiratory distress syndrome 7,8. Being the study of respiratory mechanics and its sub-components lungs and walls critical to understand some clinical situations, esophageal pressure to indirectly obtain pleural pressure has become a popular method 9,10. In this context, there are still controversies about the close correlation between esophageal and pleural pressures in PEEP ventilated patients, under sedation or anesthesia, or even with different body positions 11. This is important because abnormal esophageal pressure values may result in errors in respiratory mechanics calculation and interpretation, which may lead to inadequate management.
This review aimed at discussing alternative methods to obtain pleural pressure to calculate pulmonary mechanics, at reporting peculiarities of the esophageal balloon method to obtain indirect pleural pressure, peculiarities of esophageal pressure measurement in sedated or anesthetized patients, at discussing direct pleural pressure measurement and its correlation with esophageal pressure, in addition to reporting on the impact of PEEP on pleural and esophageal pressures.
It is known for more than 120 years that chest pressures variations affect esophageal pressure. Luciani, in 1878 1, was the first to publish studies involving esophageal pressure measurements, although the discovery of the method is credited to Ceradini, who has not published his results.
In the search for an alternative method to obtain intra-thoracic pressure, Otis et al. have shown that it is possible to correlate increased venous pressure to increased pulmonary pressure by placing a catheter in the cubital vein; however, the validity of this technique was questionable 12.
In 1949, Buytendijk has introduced esophageal pressure measurement technique with a balloon in the esophagus 2.
Dornhorst et al. have obtained esophageal pressure with a liquid-filled catheter 13. Other authors have observed that this system is comparable to esophageal balloon; however it is more sensitive to noises such as heart beats 14. This method has been primarily used in neonates and infants to determine the mechanics of respiratory system sub-components 15,16.
Clarysse et al. have measured esophageal pressure with two balloons in a single catheter, separated 10 cm from each other 17. Rajacich et al. have created a method to monitor esophageal pressure with a balloon irrigated with saline solutuion 18. Karason et al. have used a double-lumen liquid-filled gastric tube to obtain esophageal pressure. The efficacy of this method was compared to the esophageal balloon 19.
More recently, the flexible catheter with a microtransducer at the edge was made available to monitor esophageal pressure 20.
Some authors have directly measured pleural pressure with microtransducers coupled to the edge of catheters 21,22, and others with flat and flexible sensors 23. Tobin et al. have reported that surface inductive plethysmography is an alternative for indirect pleural pressure measurement through a transducer placed in the sternal fossa 24. However it has some limitations, such as adequate transducer positioning in the fossa, sternal cavity size, adequate fixation of patient's head and neck.
Other investigators have studied transpulmonary gradient through pleural pressure recording, using a minimally invasive technique with rib capsules to promote minor pleural space distortion 25,26.
The most popular esophageal pressure method is the latex air-filled balloon-catheter connected to a pressure transducer system 14.
The esophagus is a muscle-membranous tube located in the chest and measuring approximately 4 cm diameter and 25 cm length. It is maintained collapsed and is connected to other mediastinal structures by connective tissue and small muscles. There are functional sphincters on its edges. Esophageal pressure variations may be intrinsic or extrinsic. Extrinsic pressures are those originating in the chest, while intrinsic pressures are essentially two: located spasms or changes in tone which may be generalized, and peristaltic waves 3.
Mead et al. have compared short (3 cm length and 1 cm diameter) and long (16 cm length and 0.8 cm diameter) esophageal balloons and have observed that the long balloon shows lower pressure variations with changes in position inside the esophagus 14. Other authors 27 have also stated that pressure measurement with long balloons is more accurate; however they reported that the best results were obtained when measures were taken in the esophageal medium third, showing that in this region the shape of the pressure-volume curve is not significantly affected by changes in body position.
Petit and Milic-Emili have studied the mechanical properties of human esophageal wall using esophageal balloons of different diameters. They have observed that esophageal balloons with perimeter above 4.8 cm are ideal because they are flaccid and more accurately transmit esophageal wall tension variations.
These authors have noted that specific esophageal elastance is not uniform, has lower value in the lower third and progressively increase in the cephalad direction. The histological difference of muscles in different esophageal regions (striated muscles in the upper third, smooth muscles in the lower edge and mixed muscles in the medium third), with corresponding muscle activity differences, may explain different elastic properties.
The authors infer that, due to differences in specific elastance along the esophageal wall, the difference between intra-thoracic and intra-esophageal pressures will depend on the position of the balloon, and will be lower when it is placed in the lower third where there is more distensibility. This same study has observed more frequent peristaltic waves with the individual in the supine position. However, when a wider and longer cuff was used, the effect of peristaltic waves on esophageal pressure was substantially decreased 28.
The hypothesis that body position could affect the fidelity of esophageal pressure measurement with regard to pleural pressure has led some authors to perform several investigations. Ferris et al. have studied six normal adult patients maintained under spontaneous ventilation and measuring esophageal pressure through a balloon placed in the lower third of the esophagus, in different body positions.
They have observed that esophageal pressure values in the prone and the lateral positions were similar to the value in the upright position, while in the supine position esophageal pressure was much higher, supposing that this increase was related to esophageal pressure exerted by the heart and great vessels by the action of gravity 29. Knowles et al. have evaluated esophageal pressure obtained with a 5.5 cm balloon in four patients in different positions sitting, supine with 30º cephalic inclination and prone in different pulmonary volumes and have observed that in low pulmonary volumes, that is, 20% of vital capacity (VC) in the supine position, esophageal pressure was more positive. They have also attributed this fact to esophageal compression by mediastinal content, especially the heart which is moved closer to the balloon by diaphragm displacement 30.
Milic-Emili et al. have shown that esophageal balloon pressure is identical to pleural pressure when pressure difference throughout its structures, that is balloon wall, esophageal wall and different mediastinal structures, is zero 31. Balloon pressure increases with volume. Analyzing this aspect, authors have evaluated esophageal pressure in eight patients with increasing pulmonary volumes, and with the balloon filled with different volumes of air. All measures were obtained in the upright position. Results indicated that the effect of balloon volume on esophageal pressure is higher in both vital capacity extremes, especially with high pulmonary volumes 20% above VC. They have concluded that the balloon filled with low volumes, approximately 0.2 mL of air, will more accurately reflect pleural pressure. The ideal volume for the adequate filling of the esophageal balloon should be obtained through the balloon compliance curve. In long balloons, the plateau of this curve is in general between 0.2 to 0.5 mL of air 32,33.
Gerhardt and Bancalari have observed that airway pressure percentage (Paw) transmitted to the esophagus depends on pulmonary compliance. They have studied 26 premature neonates and have observed low correlation between Paw and Pes variation. Only 5% of Paw was transmitted to the esophagus of children with hyaline membrane disease, and 12% to neonates with patent ductus arteriosus 34.
Always trying to validate the adequate catheter-balloon position in the esophagus, several tests were proposed. Pes validity may be obtained by static Valsalva or Mueller maneuvers against the occluded airway. An approximate matching between esophageal (DPes) and tracheal (DPtr) pressure variation airway pressure indicates satisfactory balloon positioning. Since many untrained individuals find difficulties in performing this static maneuver, Baydur et al. have introduced a dynamic alternative to solve this problem. The "occlusion test" consists on airway occlusion at the end of expiration, allowing the patient to do three to five inspiratory efforts with occluded airways.
This technique was tested in 10 volunteers in the sitting, right and left lateral and supine position with the esophageal balloon placed 10 cm above the cardia. Authors have observed that in the sitting and lateral positions the DPes/DPtr ratio was close to the unit, while in the supine position DPes/ DPtr was lower than the unit in seven out of ten volunteers.
These esophageal pressure changes were primarily attributed to cardiac artifacts. Authors have concluded that in some individuals in the supine position, esophageal pressure measured with conventionally placed balloon does not presumably reflect pleural surface pressure. With the repositioning of the balloon in a different level, 5 or 15 cm above the cardia, a position may be found where DPes/DPtr ratio is close to the unit. Pulmonary mechanics measurements estimating pleural pressure are presumably valid, based on esophageal pressure as from this site 35. This test was also validated in anesthetized non-paralyzed patients under spontaneous ventilation 9.
Fonseca-Costa and Nardi have also applied the "occlusion test" to validate esophageal pressure in eight volunteers in different positions: sitting with the chest in the vertical position (90º) and in 45º, 0º and -10º angles with the balloon placed 10 cm above the cardia. They have concluded that by carefully repositioning the catheter after each change in body angle, it is possible to obtain acceptable measurements in all studied positions. Major difficulty of the study was observed in the horizontal and head-down positions due to higher interference of heartbeats. Asher et al. have studied this same test to validate the liquid-filled catheter in six healthy neonates in the right lateral, prone and supine positions. They inferred that the catheter placed in the lower esophageal third is more accurate to indirectly determine pleural pressure variation in those patients 36.
Coates et al. have also validated Ppl measure by the "occlusion test" using liquid-filled catheter. The study was performed with eight intubated neonates and measures were obtained in the supine position. Mild pressures were applied to the larynx during the test to prevent air leakage. "Occlusion tests" were performed in the lower esophageal third starting from the cardia until the level where DPes/DPtr was lower than or close to the unit. All them presented a range between the cardia and the carina where DPes/DPtr was very close to the unit 15. This test has also been used to validate the position of liquid-filled catheter aiming at measuring esophageal pressure of small animals 37.
The "occlusion test" for esophageal balloon validation may also be used during mechanically controlled ventilation under neuromuscular blockers. In this condition it is not possible to perform spontaneous inspiratory efforts so the recording of airway and esophageal pressure is only possible through chest or abdominal compressions. Lantieri et al. have applied airway occlusion associated to mild upper abdomen or rib compressions in paralyzed dogs maintained under mechanically controlled ventilation. They were able to record concomitant oscillations of esophageal and airway pressures, thus validating esophageal balloon position 38. Barnas et al. have performed abdominal compressions associated to airway occlusion in 13 anesthetized paralyzed patients in the postoperative period of cardiac procedures, validating the balloon technique 39.
A study with 1.5 cm catheter-balloon system positioned in the esophagus at 2-cm intervals has analyzed esophageal pressure along intra-thoracic and cervical segments of healthy humans. They have observed that esophageal pressures were progressively more negative from the intra-thoracic to the cervical region, that is, there is a pressure gradient inside the esophagus 32.
Clarysse et al. have used two balloons in a single catheter, placed 10 cm apart from each other to measure esophageal pressure. The lowest balloon was positioned 5 cm above the cardia. They have investigated changes in transpulmonary pressure before and after turning the body 180º. They have observed that transpulmonary pressure is more positive in the upper balloon in both positions, that is, in the medium esophagus in the upright position and in the distal esophagus in the head down position. They have also observed that there was increased transpulmonary pressure gradient with decreased pulmonary volume from 80% to 20% of VC, implying that pressure changes follow global volume changes. They have also found a reverse esophageal pressure gradient in the head down position 17.
Dechman et al. have investigated the influence of body position, balloon position and lung volume in the "occlusion test" of anesthetized dogs spontaneously breathing and paralyzed under mechanically controlled ventilation. They speculated that Pes more precisely reflects Ppl during inspiration as compared to expiration. They have observed that DPes/DPtr ratio is closest to unit in the paralyzed state, indicating that Pes more precisely reflects Ppl in the presence of muscle paralysis 40.
A possible explanation for this finding is the fact that the canine esophagus, as well as man's, is made of striated muscles. Pes measured in the upper esophageal third less accurately reflects Ppl as opposed to what has been observed in the distal third. In the supine position in spontaneous ventilation, the Pes versus Ptr loop has often differed from the unit, while under muscle paralysis the result was consistently very close to the unit. This study has suggested that mediastinal content weight is not responsible for poor "occlusion test" results during spontaneous ventilation in the supine position.
Baydur et al. have analyzed esophageal pressure of volunteers under spontaneous ventilation in three different levels (5, 10 and 15 cm above the cardia) in the presence of different pulmonary volumes in the sitting and supine positions. They observed that during relaxed breathings esophageal pressure has varied 30% more in the lower esophagus as compared to the upper region. During Valsalva's maneuver, DPes/DPtr remained close to the unit in most pulmonary volumes, except for the sitting position in volumes close to 20% VC 41.
Ingimarsson et al. have investigated possible differences in Pes resulting from changes in body position. They have studied 17 anesthetized paralyzed children (1.5 month to 15.5 years) in the supine and left lateral position. Pressure-volume curve was obtained and it was observed that when Pva = 30 cmH2O, Pes was very similar in both positions, approximately 11 cm H2O. However, when Pva = 0 cmH2O, Pes was very positive in the supine position (6.6 ± 2.2 cmH2O) and close to zero in the lateral position (1.1 ± 1.9 cmH2O) 42. These results have impaired the validation of the hypothesis that Pes is representative of global Ppl in the supine position.
As to ideal esophageal balloon size for adults, it is currently known that its perimeter should correspond to that of the esophagus, between 4 and 4.8 cm. In practice, thin latex balloons with 0.1 mm thickness, 5 to 10 cm length and perimeter varying from 3.2 to 4.8 cm are adequate. Conventional catheters are made of polyethylene with internal diameter of 1.4 mm and 100 cm length (Figure 1). Volume of air should follow balloon's compliance and in the vast majority, 0.5 mL is adequate for measurements 43. Satisfactory measurements have been obtained in neonates with 30 to 50 mm length, 7.6 mm diameter and 0.045 to 0.075 mm thickness balloons. Air volume should be determined by the pressure-volume curve in vitro, before its introduction in the esophagus 44.
The catheter-balloon system has been used in most different studies on respiratory system and its sub-component mechanics in the anesthetized patient, considering esophageal pressure value as pleural pressure estimate, although some studies question esophageal pressure validation, which would pose problems for ventilatory mechanics calculation.
Higgs et al. have studied 10 patients submitted to general anesthesia with oxygen, nitrous oxide and halothane and maintained under spontaneous ventilation. With the balloon conventionally positioned (10 cm above the cardia) they performed the "occlusion test" and showed that the difference between Pes and Ptr was below 10% in most patients. These authors have evidenced the presence of artifacts caused by heartbeats and posing problems for ventilatory mechanics calculation with the need to reposition the balloon in some cases 9.
Some authors have calculated ventilatory mechanics in anesthetized patients through esophageal pressure measurement and reported only that they have fixed the balloon 35 cm apart from the lips of all patients 45; or 40 cm above the nose 46, regardless of patients' height. No additional test was performed to validate the correct position of the balloon. Others have fixed the balloon at the point where the highest esophageal pressure variation was found, and a constant increase in this pressure was recorded during positive pressure ventilation 47,48.
Other investigators 49,50 have performed the "occlusion test" to validate the balloon technique in anesthetized non-paralyzed patients to calculate ventilatory mechanics during sedation or anesthesia. D'Angelo et al. have performed the "occlusion test" in the supine position before anesthetic induction 51. In some studies on ventilatory mechanics in anesthetized patients, no details were reported on the validation of the esophageal balloon technique before obtaining esophageal pressure 33,52.
Pelosi et al. investigating ventilatory system mechanics in 10 morbidly obese patients have validated the position of the balloon before muscle paralysis through the "occlusion test", when there were still some ventilatory efforts, and have also used chest X-rays to confirm catheter-balloon position in the medium third of the esophagus 53.
Several methods were developed to obtain esophageal pressure variation to calculate pulmonary mechanics in patients under mechanically controlled ventilation. The single breath method described by Zin et al. 54 to measure passive ventilatory system properties 55,56, the interruption technique 57 and the end inspiratory occlusion method (EIOM) are examples. Among them, EIOM with constant flow has been the most widely used method. EIOM is based on the theoretical development proposed by Bates et al. 58,59, based on pioneer studies by Don and Robson, Rattenborg and Holaday 60,61. As from those studies, the ventilatory system may be described as being made of multiple compartments connected in parallel, each one with different emptying times defined as time constants.
At a certain zero inspiration moment with flow entry occlusion for a certain period of time (e.g.: 4 seconds), a fast decrease may be observed in the pressure which was previously being generated. This decrease represents the resistive pressure of the system and after this fast decrease there is a gradual pressure curve decrease until a plateau is reached which represents elastic shrinkage pressure. This variation is more evident it the airway trace and less evident in the esophageal pressure curve. Both sub-components represent different physiological processes during gases distribution in lungs. The first is characterized by fast and homogeneous pressure decrease and represents the pressure needed to overcome airway resistance.
The second, slower and not homogeneous 58,59, would involve pendelluft and stress relaxation phenomena. Pendelluft is the inspired gas redistribution process seen between the units and with unequal time constants during the zero flow phase. It is possible that time constants are unequal due to different lung compartments presenting different fibro-elastic constitutions. The stress relaxation process is the property of the lung of decreasing pressure and distention created with pulmonary inflation when it is inflated and maintained at a constant volume. Pressure decrease would have two reasons. On one hand there would be a realignment of interstitial fibrillar matrix elastic fibers of the pulmonary parenchyma; on the other hand there would be interstitial alveolar film reorganization which would decrease forces generated by superficial stress 62. Stress relaxation represents the accommodation of lungs to positive intra-alveolar pressure. Jonson et al. have found that viscoelastic time constant in normal adults is 0.82 ± 0.11 seconds 63. This implies an occlusion time above 2 seconds to obtain the true plateau pressure needed for mechanic calculations.
Auler Jr. et al. have used this method to calculate lung and chest wall elastic and resistive properties of morbidly obese patients and of normal weight patients anesthetized and paralyzed using 5 seconds inspiratory pause 64.
The access to pleural cavity for pressure measurement has disadvantages because it is invasive and has a high risk of pneumothorax. Ethically, this would be virtually impossible, except when there is already a pleural space drain 65. So, esophageal pressure has been used to infer pleural pressure. To evaluate esophageal pressure validity as pleural pressure measurement, Fry et al. have studied the relationship between both pressures in two manners. The first method consisted on the simultaneous measurement of esophageal and pleural pressure in three individuals under spontaneous ventilation. They concluded that esophageal pressure is an accurate method to obtain pleural pressure variations. The second method consisted on the simultaneous recording of both pressures of a young man with minor pneumothorax and they concluded that relative pleural pressure changes were quantitatively reflected by esophageal pressure. They have also observed that pleural pressure was slightly more negative than the esophageal pressure. Authors have inferred that esophageal pressure safely and accurately reflects static and dynamic pleural pressure variations 3.
Cherniack et al. have compared esophageal and pleural pressure of 14 patients, of whom eight were studied under anesthesia and six were conscious during the procedure. They have observed that pleural pressure was consistently more negative during spontaneous ventilation as compared to esophageal pressure. Esophageal pressure variations were not higher than pleural pressure variations under controlled ventilation, both during inspiration and expiration.
Since patients were in the supine position, authors have raised the possibility of mediastinal weight influencing the esophagus and resulting in more positive pressure. They concluded that esophageal pressure is not identical to pleural pressure and does not follow a parallel ratio. In addition, they observed extreme individual variations in both pressures ratio, suggesting that pulmonary mechanics results should be carefully interpreted 66. One year later, Attinger et al. have simultaneously measured esophageal and pleural pressure in four patients (two with spontaneous pneumothorax with 10% pulmonary collapse and two with pleural effusion) in spontaneous ventilation and in different positions. They have observed that pleural pressure variation was usually higher as compared to esophageal pressure.
The difference has varied in a patient-by-patient basis and depended on body position. End expiratory pleural pressure was in general more negative as compared to end expiratory esophageal pressure. Both end expiratory pressures were consistently more negative in the sitting position as compared to the supine position, and in most patients it was more negative in the prone position as compared to the sitting position 67.
Mead and Gaensler, in 1959, have simultaneously recorded pleural and esophageal pressures in seven patients in the upright position and in five patients in the supine position. They have observed that cardiac oscillations were three times higher in the supine position as compared to the upright position and that this could partially contribute for the higher difference found in this position. They have also observed that the best correspondence between esophageal and pleural pressure was obtained in the upright position 68. Absolute pressure values in the supine position have shown consistently more positive esophageal pressure, which may be explained by esophageal compression by mediastinal structures interfering with pulmonary compliance and resistance calculations.
Daly and Bondurant, in 1963, have simultaneously studied pleural pressure in different intercostal spaces (3rd, 5th and 8th) and esophageal pressure in human volunteers in the sitting position. They observed that pleural pressure has varied according to measurement site, and that such values where higher in the lower thoracic region as compared to upper chest. Even with 200 mL pneumothorax, there were no differences in pleural and esophageal pressures 69. Most studies have considered absolute pressure values to compare pleural and esophageal pressures. It is currently known that this comparison should be performed by relating pressure variations.
PEEP in mechanically controlled ventilation, both during anesthesia or Intensive Care is unquestionable. Respiratory mechanics understanding in any clinical condition is critical for the adequate treatment. Esophageal pressure as indirect pleural pressure measurement is a less invasive alternative to calculate respiratory system elastic and resistive properties. So, it is important to understand whether PEEP interferes with the correspondence of esophageal and pleural pressures.
Chapin et al. have investigated changes in chest (Cc) and pulmonary (Cp) compliance and the required PEEP level to establish adequate pulmonary expansion in 10 anesthetized pigs ventilated with 10 cmH2O PEEP and Ppl monitoring. They have observed that in normal chest and pulmonary compliance conditions, approximately half (52% ± 9%) of applied airway pressure (Paw) was transmitted to the pleural space, but has increased to 65% ± 9% when Cc was normal and Cp was decreased by pneumatic tourniquet applied to abdomen and chest. Pulmonary hydrochloric acid instillation decreased Cp, median sternotomy increased Cc and in this situation, Paw transmission to pleural space was decreased to 11% ± 6%. Results indicated that both Cc and Cp are significantly important to determine the level of pulmonary expansion and pressure transmission to intrathoracic structures during PEEP 22. This study, however, has not monitored esophageal pressure.
Craven and Wood have studied six anesthetized dogs comparing esophageal and pleural pressure close to the heart in the right lateral position. They have observed that esophageal pressure is very similar to the pressure between the lung and the left pericardium with PEEP levels of 0, 10 and 20 cmH2O. Although right extra-pericardial pressure is 4.5 to 5 times more positive, authors have related this fact to direct heart weight on pericardial space 70. Marini et al. have examined the effect of PEEP on juxtacardiac and esophageal pressures of eight dogs in the prone and supine positions. Juxtacardiac pressure was significantly higher than esophageal pressure in the supine position, while there has been no statistically significant difference between pressures in the prone position. In this same study, authors have recorded esophageal pressure of three humans in the supine, prone and lateral positions, with 0, 10 and 20 cmH2O PEEP. They have observed heart elevation and significant esophageal pressure increase during PEEP increase. This increase was higher in the prone and lateral positions as compared to the supine position 71.
O'Quin et al. have studied in dogs the ratio between Pes and Ppl measured in the juxtacardiac space during different pulmonary and chest compliance conditions in different PEEP levels (5, 10, 15 and 20 cmH2O), all in the supine position. Comparisons were made at the end of expiration. In all compliance conditions, Ppl variation was significantly higher as compared to Pes. This difference depended on Cp and Cc, however it was independent of PEEP. During normal Cp, 61% of applied PEEP was reflected in the pleural space at the end of expiration, while 52% was reflected by esophageal pressure. After Cp decrease, 55% and 46% PEEP were transmitted to pleural and esophageal spaces, respectively 72.
Smiseth et al. have studied the ratio between juxtacardiac esophageal and pleural pressures during 10, 20 and 30 cmH2O PEEP ventilation applied to both lungs, and selectively in a single lung, in eight dogs in the supine position. They have observed that bilateral 10, 20 and 30 cmH2O PEEP has promoted progressive and similar right and left pleural pressures increase. They concluded that the esophageal balloon does not reflect sharp regional pleural pressure increase when selective PEEP is applied to one lung, and that it consistently underestimates pleural pressures when PEEP is applied to both lungs 73. It is important to stress that these authors considered absolute pressure values rather than pressure variation.
Klingstedt et al. have evaluated in eight humans in the lateral position the effect of PEEP (8 and 16 cmH2O) solely in the dependent lung, on the compliance and resistance of the same hemithorax. They have observed that selective 8 cmH2O PEEP increased dependent hemithorax compliance while the non dependent remained unchanged. With 16 cmH2O PEEP, both hemithoraces compliance were virtually the same. Inspiratory resistance has also progressively decreased with selective PEEP increase, being significant with 16 cmH2O PEEP. Esophageal pressure was measured with the balloon and authors concluded that esophageal pressure variation does not truly reflect pleural pressure variation when selective PEEP is applied in the lateral position 45.
Jardin et al. have observed the effect of airway pressure transmission to the esophagus in 19 acute respiratory failure patients divided in three groups, with mild, moderate and severe total respiratory system compliance decrease. Observations were made at three PEEP levels: ZEEP, 10 and 20 cmH2O. Measurement variations were checked at the end of expiration and at the end of inspiration. Pes was linearly correlated to tracheal pressure in all patients. In the group with mild Crs decrease, Pes variation was 2.73 ± 0.45%, related to Pt transmission in approximately 37%. In the group with moderate Crs decrease, Pes variation was 3.14 ± 1.04 and transmitted Pt was 32%. In the group with important Crs decrease, variation was 4.13 ± 1.55 and transmited Pt was just 24%. Airway pressure transmission for the esophagus was decreased in the presence of severe respiratory system compliance deterioration 46.
Bonnet et al. have determined the magnitude of juxtacardiac pressure changes through esophageal, pericardial and mediastinal pleural pressures, related to 0 to 20 cmH2O PEEP, increased in 11 patients submitted to cardiac procedures. There has been intra-thoracic pressure increase with increased PEEP levels in all patients. Changes in esophageal pressure were less important, however they presented linear correlation with pleural pressure changes 11.
Rajacich et al. have studied the variation of esophageal pressure per applied PEEP (0, 5, 10, 15 and 20 cmH2O) of patients in the postoperative period of mycardial revascularization procedures. They have observed that Pes was significantly increased at 10, 15 and 20 cmH2O PEEP with patients in the supine position 18.
Smiseth et al. have directly measured extracardiac pleural pressure in eight patients submitted to cardiac procedures. Measurements were obtained in the expiratory period with 5, 10 and 15 cmH2O PEEP. They have observed that PEEP has progressively increased extracardiac pleural pressure 74.
Pelosi et al. have studied six dogs with respiratory failure caused by oleic acid under anesthesia and muscle paralysis in the supine position. They have simultaneously measured esophageal and pleural pressures in the apical and median region and in the more dependent region of the chest, after 5 and 15 cmH2O PEEP associated to different tidal volumes (low, medium and high). They have observed that pleural surface pressure is underestimated by esophageal pressure when airway pressure is increased. They have shown that absolute Pes value is only useful as a good Ppl estimate for the medium pulmonary region, being consistently different from pulmonary dependent and non dependent region values. However there is satisfactory statistical correlation between Pes and Ppl variation in all pulmonary regions 23. Auler Jr and Fernandes have observed that in anesthetized paralyzed patients in the postoperative period of cardiac surgeries, there was excellent correlation between esophageal and pleural pressures with intermediate PEEP levels (5 and 10 cmH2O); however, with zero PEEP these pressures were not correspondent 65
Further studies are needed in humans to validate the esophageal balloon in patients with pulmonary compliance changes under PEEP. Some recommendations for the use of esophageal balloon in sedated patients under mechanically controlled ventilation or under anesthesia should be followed 75:
- Adequate balloon positioning in the medium third of the esophagus, confirmed by the "occlusion test";
- Catheter-balloon system position should be confirmed by chest X-rays, since most catheters are radiopaque;
- Balloon filling with adequate volume, obtained by balloon compliance test, aiming at recording actual pressure values obtained in the intra-esophageal space;
- It is recommended that esophageal pressure measurements in anesthetized paralyzed patients should be obtained in the supine position with PEEP above 5 cmH2O, since in this situation, in ZEEP, esophageal and pleural pressures do not correspond. The best correspondence between both pressures is achieved with 10 cmH2O PEEP.
- Adequate choice of signals monitoring equipment and high sensitivity of transducers are fundamental, in addition to gauging the equipment before each use.
Accurate lung and chest wall elastic and resistive properties calculation is only possible with accurate pleural pressure.
The esophageal balloon is the most popular method to obtain indirect pleural pressure values. The "occlusion test" is critical for adequate balloon positioning. With intermediate 5 to 10 cmH2O PEEP levels, there is adequate correlation between Pes and Ppl variation in sedated or anesthetized patients without major pulmonary compliance impairment.
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32. Brown IG, Clean PA, Webster PM et al Lung volume dependence of esophageal pressure in the neck. J Appl Physiol, 1985; 59:1849-1854. [ Links ]
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35. Fonseca-Costa A, Nardi AE Relationship between mouth and esophageal pressures in different body postures. Braz J Med Biol Res, 1983;16:119-125. [ Links ]
36. Asher MI, Coates AL, Collinge JM et al Measurement of pleural pressure in neonates. J Appl Physiol, 1982;52:491-494. [ Links ]
37. Correa FC, Ciminelli PB, Falcão H et al Respiratory mechanics and lung histology in normal rats anesthetized with sevoflurane. J Appl Physiol, 2001;91:803-810. [ Links ]
38. Lanteri CJ, Kano S, Sly PD Validation of esophageal pressure occlusion test after paralysis. Pediatr Pulmonol, 1994;17:56-62. [ Links ]
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40. Dechman G, Sato J, Bates JH Factors affecting the accuracy of esophageal balloon measurement of pleural pressure in dogs. J Appl Physiol, 1992;72:383-388. [ Links ]
41. Baydur A, Sassoon C, Carlson M Measurement of lung mechanics at different lung volumes and esophageal levels in normal subjects: effect of posture change. Lung, 1996;174:139-151. [ Links ]
42. Ingimarsson J, Thorsteinsson A, Larsson A et al Lung and chest wall mechanics in anesthetized children. Influence of body position. Am J Respir Crit Care Med, 2000;162:412-417. [ Links ]
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48. Ruiz Neto PP, Auler Júnior JO Respiratory mechanical properties during fentanyl and alfentanil anaesthesia. Can J Anaesth, 1992;39:458-465. [ Links ]
49. Baydur A, Sassoon CS, Stiles CM Partitioning of respiratory mechanics in young adults Effects of duration of anesthesia. Am Rev Respir Dis, 1987;135:165-172. [ Links ]
50. Nava S, Rubini F Lung and chest wall mechanics in ventilated patients with end stage idiopathic pulmonary fibrosis. Thorax, 2000;54:390-395. [ Links ]
51. D'Angelo E, Calderini E, Torri G et al Respiratory mechanics in anesthetized paralyzed humans: effects of flow, volume, and time. J Appl Physiol, 1989;67:2556-2564. [ Links ]
52. Putensen C, Leon MA, Putensen-Himmer G Effect of neuromuscular blockade on the elastic properties of the lungs, thorax, and total respiratory system in anesthetized pigs. Crit Care Med, 1994;22:1976-1980. [ Links ]
53. Pelosi P, Croci M, Ravagnan I et al Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest, 1996;109:144-151. [ Links ]
54. Zin WA, Pengelly LD, Milic-Emili J Single-breath method for measurement of respiratory mechanics in anesthetized animals. J Appl Physiol, 1982;52:1266-1271. [ Links ]
55. Behrakis PK, Higgs BD, Baydur A et al Respiratory mechanics during halothane anesthesia and anesthesia-paralysis in humans. J Appl Physiol, 1983;55:1085-1092. [ Links ]
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57. Gottfried SB, Higgs BD, Rossi A et al Interrupter technique for measurement of respiratory mechanics in anesthetized humans. J Appl Physiol, 1985;59:647-652. [ Links ]
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59. Bates JH, Baconnier P, Milic-Emili J A theoretical analysis of interrupter technique for measuring respiratory mechanics. J Appl Physiol, 1988;64:2204-2214. [ Links ]
60. Don HF, Robson JG The mechanics of the respiratory system during anesthesia. The effects of atropine and carbon dioxide. Anesthesiology, 1965;26:168-178. [ Links ]
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Correspondence to:
Dra. Cláudia Regina Fernandes
Rua Marcelino Lopes, 4520/09
60834-370 Fortaleza, CE
E-mail: firstname.lastname@example.com
Submitted for publication
7 de outubro de 2005
Accepted for publication 20 de fevereiro de 2006
* Received from Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE


text:
Galveston College announced that it has signed an agreement with Pearson VUE, the electronic certification and licensure testing business of Pearson. This will provide Information Technology certification test delivery using the Pearson VUE® Testing System. The Pearson VUE advanced computer-based testing system administers exams for leading IT certification programs such as Cisco®, CompTIA®, Citrix®, Novell® and others through a global network of quality test centers.
"We're very excited about our new partnership with Pearson VUE," said, Michelle Mackey, Assessment Coordinator. "The Pearson VUE Testing System is the most powerful available. We're pleased to partner with a company whose breakthrough technology and passion for service will allow us to provide even greater service for our customers."
The Pearson VUE system has several advances, such as, the ability of test candidates to register or reschedule their tests at the test center through the Pearson VUE website or through a Pearson VUE call center. "The Pearson VUE Testing System gives us unparalleled control and flexibility over our ability to manage our business our way," added Michelle Mackey. "With so many options, we will be able to experiment with testing hours and number of testing stations. We can easily offer same-day testing, or bring testing to our customers' locations. Everyone benefits."
The increasing list of IT certification tests are delivered directly from the test sponsors to the Pearson VUE system. The test results are quickly transmitted back, ensuring the candidate's certification status is promptly updated.
Randy Trask, Pearson VUE Vice President Market Development, said, "We are proud to welcome Galveston College to the rapidly growing global network of Pearson VUE Authorized Test Centers, providing candidates with an opportunity to participate in a positive, rewarding test experience."


text:
how does it work? extending one's visa for 3 months, by working for 3 months? how does this 3 months work...work?
i have been working for 38 days within the span of 3 months. is 5 working days count as a week?
i am really confused on how they see 3 months work as.....


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Insanely lightweight module for converting times to milliseconds.
Literally 9 lines of code, it's just to make writing time in a way that's more readable without having to remember how many milliseconds are in a day, week, month, year.
For those curious, the exact definition of "years" and "months" can vary slighly but these are based on the Julian Year which is 365.25 days of 86400 seconds (http://en.wikipedia.org/wiki/Year) and a month is simply 1/12th of that.
npm install milliseconds
var ms = ; ms; // 2000 ms; // 120000 ms; // 7200000 ms; // 172800000 ms; // 1209600000 ms; // 5259600000 ms; // 63115200000
If you like this follow @HenrikJoreteg on twitter.


text:
Yes, I am aware of how many "Origin" stories there are, but I wanted to present my ideas of the origin of the Pokemon World, and thus The Origins was born. I plan to make several short stories, each explaining how different aspects of the Pokemon World came to be.
Now, I present the first story, The Origin of All
It wasnt a world of shadows, nor one of light. It was merely a world of the betwixt and between, a never ending war between time and space. Nothing existed, and it seemed that no life ever could, as there was no chance of survival. Many times, half-creatures where created but faded away quickly into the nonexistence of the universe. The faded souls of these creatures lived on, however, until they finally clustered together to form an awesome monster, an angel and a demon, a spirit guardian that was neither alive nor dead.
In a world without time or space, millenia passed forwards and backwards, reversing and speeding up the growth of the monster. It was either a very long or short time that passed before the creature finally took its first breath. It was still not whole.
Still, the monster grew, slowly taking form and quickly growing smaller. It almost became a true being many times, but as its form changed, it would sink into nonexistence. It often failed to breathe, and as a result, its form would wither and die, and it would return to light and shadow as a new, stronger form took shape. The souls of the many other failed lifeforms still huddled together, until finally, it was alive.
Its structure was wavy, and it was easily moulded by the pure existence of its surroundings, and it was unable to save any thoughtsor emotions. Once it had become alive, it began to die, but without being whole, the monster would always survive, even if it became no more than a microscopic spec of mass and energy. It lived on, growing more powerful constantly.
Finally, after many long and short years and lightyears, the creature was formed. It was still blurry, like a phantom hiding within the shadows, but equally as powerful as a monster. It was fashioned roughly, and looked as if it had been carved with a blunt knife out of the universe. It was small, but in comparison to nothing, it was massive. It was sealed in a hard protective shell, a prototype egg object that shielded the monster from all things on the exterior, which may have been nothing or everything, as anything void of something is merely the opposite of the original. As the creature grew more massive and awesome, it began to break free of its protective bonds, and it was fully born.
Its skin was clear, and showed the fluctuating light patterns through its flesh, creating an ultimate camouflage ruined only by the facial features. It had two small eyes, a vividly bright green with blood-red pupils to see with. The rest of its face was obscured by a cloud of shadow, like a mask made of pure darkness. It moved gently through the antimatter, its transparent legs swishing through the void, propelling it forwards. It still grew as it aged, and its growth brought power.
Slowly, yet altogether rather quickly, the monster grew tired of merely existing in a world of nonexistence. No sooner had the thought passed through its mind than a very faint object appeared in front of it. The creature drew close to the item, and with the very slightest touch, it began to darken, taking the form of a protective sphere, very much like the one that had fashioned around the monster at its creation. It became a cloud of darkness, swirling with power and hypnotizing the creature. Finally the monster approached the egg once more, and it burst apart in a dazzling array of light and shadow. Three larger objects began to take shape around the creature, who stayed by the objects for all the length of their creation, until they finally began to break apart.
From the first egg, a grand serpentine monster appeared, with wings made of the same dark material as its egg. It had large red claws on each of the wings, which began to divide into several bony appendages. It sprouted short, golden talons from all of the different segments of its reptilian body. Its face was mostly covered in a bright gold mask, with two thin slits for its black eyes with scarlet pupils.
From the second egg, a bulky, dirty white monster with veins filled with a dark pink substance. It had a long neck, which stuck a small head out quite a bit from the body, and was followed by two large, but seemingly flightless wings protruding from the rear of its neck. Each of its two arms had a shining pink orb sunk in, and short hands that ended in five razor-sharp claws. It had two heavy legs with deadly talons and a long, curling tail.
From the third and final egg burst a brilliantly sea blue quadrupedal dragon that was partially armored by thick, silver plates. It had a tall, long neck that ended in a long, spear-shaped head. It had metallic horns above its eyes, across the base of its neck, and a row of spikes lined on the back of its spine. Each of its four feet was covered in hard, sharp claws that rose up to the sky blue veins that wrapped around the monster. Sunken into its large chest plate was a bright blue hexagonal jewel.
The original monster stared at the three new creatures in awe. Slowly, it realized that it had created them with its own powers, and upon realizing this, it stared blankly around in the world that the four monsters shared. It was then that it devised the most important system it could ever create.
Ar...ce...us it spoke slowly, forcing the harsh sounds to emerge from its throat. The shadow creature lifted its head at the monster, and emitted a sound in much the same way.
Gi...ra...ti...na it sounded, and the voice echoed in the endless nothingness.
Originally, the being that had spoken Arceus was trying to communicate the existence of life. The Giratina monster was attempting to convey a response, specifically, ghost, in saying that it was partially a ghost, and thus, not fully alive.
Di...al...ga . roared the third monster, the quadrupedal, more loudly than the others. Its message was received as its name as well, despite its attempt to speak of deciphering the time of the distorted world.
Pal...ki...a ? spoke the fourth and final creature, as a question, unlike the others. It was trying to ask the Arceus monster, who was its creator, and was assumed as the wisest, what was this space.
The four monsters lived in an almost dream state of confusion and wonder. Each slowly helped to create the communication system, as well as discovering their own special abilities. Giratina, as the serpentine dragon had been officially named because of its first speech, gained an odd ability to travel through the light and darkness to other places, other worlds. Its form varied each time it found or created a new dimension, becoming warped differently for each world.
Palkia discovered its incredible ability to create matter from the nothingness, and with the help of Dialga, began to shape a whole new world in one of Giratinas own dimensions. Dialga would use its powers to control time to make time pass through Palkias world.
Arceus watched all of this, thinking in wonder and amazement at how his own creations had shaped a world that was inhabitable without the fluctuating life patterns of the antimatter world. It found that when traveling through the new world, different things, elements, changed its form and powers. It began to grow a mystical armor that encircled its back, a complicated figure of various elemental materials. It was able to produce and control fire, water, earth, and air, and slowly created new forces that helped shape the world into a hospitable environment.
For a long time, which could now be measured thanks to Dialga, each of the four monsters lived harmoniously, sharing the world of their creation peacefully. Arceus had created fifteen new elements which now shrouded the world in hope and happiness. Of course, as was inevitable, the four monsters quarreled now and then, but Arceus would manage to calm them down each time. The creatures had created a paradise, and it seemed that nothing could ever ruin the life they had created for themselves.
- - - - - - - - - -
Please be sure to leave any comments or concerns you may have about my Fan Fic, thanks!


text:
Winnie Jo Wallet | Black (spring)
Winnie Jo Wallet
We all wear multiple hats in one day. This gem can be used as a wallet in one of your Sapahn bags and can seamlessly transform to a stand-alone crossbody when you only want to take your essentials with you.
*Wondering why you're seeing two of the same colored bags on our site? Check out the lining!*
- From the Omega Leather Collection by artisans Mana & Arpa + 22 talented artisans
- Design: Drawstring closure, exterior zip pocket, interior zip pocket, double interior leather pockets, fully lined, shoulder strap, brass feet
- Material: Buttery-soft Premium Leather, cotton lining, YKK zipper, plated brass hardware
- Measurement: H 4.5 x L 8 x W 1
- Product Care: Leather will naturally patina from daily use. For the freshest appearance, occasionally wipe your leather using a soft damp cloth in circular motions. Be aware that dark dyes from clothing can migrate onto your leather.
- Handmade


text: A hand-made frame alongside some of the best components available, Detroit Bicycle Company's Madison Street bike is probably the most beautiful I've ever seen. With the forks, stem, seatpost and steastays all plated in fine, golden copper, you'd almost be tempted to hang the Madison Street on your wall, and leave it there, for fear of it getting dirty. What a waste, however, that would be, and with prices for Detroit Bicycle Company's bike around the $3,200 ballpark, you'll want to get some use out of it too. All of their frames are made with Columbus SL CRO-Mo tubing and Nova lugs, while Campagnolo and Cinelli parts, track rims with Vittoria Zaffiro tires and a Brooks leather saddle fill out this model too. Unfortunately there's shipping and import tax to add on if you're far away from the States, but see if that'll hold you back.


text:
Support the good work of Happiness House in the Finger Lakes community.
Administration: (315) 789-6828
Children's Programs: (315) 789-6850
Adult Programs: (585) 394-9510
Children's Programs: (585) 394-1190
Toll free: (866) 408-2550
Sign up to receive communications from Happiness House
Home > Programs and Services > Birth to Five Services > Daycare Services
Happiness House offers daycare to children ages three to five at both the Canandaigua and Geneva centers. Both centers are licensed by the New York State Office of Children and Family Services. Daycare is available year round, Monday to Friday, from 7:00 a.m. to 5:30 p.m. Breakfast, lunch and snacks are served. Children in the daycare program also participate in the New Friends Integrated Preschool from 9:00 a.m. – 3:00 p.m. each school day.
For more information about Happiness House Daycare, contact the Children's Program Secretary where you live.
Contact Judy Schwarz at (585) 394–1190 or firstname.lastname@example.com
Contact Jamie Simon at (315) 789-6850 or firstname.lastname@example.com
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731 Pre-emption Road Geneva, Ontario County, NY 14456
Office Outlook Web Access Paychex HR Online
5415 County Road 30 Canandaigua, Ontario County, NY 14424


text:
Welcome Hotel Cristallo Riccione
In this land, with experience and tradition of hospitality, the Archangeli Family has created a warm and friendly atmosphere, where friendliness and courtesy combine the professionalism necessary to manage business programs, moments of leisure or pure relax.
The Hotel Cristallo is located in a strategic position just a few steps from the sea, in the center of Riccione, 30 mt. from the new conference center, 500 mt. from the station, 700 mt. from the Terme area, in the heart of fun. The famous parks Acquafan and Oltremare are easy reachable with public transport or by car.
Here, you can alternate moments of work and pleasant walks through the most exclusive streets of the Riviera Romagnola.
€ 60 Ecomondo Rimini
from € 46 SUN
from € 46 SIA GUEST
from € 46 TTG Expo Rimini
MOTOGP Hotel+Ticket
from € 55 MACFRUT