Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously. METHODS: A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (\u3e300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade. RESULTS: During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO. CONCLUSIONS: Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery

The Use of a Complexity Model to Facilitate in the Selection of a Fuel Cell Assembly Sequence

Various tools and methods exists for arriving at an optimised assembly sequence with most using a soft computing approach. However, these methods have issues including susceptibly to early convergence and high computational time. The typical objectives for these methods are to minimise the number of assembly change directions, orientation changes or the number of tool changes. This research proposes an alternative approach whereby an assembly sequence is measured based on its complexity. The complexity value is generated using design for assembly metrics and coupled with considerations for product performance, component precedence and material handling challenges to arrive at a sequence solution which is likely to be closest to the optimum for cost and product quality. The case presented in this study is of the assembly of a single proton exchange membrane fuel cell. This research demonstrates a practical approach for determining assembly sequence using data and tools that are used and available in the wider industry. Further work includes automating the sequence generation process and extending the work by considering additional factors such as ergonomics

Hydrogen Fuel Cell Pick and Place Assembly Systems: Heuristic Evaluation of Reconfigurability and Suitability

Proton Exchange Membrane Fuel Cells (PEMFCs) offer numerous advantages over combustion technology but they remain economically uncompetitive except for in niche applications. A portion of this cost is attributed to a lack of assembly expertise and the associated risks. To solve this problem, this research investigates the assembly systems that do exist for this product and systematically decomposes them into their constituent components to evaluate reconfigurability and suitability to product. A novel method and set of criteria are used for evaluation taking inspiration from heuristic approaches for evaluating manufacturing system complexity. It is proposed that this can be used as a support tool at the design stage to meet the needs of the product while having the capability to accept potential design changes and variants for products beyond the case study presented in this work. It is hoped this work develops a new means to support in the design of reconfigurable systems and form the foundation for fuel cell assembly best practice, allowing this technology to reduce in cost and find its way into a commercial space

A Framework for Automatically Realizing Assembly Sequence Changes in a Virtual Manufacturing Environment

© 2016 The Authors. Global market pressures and the rapid evolution of technologies and materials force manufacturers to constantly design, develop and produce new and varied products to maintain a competitive edge. Although virtual design and engineering tools have been key to supporting this fast rate of change, there remains a lack of seamless integration between and within tools across the domains of product, process, and resource design-especially to accommodate change. This research examines how changes to designs within these three domains can be captured and evaluated within a component based engineering tool (vueOne, developed by the Automation Systems Group at the University of Warwick). This paper describes how and where data within these tools can be mapped to quickly evaluate change (where typically a tedious process of data entry is required) decreasing lead times and cost and increasing productivity. The approach is tested on a sub-assembly of a hydrogen fuel cell, where an assembly system is modelled and changes are made to the sequence which is translated through to control logic. Although full implementation has not yet been realized, the concept has the potential to radically change the way changes are made and the approach can be extended to supporting other change types provided the appropriate rules and mapping

The use of a complexity model to facilitate in the selection of a fuel cell assembly sequence

Various tools and methods exists for arriving at an optimised assembly sequence with most using a soft computing approach. However, these methods have issues including susceptibly to early convergence and high computational time. The typical objectives for these methods are to minimise the number of assembly change directions, orientation changes or the number of tool changes. This research proposes an alternative approach whereby an assembly sequence is measured based on its complexity. The complexity value is generated using design for assembly metrics and coupled with considerations for product performance, component precedence and material handling challenges to arrive at a sequence solution which is likely to be closest to the optimum for cost and product quality. The case presented in this study is of the assembly of a single proton exchange membrane fuel cell. This research demonstrates a practical approach for determining assembly sequence using data and tools that are used and available in the wider industry. Further work includes automating the sequence generation process and extending the work by considering additional factors such as ergonomi

Hydrogen fuel cell pick and place assembly systems : heuristic evaluation of reconfigurability and suitability

Proton Exchange Membrane Fuel Cells (PEMFCs) offer numerous advantages over combustion technology but they remain economically uncompetitive except for in niche applications. A portion of this cost is attributed to a lack of assembly expertise and the associated risks. To solve this problem, this research investigates the assembly systems that do exist for this product and systematically decomposes them into their constituent components to evaluate reconfigurability and suitability to product. A novel method and set of criteria are used for evaluation taking inspiration from heuristic approaches for evaluating manufacturing system complexity. It is proposed that this can be used as a support tool at the design stage to meet the needs of the product while having the capability to accept potential design changes and variants for products beyond the case study presented in this work. It is hoped this work develops a new means to support in the design of reconfigurable systems and form the foundation for fuel cell assembly best practice, allowing this technology to reduce in cost and find its way into a commercial space

A framework for automatically realizing assembly sequence changes in a virtual manufacturing environment

Global market pressures and the rapid evolution of technologies and materials force manufacturers to constantly design, develop and produce new and varied products to maintain a competitive edge. Although virtual design and engineering tools have been key to supporting this fast rate of change, there remains a lack of seamless integration between and within tools across the domains of product, process, and resource design - especially to accommodate change. This research examines how changes to designs within these three domains can be captured and evaluated within a component based engineering tool (vueOne, developed by the Automation Systems Group at the University of Warwick). This paper describes how and where data within these tools can be mapped to quickly evaluate change (where typically a tedious process of data entry is required) decreasing lead times and cost and increasing productivity. The approach is tested on a sub-assembly of a hydrogen fuel cell, where an assembly system is modelled and changes are made to the sequence which is translated through to control logic. Although full implementation has not yet been realized, the concept has the potential to radically change the way changes are made and the approach can be extended to supporting other change types provided the appropriate rules and mapping

The Post-Eruptive Evolution of a Coronal Dimming

We discuss the post-eruptive evolution of a "coronal dimming" based on observations of the EUV corona from the Solar and Heliospheric Observatory and the Transition Region and Coronal Explorer. This discussion highlights the roles played by magnetoconvection-driven magnetic reconnection and the global magnetic environment of the plasma in the "filling" and apparent motion of the region following the eruption of a coronal mass ejection (CME). A crucial element in our understanding of the dimming region evolution is developed by monitoring the disappearance and reappearance of bright TRACE "moss" around the active region giving rise to the CME. We interpret the change in the TRACE moss as a proxy of the changing coronal magnetic field topology behind the CME front. We infer that the change in global magnetic topology also results in a shift of energy balance in the process responsible for the production of the moss emission while the coronal magnetic topology evolves from closed, to open and back to closed again because, following the eruption, the moss reforms around the active region in almost exactly its pre-event configuration. As a result of the moss evolution, combining our discussion with recent spectroscopic results of an equatorial coronal hole, we suggest that the interchangeable use of the term "transient coronal hole" to describe a coronal dimming is more than just a simple coincidence.Comment: In Press ApJ [May 2007] - 15 pages, 5 figures, 7 movies that are available upon request [contact author

Factors Affecting Early Services for Children Who Are Hard of Hearing

To describe factors affecting early intervention (EI) for children who are hard of hearing, we analyzed (a) service setting(s) and the relationship of setting to families' frequency of participation, and (b) provider preparation, caseload composition, and experience in relation to comfort with skills that support spoken language for children who are deaf and hard of hearing (CDHH)

Timeliness of Service Delivery for Children With Later-Identified Mild-to-Severe Hearing Loss

This study examined diagnostic and intervention services for children identified with hearing loss (HL) after the newborn period