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The Sequential Organ Failure Assessment (SOFA) score was developed more than 25 years ago to provide a simple method of assessing and monitoring organ dysfunction in critically ill patients. Changes in clinical practice over the last few decades, with new interventions and a greater focus on non-invasive monitoring systems, mean it is time to update the SOFA score. As a first step in this process, we propose some possible new variables that could be included in a SOFA 2.0. By so doing, we hope to stimulate debate and discussion to move toward a new, properly validated score that will be fit for modern practice.

Purpose Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only. Methods This is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes. Results After appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient–ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm. Conclusions Pes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist’s clinical armamentarium may enhance treatment to improve clinical outcomes.

Background Respiratory mechanics is a key element to monitor mechanically ventilated patients and guide ventilator settings. Besides the usual basic assessments, some more complex explorations may allow to better characterize patients’ respiratory mechanics and individualize ventilation strategies. These advanced respiratory mechanics assessments including esophageal pressure measurements and complete airway closure detection may be particularly relevant in critically ill obese patients. This study aimed to comprehensively assess respiratory mechanics in obese and non-obese ICU patients with or without ARDS and evaluate the contribution of advanced respiratory mechanics assessments compared to basic assessments in these patients. Methods All intubated patients admitted in two ICUs for any cause were prospectively included. Gas exchange and respiratory mechanics including esophageal pressure and end-expiratory lung volume (EELV) measurements and low-flow insufflation to detect complete airway closure were assessed in standardized conditions (tidal volume of 6 mL kg −1 predicted body weight (PBW), positive end-expiratory pressure (PEEP) of 5 cmH 2 O) within 24 h after intubation. Results Among the 149 analyzed patients, 52 (34.9%) were obese and 90 (60.4%) had ARDS (65.4% and 57.8% of obese and non-obese patients, respectively, p  = 0.385). A complete airway closure was found in 23.5% of the patients. It was more frequent in obese than in non-obese patients (40.4% vs 14.4%, p  < 0.001) and in ARDS than in non-ARDS patients (30% vs. 13.6%, p  = 0.029). Respiratory system and lung compliances and EELV/PBW were similarly decreased in obese patients without ARDS and obese or non-obese patients with ARDS. Chest wall compliance was not impacted by obesity or ARDS, but end-expiratory esophageal pressure was higher in obese than in non-obese patients. Chest wall contribution to respiratory system compliance differed widely between patients but was not predictable by their general characteristics. Conclusions Most respiratory mechanics features are similar in obese non-ARDS and non-obese ARDS patients, but end-expiratory esophageal pressure is higher in obese patients. A complete airway closure can be found in around 25% of critically ill patients ventilated with a PEEP of 5 cmH 2 O. Advanced explorations may allow to better characterize individual respiratory mechanics and adjust ventilation strategies in some patients. Trial registration NCT03420417 ClinicalTrials.gov (February 5, 2018).

Purpose ICU-acquired weakness , comprising Critical Illness Polyneuropathy (CIP) and Myopathy (CIM) is associated with immobilization and prolonged mechanical ventilation. This study aims to assess feasibility of early detection of CIP and CIM by peroneal nerve test (PENT) and sensory sural nerve action potential (SNAP) screening in patients with septic shock and invasively ventilated for more than 72 h. Methods We performed repetitive PENT screening from 72 h after intubation until detecting a pathological response. We tested SNAPs in pathological PENT to differentiate CIP from CIM. We performed muscle strength examination in awake patients and recorded time from intubation to first in-bed and out-of-bed mobilization. Results Eighteen patients were screened with PENT and 88.9% had abnormal responses. Mean time between intubation and first screening was 94.38 (± 22.41) hours. Seven patients (38.9%) had CIP, two (11.1%) had CIM, one (5.6%) had CIP and CIM, six (33.3%) had a pathological response on PENT associated with ICU-acquired weakness (but no SNAP could be performed to differentiate between CIP and CIM) and two patients had (11.1%) had no peripheral deficit. In patients where it could be performed, muscle strength testing concorded with electrophysiological findings. Twelve patients (66.7%) had out-of-bed mobilization 10.8 (± 7.4) days after admission. Conclusion CIP and CIM are frequent in septic shock patients and can be detected before becoming symptomatic with simple bedside tools. Early detection of CIP and CIM opens new possibilities for their timely management through preventive measures such as passive and active mobilization.

Background In intensive care settings, doctors face low-frequency and high-stakes events such as tracheostomy-related emergencies. Junior doctors must learn to manage these situations to ensure patient safety, yet they often lack clinical exposure to such critical events. Clinical teachers should develop methods that provide enough learning opportunities while remaining feasible in terms of workload. This study compared three strategies for teaching junior doctors to manage tracheostomy-related emergencies in intensive care unit (ICU). Method In this pilot study, conducted in the ICU of Lausanne University Hospital, twenty-four junior doctors were randomized into three groups: Group A: Access to a printed algorithm; Group B: E-learning, including the algorithm with access to a toolbox; Group C: Flipped classroom course, including a short low-fidelity simulation. Performance was assessed through pre- and post-intervention sessions consisting of three tracheostomy-related simulation scenarios. A modified Delphi method was used to develop a performance assessment tool consisting of an evaluation scale for each scenario. Knowledge was also assessed before and after the intervention through a multiple-choice questionnaire. The primary outcome was the Global Performance Score (GPS), calculated for each teaching method by summing the performance scale scores across the three simulation scenarios as the total score across all scenarios, after the intervention. Results The GPS significantly improved after the intervention in the three groups (Group A: M  = 141, SD  = 22 vs. M  = 116, SD  = 16.7 p  = 0.008; Group B: M  = 157, SD  = 14 vs. M  = 110.1, SD  = 17.3 p  = 0.008; Group C: M  = 171.9, SD  = 20.1 vs. M  = 99.4, SD  = 16 p  = 0.008). There was a trend for a higher post-intervention GPS in Group B as compared to Group A ( p  = 0.105), and in Group C as compared to Group B ( p  = 0.279). By contrast, post-intervention GPS was significantly higher in Group C as compared to Group A ( p  = 0.021). Conclusion The flipped classroom strategy, combined with a brief simulation, yielded the highest post-intervention score. This strategy appears promising for junior doctors learning to manage low-frequency critical events, such as tracheostomy-related emergencies. Further research should explore its feasibility at larger scale, confirm the results in a larger population of learners with adequately powered studies and the applicability of such a teaching approach to other critical events.

Purpose To determine if, compared with pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces trigger delay, inspiratory time in excess, and the number of patient–ventilator asynchronies in intubated patients. Methods Prospective interventional study in spontaneously breathing patients intubated for acute respiratory failure. Three consecutive periods of ventilation were applied: (1) PS1, (2) NAVA, (3) PS2. Airway pressure, flow, and transesophageal diaphragmatic electromyography were continuously recorded. Results All results are reported as median (interquartile range, IQR). Twenty-two patients were included, 36.4% (8/22) having obstructive pulmonary disease. NAVA reduced trigger delay (ms): NAVA, 69 (57–85); PS1, 178 (139–245); PS2, 199 (135–256). NAVA improved expiratory synchrony: inspiratory time in excess (ms): NAVA, 126 (111–136); PS1, 204 (117–345); PS2, 220 (127–366). Total asynchrony events were reduced with NAVA (events/min): NAVA, 1.21 (0.54–3.36); PS1, 3.15 (1.18–6.40); PS2, 3.04 (1.22–5.31). The number of patients with asynchrony index (AI) >10% was reduced by 50% with NAVA. In contrast to PS, no ineffective effort or late cycling was observed with NAVA. There was less premature cycling with NAVA (events/min): NAVA, 0.00 (0.00–0.00); PS1, 0.14 (0.00–0.41); PS2, 0.00 (0.00–0.48). More double triggering was seen with NAVA, 0.78 (0.46–2.42); PS1, 0.00 (0.00–0.04); PS2, 0.00 (0.00–0.00). Conclusions Compared with standard PS, NAVA can improve patient–ventilator synchrony in intubated spontaneously breathing intensive care patients. Further studies should aim to determine the clinical impact of this improved synchrony.

Background The outcome of Veno-Venous Extracorporeal Membrane Oxygenation (VV-ECMO) in acute respiratory failure may be influenced by patient-related factors, center expertise and modalities of mechanical ventilation (MV) during ECMO. We determined, in a medium-size ECMO center in Switzerland, possible factors associated with mortality during VV-ECMO for acute respiratory failure of various etiologies. Methods We retrospectively analyzed all patients treated with VV-ECMO in our University Hospital from 2012 to 2019 (pre-COVID era). Demographic variables, severity scores, MV duration before ECMO, pre and on-ECMO arterial blood gases and respiratory variables were collected. The primary outcome was ICU mortality. Data were compared between survivors and non-survivors, and factors associated with mortality were assessed in univariate and multivariate analyses. Results Fifty-one patients (33 ARDS, 18 non-ARDS) were included. ICU survival was 49% (ARDS, 39%; non-ARDS 67%). In univariate analyses, a higher driving pressure (DP) at 24h and 48h on ECMO (whole population), longer MV duration before ECMO and higher DP at 24h on ECMO (ARDS patients), were associated with mortality. In multivariate analyses, ECMO indication, higher DP at 24h on ECMO and, in ARDS, longer MV duration before ECMO, were independently associated with mortality. Conclusions DP on ECMO and longer MV duration before ECMO (in ARDS) are major, and potentially modifiable, factors influencing outcome during VV-ECMO.

Background COVID-19 related acute respiratory distress syndrome (ARDS) has specific characteristics compared to ARDS in other populations. Proning is recommended by analogy with other forms of ARDS, but few data are available regarding its physiological effects in this population. This study aimed to assess the effects of proning on oxygenation parameters (PaO 2 /FiO 2 and alveolo-arterial gradient (Aa-gradient)), blood gas analysis, ventilatory ratio (VR), respiratory system compliance (C RS ) and estimated dead space fraction (V D /V T HB). We also looked for variables associated with treatment failure. Methods Retrospective monocentric study of intubated COVID-19 ARDS patients managed with an early intubation, low to moderate positive end-expiratory pressure and early proning strategy hospitalized from March 6 to April 30 2020. Blood gas analysis, PaO 2 /FiO 2 , Aa-gradient, VR, C RS and V D /V T HB were compared before and at the end of each proning session with paired t-tests or Wilcoxon tests (p < 0.05 considered as significant). Proportions were assessed using Fischer exact test or Chi square test. Results Forty-two patients were included for a total of 191 proning sessions, median duration of 16 (5–36) hours. Considering all sessions, PaO 2 /FiO 2 increased (180 [148–210] vs 107 [90–129] mmHg, p < 0.001) and Aa-gradient decreased (127 [92–176] vs 275 [211–334] mmHg, p < 0.001) with proning. C RS (36.2 [30.0–41.8] vs 32.2 [27.5–40.9] ml/cmH 2 O, p = 0.003), VR (2.4 [2.0–2.9] vs 2.3 [1.9–2.8], p = 0.028) and V D /V T HB (0.72 [0.67–0.76] vs 0.71 [0.65–0.76], p = 0.022) slightly increased. Considering the first proning session, PaO 2 /FiO 2 increased (186 [165–215] vs 104 [94–126] mmHg, p < 0.001) and Aa-gradient decreased (121 [89–160] vs 276 [238–321] mmHg, p < 0.001), while C RS , VR and V D /V T HB were unchanged. Similar variations were observed during the subsequent proning sessions. Among the patients who experienced treatment failure (defined as ICU death or need for extracorporeal membrane oxygenation), fewer expressed a positive response in terms of oxygenation (defined as increase of more than 20% in PaO 2 /FiO 2 ) to the first proning (67 vs 97%, p = 0.020). Conclusion Proning in COVID-19 ARDS intubated patients led to an increase in PaO 2 /FiO 2 and a decrease in Aa-gradient if we consider all the sessions together, the first one or the 4 subsequent sessions independently. When considering all sessions, C RS increased and VR and V D /V T HB only slightly increased.

Dysphagia is a frequent complication in neurologically impaired patients, which can lead to aspiration pneumonia and thus prolonged hospitalization or even death. It is essential therefore, to detect and assess dysphagia early for best patient care. Fiberoptic endoscopic and Videofluoroscopy evaluation of swallowing are the gold standard exams in swallowing studies but neither are perfectly suitable for patients with disorders of consciousness (DOC). In this study, we aimed to find the sensitivity and specificity of the Nox-T3 sleep monitor for detection of swallowing. A combination of submental and peri-laryngeal surface electromyography, nasal cannulas and respiratory inductance plethysmography belts connected to Nox-T 3 allows recording swallowing events and their coordination with breathing, providing time-coordinated patterns of muscular and respiratory activity. We compared Nox-T3 swallowing capture to manual swallowing detection on fourteen DOC patients. The Nox-T3 method identified swallow events with a sensitivity of 95% and a specificity of 99%. In addition, Nox-T3 has qualitative contributions, such as visualization of the swallowing apnea in the respiratory cycle which provide additional information on the swallowing act that is useful to clinicians in the management and rehabilitation of the patient. These results suggest that Nox-T3 could be used for swallowing detection in DOC patients and support its continued clinical use for swallowing disorder investigation.

High flow nasal cannula (HFNC) may improve CO2 elimination by washing out CO2 from the upper airways. This study aimed at assessing the effect of HFNC on minute ventilation and ventilatory ratio (VR), a surrogate of dead space, in patients hospitalized for acute hypercapnic COPD exacerbation. Physiological study comparing HFNC at 40 L/min to low flow oxygen. Variations of tidal volume (VT) and minute ventilation between the two treatments were estimated from chest plethysmography. Respiratory rate (RR) and arterial blood gases were measured. Variations in VR were calculated. Data were compared using Wilcoxon tests. Recordings performed in 10 patients. Minute ventilation was reduced with HFNC by −16.2 [−30.9–0.4] % (p = 0.049). VT was not different but RR was lower during HFNC. PaCO2 was lower with HFNC compared to standard oxygen: 48.7 [46.4–58.1] vs 50.7 [48.4–57.5] mmHg (p = 0.020). VR decreased by −18.0 [−34.7 - -4.0] % (p = 0.020) with HFNC. In patients recovering from acute COPD exacerbation, the use of HFNC reduced RR, minute ventilation, PaCO2 and VR compared to standard oxygen. These changes are consistent with a decrease in physiologic dead space with HFNC. •High flow nasal canula improves breathing efficiency in hypercapnic COPD exacerbation.•High flow nasal canula reduces ventilatory ratio, a surrogate of dead space in COPD exacerbation.•High flow nasal canula can be of interest during non invasive ventilation interruptions.