A paired sedation and ventilator weaning protocol consisting of daily spontaneous awakening trials (SATs)—ie, daily interruption of sedatives—with spontaneous breathing trials (SBTs) results in better outcomes for mechanically ventilated patients in intensive care than current standard approaches and should become routine practice, according to an Article in this week’s issue of The Lancet.
A third of patients in intensive care worldwide are mechanically ventilated. Although required to save lives, mechanical ventilation is frequently accompanied by the administration of large doses of sedatives, and together these interventions are associated with significant morbidity*. Previous studies have shown that efforts to reduce the duration of mechanical ventilation in intensive-care populations via ventilator weaning protocols and sedation protocols can improve clinical outcomes. However, there is a lack of evidence to support the routine use of SATs and anecdotal concerns regarding patient safety and agitation have led to limited use of this sedation strategy. Instead, most patients are treated with individualised patient-targeted sedation.
Dr Timothy Girard (Vanderbilt University School of Medicine, Nashville, USA) and colleagues undertook the Awakening and Breathing Controlled (ABC) trial, a randomised trial of 336 patients to assess the efficacy and safety of a two step approach—a protocol combining daily SATs with subsequent SBTs involving ventilator weaning—versus a standard protocol in patients receiving patient-targeted sedation as part of usual care. The patients were recruited from four hospitals in USA between 2003 and 2006.
The researchers found that patients in the intervention group (managed with the SAT plus SBT strategy) were able to breathe without assistance for 3 days more than those in the control group during the 28-day study period (14.7 days vs 11.6 days); they also spent less time in intensive care (9.1 days vs 12.9 days) and were discharged from the hospital 4 days earlier (14.9 days vs 19.2 days). The duration of coma was also 2 days shorter in the intervention group. Furthermore, patients in the intervention group were about a third less likely to die at any instant during the year after enrolment than were patients given usual care.
The authors conclude: “This wake up and breathe strategy was effective and was associated with few adverse events in a diverse population in intensive care in both community and university hospitals.” ** They continue: “Patients with more severe critical illness, who tend to have prolonged stays in intensive care—ie, those who accrue the largest cumulative exposure to sedative medications—could receive the greatest benefit from management with the SAT plus SBT strategy.”
In an accompanying Comment, Dr Laurent Brochard (AP-HP, Centre Hospitalier Albert Chenevier-Henri Mondor, Creteil, France) questions the difficulties of applying this approach outside the context of a trial and says: “The amount of time needed for research personnel to use the wake up and breathe approach is unknown and might limit opportunities for safe implementation in routine care…The actual staff available at the bedside (doctors, nurses, therapists etc) is probably a more important factor for efficient ventilator weaning than the protocol per se. To be applicable and relevant, a ventilator-weaning approach has to be simple, feasible, and safe.”
Dr Timothy Girard, Vanderbilt University School of Medicine, Nashville, USA. T) +1 615 936 5069 timothy.girard@vanderbilt.edu
Comment Dr Laurent Brochard, AP-HP, Centre Hospitalier Albert Chenevier-Henri Mondor, Creteil, France. T) +33 1 4981 2389 or 2545 Laurent.brochard@hmn.aphp.fr
Notes to Editors
*Respiratory failure and mechanical ventilation frequently result in anxiety and pain. Thus, large doses of sedatives and analgesics are used to alleviate patient discomfort, decrease oxygen consumption, facilitate nursing care, and ensure patient safety. However, these medications are associated with adverse effects including oversedation, delirium, and prolonged mechanical ventilation.
**Quote directly from author and cannot be found in text of article.
Journal
The Lancet