Full text is available at the source.
The Cochrane database of systematic reviews··
Daily sedation breaks compared to no breaks for critically ill adults on breathing machines
Updated
Abstract
A pooled analysis of nine trials involving 1282 patients showed a 13% reduction in the geometric mean duration of mechanical ventilation with daily sedation interruption (DSI), though results were imprecise.
- There was no strong evidence that DSI significantly affected the total duration of mechanical ventilation.
- The analysis indicated a 10% reduction in ICU length of stay, but this was not statistically significant.
- Mortality rates in the ICU were similar between patients managed with DSI and those without it.
- DSI was associated with a lower frequency of tracheostomy procedures, with a risk ratio of 0.73.
- No significant differences were found in drug doses or quality of life scores.
- The effect of DSI on the duration of mechanical ventilation varied by region, with North American studies showing a reduction of 21%.
Simplified
BACKGROUND: Daily sedation interruption (DSI) is thought to limit drug bioaccumulation, promote a more awake state, and thereby reduce the duration of mechanical ventilation. Available evidence has shown DSI to either reduce, not alter, or prolong the duration of mechanical ventilation.
OBJECTIVES: The primary objective of this review was to compare the total duration of invasive mechanical ventilation for critically ill adult patients requiring intravenous sedation who were managed with DSI versus those with no DSI. Our other objectives were to determine whether DSI influenced mortality, intensive care unit (ICU) and hospital lengths of stay, adverse events, the total doses of sedative drug administered, and quality of life.
SEARCH METHODS: We searched, from database inception to February 2014, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 1); MEDLINE (OvidSP); EMBASE (OvidSP); CINAHL (EBSCOhost); Latin American and Caribbean Health Sciences Literature (LILACS); Web of Science Science Citation Index; Database of Abstracts of Reviews of Effects (DARE); the Health Technology Assessment Database (HTA Database); trial registration websites, and reference lists of relevant articles. We did not apply language restrictions. The reference lists of all retrieved articles were reviewed for additional, potentially relevant studies.
SELECTION CRITERIA: We included randomized controlled trials that compared DSI with sedation strategies that did not include DSI in mechanically ventilated, critically ill adults.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and three authors assessed risk of bias. We contacted study authors for additional information as required. We combined data in forest plots using random-effects modelling. A priori subgroups and sensitivity analyses were performed.
MAIN RESULTS: Nine trials were used in the analysis (n = 1282 patients). These trials were found to be predominantly at low risk of bias. We did not find strong evidence of an effect of DSI on the total duration of ventilation. Pooled data from nine trials demonstrated a 13% reduction in the geometric mean, with relatively wide confidence intervals (CI) indicating imprecision (95% CI 26% reduction to 2% increase, moderate quality evidence). Similarly, we did not find strong evidence of an effect on ICU length of stay (-10%, 95% CI -20% to 3%, n = 9 trials, moderate quality evidence) or hospital length of stay (-6%, 95% CI -18% to 8%, n = 8 trials, moderate quality evidence). Heterogeneity for these three outcomes was moderate and statistically significant. The risk ratio for ICU mortality was 0.96 (95% CI 0.77 to 1.21, n = 7 trials, moderate quality evidence), for rate of accidental endotracheal tube removal 1.07 (95% CI 0.55 to 2.12, n = 6 trials, moderate quality evidence), for catheter removal 1.48 (95% CI 0.76 to 2.90, n = 4 trials), and for incidence of new onset delirium 1.02 (95% CI 0.91 to 1.13, n = 3 trials, moderate quality evidence). Differences in the doses of any drug used or quality of life score (Short Form (SF)-36) did not reach statistical significance. Tracheostomy was performed less frequently in the DSI group (RR 0.73, 95% CI 0.57 to 0.92, n = 6 trials, moderate quality evidence). Sensitivity analysis of unlogged data resulted in similar findings. Post hoc analysis to further explain heterogeneity, based on study country of origin, showed that studies conducted in North America resulted in a reduction in the duration of mechanical ventilation (-21%, 95% CI -33% to -5%, n = 5 trials).
AUTHORS' CONCLUSIONS: We have not found strong evidence that DSI alters the duration of mechanical ventilation, mortality, length of ICU or hospital stay, adverse event rates, drug consumption, or quality of life for critically ill adults receiving mechanical ventilation compared to sedation strategies that do not include DSI. We advise that caution should be applied when interpreting and applying the findings as the overall effect of treatment is always < 1 and the upper limit of the CI is only marginally higher than the no-effect line. These results should be considered unstable rather than negative for DSI given the statistical and clinical heterogeneity identified in the included trials.
Related papers
Jan '15
Using set sedation plans versus flexible sedation to shorten ventilator time in ICU patients
cited by 11 papers
systematic review
Jun '14
Automated versus manual breathing support weaning to shorten ventilation time in critically ill adults and children
cited by 10 papers
systematic review
Nov '18
Sedation guided by protocols versus usual sedation in ventilated adults and children in intensive care
cited by 17 papers
systematic review
Jun '13
Automated versus manual breathing support to shorten ventilator time in critically ill adults and children
cited by 15 papers
systematic review
Apr '15
Using alpha-2 agonists for long-term sedation in critically ill patients on mechanical ventilators
cited by 50 papers
systematic review
Nov '22
Folic acid supplements and malaria risk and severity in people using antifolate malaria drugs in affected areas
cited by 29 papers
systematic review
Jul '25
Automatic versus manual breathing support to shorten ventilator time in critically ill adults and children
cited by 6 papers
systematic review
Jan '15
Single dose of etomidate compared to other drugs for putting critically ill patients on breathing tubes
cited by 39 papers
systematic review
Dec '20
Oral care for seriously ill patients to help prevent pneumonia from ventilators
cited by 77 papers
systematic review
Jan '17
Methods to Boost Cough Strength for Removing Breathing Tubes in Seriously Ill Patients
cited by 25 papers
systematic review