January 18, 2008

New strategy helps patients on ventilators

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Wes Ely, M.D., left, and Tim Girard, M.D. (photo by Anne Rayner)

New strategy helps patients on ventilators

Vanderbilt University Medical Center researchers, along with collaborators from Saint Thomas Hospital and three other medical centers, have shown that intensive care unit patients on mechanical ventilators experience dramatically improved outcomes if they are managed with a “wake up and breathe” protocol each day.

Their findings were published in last week's The Lancet.

The results of the Awakening and Breathing Controlled (ABC) trial show that a sedation and ventilator weaning protocol consisting of daily spontaneous awakening trials (SATs) plus spontaneous breathing trials (SBTs) resulted in patients spending three more days off mechanical ventilation, less time in coma, four fewer days in intensive care and the hospital, and a 14 percent absolute improvement in one-year survival, compared with usual care.

“For every seven people who get the “wake up and breathe” strategy that we developed, one life is saved at one year,” said Wes Ely, M.D., M.P.H., professor of Medicine and senior author on the study.

Tim Girard, M.D., M.S.C.I., instructor in Medicine and first author on the study, said that the survival benefit was the most surprising finding.

“No other ventilator or sedation study has ever shown that modifying sedation resulted in a reduction in mortality, and the implications for care for the millions of ventilated, critically ill patients every year are large,” he said. “Considering that this is an intervention that involves stopping medications and the ventilator when they are no longer needed — rather than by adding new or risky therapies — we expect that this intervention will be adopted widely by many ICUs.”

Patients on mechanical ventilators are typically sedated to keep them comfortable and safe. The respiratory therapist is responsible for testing the patient's ability to breathe independently by turning off the ventilator once a day. The nurse is responsible for controlling the level of sedation, which is not routinely turned off on a daily basis.

The ABC trial linked the two caregivers and empowered them to work together to get the patient breathing independently and comfortably awake sooner.

“Currently the coordination of ventilator and sedation management is left up to the treating physician, and that might not be the most efficient process,” Girard said. “We thought we could improve that process by creating a protocol that linked what is happening with sedation to what is happening with the ventilator.”

Patients in the control group were assessed every morning, and if they passed a safety screen, their ventilator was effectively turned off, and they were allowed to breathe on their own for up to two hours.

Patients in the “wake up and breathe” intervention group had their sedatives and analgesics interrupted each day that they met safety criteria and were monitored for up to four hours to see if they would open their eyes to verbal stimuli. If they did, they, too, had their ventilators turned off to test their ability to breathe on their own.

Vanderbilt coordinated the study, which enrolled 336 ICU patients at four medical centers: Saint Thomas Hospital, University of Chicago Hospitals, Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center. Funding was provided by the Saint Thomas Foundation and the National Institutes of Health.