“Wake Up and Breathe” Strategy Safely Speeds Ventilator Weaning

Key Point

The “wake up and breathe” strategy—ie, a spontaneous awakening trial followed by a spontaneous breathing trial—safely and effectively improved weaning success in a large study involving critically ill, mechanically ventilated patients.

NEW ORLEANS—Ventilator-weaning protocols that incorporate spontaneous breathing trials (SBTs) have been shown to speed weaning and reduce the duration of mechanical ventilation. A question that intensivists now wish to answer is whether the addition of spontaneous awakening trials (SATs; ie, the interruption of sedatives so that the patient regains consciousness) to weaning protocols facilitates weaning even further.

In the Awakening and Breathing Controlled (ABC) Trial, this strategy—termed “wake up and breathe”—significantly improved outcomes in 335 critically ill, mechanically ventilated patients in four hospitals. “On average, patients managed with the intervention spent four more days alive and out of the ICU and out of the hospital than those managed in the control group,” senior investigator E. Wesley Ely, MD, MPH, explained during a press conference about the trial that was held at the American Thoracic Society’s 103rd International Conference.

In an interview with Pulmonary Reviews, Dr. Ely emphasized that “‘wake up and breathe’ is simple and can be done in any ICU without any additional technology or expense, just by coordinating the patient’s caregivers. By getting patients off the ventilator and out of the hospital more quickly, it results in less resource use.” Dr. Ely is Professor of Medicine at the Vanderbilt University Medical Center in Nashville.

The apparent effectiveness of “wake up and breathe” was attributed to the ability to better determine readiness for extubation in a patient who is more alert. “Numbers on the monitor in the ICU are not good at predicting if a patient is ready to come off a ventilator,” observed Timothy D. Girard, MD, MSCI, lead author of the trial and Instructor in Medicine in the Division of Allergy, Pulmonary, and Critical Care Medicine at Vanderbilt University.

He stressed, however, that patient safety and comfort were a central concern during the trial. If it was clear that a patient could not tolerate the withdrawal of sedatives, sedation was immediately restarted.

The patients in the 28-day trial were randomized to the “wake up and breathe strategy” of a daily SAT and then an SBT, or to a control group that received daily SBTs. For the controls, the patient’s ICU physician and nurses managed sedation using best clinical judgment. A major problem with this approach is the tendency to oversedate to the point where the patient is unresponsive and difficult to extubate, Dr. Girard remarked.

Although the two groups had similar baseline characteristics, the “wake up and breathe” group spent more days alive and off the ventilator (14.7 vs 11.6 in the control group) and fewer days in coma (2.0 vs 3.0). In addition, both ICU and hospital discharge occurred four days earlier, on average, in the “wake up and breathe” group.

The patients in the intervention group did, however, have a higher self-extubation rate (10% vs 4% in the control group). The two groups had virtually the same overall reintubation rate, though (22% and 23%, respectively).

The trial was not adequately powered to assess short-term differences in survival. However, the researchers found a trend toward lower 28-day mortality in the “wake up and breathe” group (28% vs 35% for the controls).

The investigators concluded that the trial findings support the use of a “wake up and breathe” strategy in the management of mechanically ventilated ICU patients. “In the past, the process of turning sedation drugs off has been done separately from turning off the ventilator,” Dr. Girard related. “Our study proved our hypothesis that if we connect these two processes, it will safely allow patients to come off the ventilator earlier.”             

—Timothy Begany

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