Sign-out is being given for the Night. There are a few pt.’s on Ventilator who appear to be comfortably sedated. Before the Fellow leaves he makes a comment - 'Do have the Ventilated pt.’s lined up for Liberation early morning’. Seeing your puzzled look, Nurses & RT's on call try to fill you in.



It seems there is a Sedation Scale that the Nurses use - RASS (+5 to -4), the goal being -1 to +1, -2 is also acceptable (more negative=more sedated=Bad). Every morning they are required to shut off the sedation - S pontaneous A wakening T rial (SAT) if a set criteria/ checklist is met & the RT have to start the S pontaneous B reathing T rial (SBT).

There seems to be some disagreement between RT's, Re: SBT- 'how & how long'? Statement's like- 'We need a real stress test with a T-piece trial vs a more gentler approach on Pressure Support Mode’. The length/duration of the trial, is also debated...



Curiosity aroused, you put on your Sherlock Holmes hat decide to investigate...



Seems like - someone came up with the idea of daily SAT & showed it leads to early extubation, then somebody started doing daily SBT with resulting early extubations. Finally, someone combined both SAT & SBT, to be performed together (seems logical) ...



Lancet Jan 12th, 2008; vol 371; pp 126.

The ABC Trial (Awakening & Breathing Controlled Trial).

336 pt.’s were randomized to - SBT+SAT arm (168) vs sedation & usual care (168). The combined arm showed significantly more days off ventilator (14.7 vs 11.6; p=0.02). ICU LOS was also less in combined arm (9.1 vs 11.6; p=0.04). The rate of reintubation was same in both arm.



As far as Sedation is concerned - 'Less is More' - is the new mantra, with some center's claiming - they don't use any. Seems a bit extreme - luckily NEJM has an article hot off the Press - addressing this particular issue.



NEJM Feb 16th 2020 (online publication).

Non Sedation vs Light Sedation in Critically Ill Mechanically Ventilated pt.’s.

700 pt.’s were randomized across multiple sites in 3 countries. Primary outcome of mortality at 90 days was same in both arms (42.4% vs 37%).The ICU & Ventilator free days were also similar in both arms.1/4- 1/3rd pt.’s in no sedation arm did require sedation on the first day.



SBT it seems can be performed by placing the pt. in Pressure Support mode - 'Gentle' or by placing the pt. on a T-Piece (no help, no machine) - 'True Stress test’. There is also some confusion re: time of trial - 30 minutes or 2 hours.



JAMA June 11th 2019; vol 321; pp 2175.

Pressure Support (PS) vs T-piece; SBT compared.

30 minutes of pressure support was compared to 2 hrs. of T-Piece trial.

A multicenter trial in which - 1153 pt.’s were randomized across 18 Spanish ICU's.575 pt.’s to 30 min PS arm & 578 pt.’s to 2-hour T-piece arm. Primary outcome of successful extubation was significantly higher in PS arm 82.3% vs 74% p=0.01 an 8.2% difference. The reintubation rate was same in both arms (11.1% vs 11. 9%).There was no difference in ICU & Hospital LOS.The 90-day mortality was lower in PS arm (13.2% vs 17.3%p=0.04).



Once Liberated there appears to be a high-risk population that needs some assistance post extubation (per criteria - everyone on vent in your ICU qualifies for this assistance).





JAMA Oct 15th 2019, vol 322; pp 1465-75.

NIPPV + High Flow OXYGEN vs High Flow Oxygen in High Risk Pt's post Extubation.

A Multi-center trial across 30 ICU in France. 648 High Risk pt.’s (> 65 yrs., Cardiac Disease or Pulmonary Disease) on MV for at least 24 hrs. & successful SBT were randomized to extubation to HFO2 (50lt/min) + NIPPV (339) or HFO2 alone (302). Therapy was continued for at least 48 hrs.

A significant decrease in reintubation rate at 7 days was seen in NIPPV + HFO2 arm 11.8% vs 18.2% in HFO2 arm. (p=0.02). The LOS & Mortality were the same in both arm. The time to reintubation was same.



Your Conclusion: Analgesia first sedation seems appropriate, Light sedation is the way to go. No sedation- maybe/sometimes, but not as a rule - 'the mortality graph appeared to favor Sedation group after a few days' in the latest trial.





SAT + SBT = Standard of Care, 100% is what you strive for but even the Well-run trials had compliance rates of 70%.





SBT should be with PS mode & only for 30 minutes & maybe you should extubate your high-risk pt.’s to NIPPV support as a rule (adding High Flow to it - might be a Bridge to far - Air Leak off NIPPV mask, number of equipment needed).



It also appears - movement is to take the phrase - 'Let me evaluate first', out of Physician's hands & auto-pilot the 'SAT + SBT --> Extubation'.



Maybe you should take the Initiative, do the above & extubate prior to Fellow's arrival ...✌ make sure -Intubation skills are good..



