Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation: Slide Presentation

Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients

Introduction to Daily Care Processes: Evidence Behind Spontaneous Awakening Trials, Spontaneous Breathing Trials, and Head of Bed Elevation

Slide 2: Learning Objectives

After this session, you will be able to—

• Identify how the use of spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) can reduce the length of mechanical ventilation and the risk of ventilator-associated pneumonia (VAP).
• Follow and perform the recommended SAT and SBT protocols when clinically indicated.
• Understand the benefits of utilizing head of bed (HOB) elevation techniques.
• Access the supporting resources for these daily care process measures.

Slide 3: SATs and SBTs

SATs and SBTs

Slide 4: Complications of Sedation

• Suppresses respiratory drive, prolonging ventilator dependence.
• Increases risk for delirium.
• Impairs mobility.
• Prolonged ventilator dependence can increase the risk of pneumonia, atelectasis, and acute respiratory distress syndrome (ARDS), among others.

Slide 5: Daily Interruption of Sedatives

Fewer than half of practitioners worldwide reported implementing daily interruption of sedatives:^1,2

• Germany - 34%.
• Canada - 40%.
• USA - 40%.

^1. Tanios MA, de Wit M, Epstein SK, et al. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care 2009 24(1):66-73. PMID: 19272541.

^2. Devlin JW, Tanios MA, Epstein SK. Intensive care unit sedation: waking up clinicians to the gap between research and practice. Crit Care Med 2006 34(2):556-7. PMID: 16424748.

Slide 6: SAT & SBT Specific VAP Prevention Guidelines

Centers for Disease Control and Prevention³

• Does not specifically address SAT and SBT, but supports weaning.

American Thoracic Society⁴

• Recommends use of daily interruption or lightening of sedation to avoid constant heavy sedation and to facilitate and accelerate weaning.
• Does not specifically address SBT.

Images: Logo for CDC, Center for Disease Control and Prevention. Logo for ATS, The American Thoracic Society.

^3. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. PMID: 15048056.

^4. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005 171(4):388-416. PMID: 15699079.

Slide 7: SAT & SBT Specific VAP Prevention Guidelines

Society for Healthcare Epidemiology of America (SHEA)⁵

• Recommends simultaneous use of daily SATs and the daily assessment of readiness wean through SBTs.
• Recommends management of ventilated patients with minimal sedation whenever possible and avoidance of benzodiazepines.

Image: Logo for SHEA, The Society for Healthcare Epidemiology of America.

^5. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 35(8):915-36. PMID: 25026607.

Slide 8: 2014 SHEA Compendium Update⁵

• Manage ventilated patients without sedatives whenever possible.
• Interrupt sedation once a day with SATs.
• Assess readiness to extubate once a day with SBTs.
• Pair spontaneous breathing trials with spontaneous awakening trials.
• Employ early exercise and mobilization.
• Use noninvasive positive pressure ventilation whenever feasible.

^5. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 35(8):915-36. PMID: 25026607.

Slide 9: SAT & SBT Protocol^6,7

Image: SAT and SBT Protocol flowchart.

^6. Kress J, Pohlman A, O'Connor M, et al. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N Engl J Med 2000 342(20):1471-7. PMID: 10816184.

^7. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet 2008 371(9607):126-134. PMID: 18191684.

Slide 10: SAT Summary

Image: SAT Safety Screen flowchart.

Slide 11: SAT Protocol^6,7

• SAT consists of two parts: safety screen and trial.
• SAT safety screen checks for contraindications to performing SAT trial.
• For patients who are not responsive to verbal stimuli, the SAT trial checks for contraindications to performing the SBT safety screen and SBT trial.

^6. Kress J, Pohlman A, O'Connor M, et al. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N Engl J Med 2000 342(20):1471-7. PMID: 10816184.

^7. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet 2008 371(9607):126-134. PMID: 18191684.

Slide 12: SAT Safety Screen Eligibility^6,7

The patient must meet the following criteria to be eligible for the SAT safety screen:

• No high-frequency oscillatory ventilation.
• No active seizures.
• No benzodiazepines for alcohol withdrawal.
• No objective evidence of active alcohol withdrawal.
• No agitation.
• No paralytics.
• No active myocardial ischemia in the previous 24 hours.
• No increased intracranial pressure in the previous 24 hours.
• No planned surgery within 24 hours.

^6. Kress J, Pohlman A, O'Connor M, et al. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N Engl J Med 2000 342(20):1471-7. PMID: 10816184.

^7. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet 2008 371(9607):126-134. PMID: 18191684.

Slide 13: Passing the SAT Safety Screen

• The patient must meet the following criteria to PASS the SAT safety screen:
  • No persistent anxiety, agitation, or pain.
  • Respiratory rate <35/min.
  • SpO₂ >88%.
  • Heart rate >130.
  • Does not experience respiratory distress.
  • Does not experience acute cardiac dysrhythmia.
  • Does not experience diaphoresis.
• If the patient PASSES the safety screen, proceed to the SAT trial.
• If the patient FAILS the SAT safety screen, they should be rescreened the following day.

Slide 14: Passing the SAT Trial

There are two different ways a patient can pass the SAT trial:

The patient passes the SAT trial if they can perform three out of four following tasks on request:

• Open their eyes.
• Look at their caregiver.
• Squeeze the hand.
• Put out their tongue.

The patient passes the SAT trial if they can go without sedation for 4 hours without new symptoms or complications such as:

• Sustained anxiety, agitation or pain.
• Respiratory rate of 35 breaths/minute for ≥ 5 minutes.
• SpO₂ of less than 88% for ≥ 5 minutes.
• Acute cardiac dysrhythmia.
• Two or more signs of respiratory distress.
  • Tachycardia.
  • Bradycardia.
  • Use of accessory muscles.
  • Marked dyspnea.
  • Abdominal paradox.
  • Diaphoresis.

Slide 15: Passing the SAT Trial

If patient tolerates the SAT trial:

• Proceed to the SBT safety screen.

If patient fails the SAT trial:

• Sedatives are started at half the prior dosage.
• Then titrated up as needed.
• Perform the SAT screen again the following day.

Slide 16: SBT Safety Screen

Image: Graphic of SBT Safety Screen.

Slide 17: SBT Protocol

• SBT consists of two parts: safety screen and trial.
• SBT safety screen checks for contraindications to performing SBT trial.
• SBT trial checks for contraindications to considering extubation.

Slide 18: Passing the SBT Safety Screen

The patient must have the following to pass the safety screen:

• Inspiratory efforts.
• Oxygen saturation ≥88%.
• FiO₂ ≤50%.
• PEEP ≤8cm H₂O.
• No active myocardial infarction.
• No paralytics.
• No agitation (RASS ≤ +2).
• Low or no vasopressors.

Slide 19: Passing the SBT Trial

The patient must meet the following to pass the SBT trial:

• No evidence of sustained anxiety or agitation.
• Respiratory rate of ≤35 breaths/minute and ≥8 breaths per minute.
• SpO₂ greater than 88%.
• No change in mental status.
• No acute cardiac dysrhythmia.
• Fewer than two signs of respiratory distress:
  • Tachycardia.
  • Bradycardia.
  • Use of accessory muscles.
  • Marked dyspnea.
  • Abdominal paradox.
  • Diaphoresis.

Slide 20: Failing the SBT trial

• If the patient fails the SBT trial:
  • Re-ventilate immediately.
  • Reassess the following day.
• If the patient passes the SBT trial:
  • Notify physician to consider performing extubation.

Slide 21: Perceived Barriers to Sedation Protocols and SATs¹

• Multidisciplinary Web-based survey (n=904).
• Reasons for lack of protocol use:
  • No physician order, 35%.
  • Lack of nursing support, 11%.
  • Fear of oversedation, 7%.
• Barriers for daily sedation interruption:
  • Nursing acceptance, 22%.
  • Risk of device removal, 19%.
  • Respiratory compromise, 26%.
  • Patient discomfort, 13%.

^1. Tanios MA, de Wit M, Epstein SK, et al. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care 2009 24(1):66-73. PMID: 19272541.

Slide 22: Intensive Care Unit (ICU) Barriers to SATs

• View SATs as unnecessary, and light sedation as more appropriate and safer.
• Claim no physician orders.
• Maintain inadequate staff to undertake protocols.
• Unconvinced lowering sedation will benefit patients.

Slide 23: ICU Barriers to SATs⁸

• Nursing attitudes account for one-third of variance in number of patients who received sedatives.
• Only 17.7% of respondents thought it was easier to care for an awake and alert patient receiving mechanical ventilation than to care for a similar patient more sedated.

^8. Guttormson JL, Chlan L, Weinert C, et al. Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive Crit Care Nurs 2010 26(1):44-50. PMID: 19945879.

Slide 24: Evidence for SATs and SBTs

Evidence for SATs and SBTs

Slide 25: Strøm et al.⁹

A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial

• 140 patients randomized to routine sedation versus no sedation:
  • 70 prescribed routine sedation (propofol then midazolam).
  • 70 prescribed no sedation (morphine boluses as needed).
• Patients with no sedation:
  • Mean 4.2 (95% confidence interval [CI] 0.3 to 8.1) fewer days on ventilation.
  • Shorter ICU stay (hazard ratio [HR] 1.86, 95% CI 1.1 to 3.2).
  • Shorter hospital stay (HR 3.6, 95% CI 1.5 to 9.1).
  • More agitated delirium (20% vs. 7%) but no difference in self-extubations.
  • 1:1 nursing.

^9. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010 Feb 6;375(9713):475-80. PMID: 20116842.

Slide 26: Kress et al.⁶

Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation

Intervention group:

• 2.4 more days alive and off the ventilator (p=.004).
• 1.9 times more likely to be extubated (p<0.001, 95% CI 1.3 to 2.7).
• ICU length of stay shorter by 3.5 days (p=0.02).

^6. Kress J, Pohlman A, O'Connor M, et al. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N Engl J Med 2000 342(20):1471-7. PMID: 10816184.

Slide 27: Girard et al.⁷

Image: Graph showing Daily SBT Alone versus Daily SAT and SBT and their effect on vent days, ICU days, and hospital days.

^7. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet 2008 371(9607):126-134. PMID: 18191684.

Slide 28: Wake Up and Breathe

Wake Up and Breathe

Slide 29: CDC Prevention Epicenters' Wake Up and Breathe Collaborative¹⁰

• What: First prospective study of the preventability of Ventilator-Associated Events (VAEs).
• Who: 12 ICUs affiliated with 7 hospitals.
• Why: Prevent VAEs through less sedation and earlier liberation from mechanical ventilation.
• How:  Increase performance of paired daily SATs and SBTs.

^10. Klompas M, Anderson D, Trick W, et al. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015 Feb 1;191(3):292-301. PMID: 25369558.

Slide 30: CDC Prevention Epicenters' Wake Up and Breathe Collaborative¹⁰

• Included opt-out protocol for paired daily SATs and SBTs.
• Registered Nurses and Respiratory Therapists initiate SATs/SBTs rather than doctors:
  • Automatic for all patients unless doctor actively "opts out."
• Protocol developed by national experts:
  • Narrow set of well-defined contraindications.
• Multicenter learning collaborative to aid implementation.

^10. Klompas M, Anderson D, Trick W, et al. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015 Feb 1;191(3):292-301. PMID: 25369558.

Slide 31: CDC Prevention Epicenters' Wake Up and Breathe Collaborative¹⁰

SATs and SBTs Increases

• +63% in SATs.
• +16% in SBTs.
• +81% in SBTs done with sedatives off.

Ventilator Days and Length of Stay (LOS) Reductions

• -2.4 vent days.
• -3.0 ICU days.
• -6.3 LOS days.

VAE Reductions

• -37% in VACs.
• -65% in IVACs.

IVAC = infection-related ventilator-associated complication; VAC = ventilator-associated condition.

Images: Arrow pointing up over SATs and SBTs increases. Arrow pointing down over VAE Ventilator days and length of stay reductions.

^10. Klompas M, Anderson D, Trick W, et al. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015 Feb 1;191(3):292-301. PMID: 25369558.

Slide 32: Resources: SAT and SBT Fast Facts

• Ready to post in the unit.
• Provides quick reference to latest evidence-based protocols.
• Summarizes position of four leaders in the VAP field.
• Can be found on the AHRQ Web site at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/sat-sbt-factsheet.docx (1.59 MB).

Image: The SAT and SBT Fast Fact sheet.

Slide 33: Resources: SAT and SBT Literature Review

• Ready to post in the unit.
• Provides quick reference to latest evidence-based protocols.
• Summarizes position of four leaders in the VAP field.
• Can be found on the AHRQ Web site at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/sat-sbt-litreview.docx (1.6 MB).

Image: The SAT and SBT Literature Synopsis.

Slide 34: HOB Elevation

HOB Elevation

Slide 35: HOB Elevation¹¹

• The elevation of the HOB to a semi-recumbent position (>30 degrees) is associated with a decreased incidence of aspiration and VAP.
• Study showed that both the supine position and length of time the patient is kept in this position are potential risk factors for aspiration of gastric contents.

^11. Torres A, Serr-Battles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position.. Ann Intern Med 1992 Apr 1;116(7):540-3. PMID 1543307.

Slide 36: HOB Elevation

• Several successful strategies have been used to improve compliance with HOB elevation of at least 30 degrees. These include:
  • Use of a bed with a specific attachment that will show the angle at a glance.
  • Use of a handheld protractor.
  • A determination of what mark on which bed can signify the correct angle for recline.
• HOB elevation should be fed back to unit staff on a regular basis.
• Involve everyone who cares for the patient, including family members, to ensure the HOB is maintained at the correct angle.
• The intervention is supported unanimously by all four leading guidelines, and newer publications in the field accept HOB elevation as an effective, low-cost and low-risk intervention.

Slide 37: HOB Specific VAP Prevention Guidelines

Society for Healthcare Epidemiology of America⁵

• Recommends the use semi-recumbent position (30-45 degrees) as a strategy to prevent aspiration.

ZAP the VAP: Ventilator-Associated Pneumonia¹²

• Recommends the head of bed elevation to be 45 degrees, as long as not contraindicated.

Images: The SHEA logo and ZAP the VAP logo.

^5. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 35(8):915-36. PMID: 25026607.

^12. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004 Aug 17;141(4):305-13. PMID: 15313747.

Slide 38: HOB Specific VAP Prevention Guidelines

Centers for Disease Control and Prevention³

• In the absence of medical contraindication(s), elevate the HOB at an angle of 30–45 degrees for patients with a high risk for aspiration (e.g., a person receiving mechanically assisted ventilation).

American Thoracic Society⁴

• Recommends that patients should be kept in a semi-recumbent position (30-45 degrees) rather than supine to prevent aspiration.

Images: Logo for CDC, Center for Disease Control and Prevention. Logo for ATS, The American Thoracic Society.

^3. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. PMID: 15048056.

^4. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005 171(4):388-416. PMID: 15699079.

Slide 39: Resources: HOB Literature Review

• Ready to post in the unit.
• Provides quick reference to latest evidence-based protocols.
• Summarizes position of four leaders in the VAP field.
• Can be found on the AHRQ Web site at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx (1.6 MB).

Image: The HOB Literature Review.

Slide 40: Questions?

Image: Photograph of people holding up signs with question marks on them.

Slide 41: References

^1. Tanios MA, de Wit M, Epstein SK, et al. Perceived barriers to the use of sedation protocols and daily sedation interruption: a multidisciplinary survey. J Crit Care 2009 24(1):66-73. PMID: 19272541.

^2. Devlin JW, Tanios MA, Epstein SK. Intensive care unit sedation: waking up clinicians to the gap between research and practice. Crit Care Med 2006 34(2):556-7. PMID: 16424748.

^3. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing healthcare-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. PMID: 15048056.

^4. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005 171(4):388-416. PMID: 15699079.

^5. Klompas M, Branson R, Eichenwald EC, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014 35(8):915-36. PMID: 25026607.

^6. Kress J, Pohlman A, O'Connor M, et al. Daily interruption of sedative infusion in critically ill undergoing mechanical ventilation. N Engl J Med 2000 342(20):1471-7. PMID: 10816184.

Slide 42: References

^7. Girard TD, Kress JP, Fuchs BD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): A randomised controlled trial. Lancet 2008 371(9607):126-134. PMID: 18191684.

^8. Guttormson JL, Chlan L, Weinert C, et al. Factors influencing nurse sedation practices with mechanically ventilated patients: a U.S. national survey. Intensive Crit Care Nurs 2010 26(1):44-50. PMID: 19945879.

^9. Strøm T, Martinussen T, Toft P. A protocol of no sedation for critically ill patients receiving mechanical ventilation: a randomised trial. Lancet 2010 Feb 6;375(9713):475-80. PMID: 20116842.

^10. Klompas M, Anderson D, Trick W, et al. The Preventability of Ventilator-Associated Events: The CDC Prevention Epicenters' Wake Up and Breathe Collaborative. Am J Respir Crit Care Med 2015 Feb 1;191(3):292-301. PMID: 25369558.

^11. Torres A, Serr-Battles J, Ros E, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992 Apr 1;116(7):540-3. PMID 1543307.

^12. Dodek P, Keenan S, Cook D, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004 Aug 17;141(4):305-13. PMID: 15313747.