Reducing the duration of ventilation time is an important goal because prolonged mechanical ventilation can lead to undesirable outcomes.

Within the ABCDEF bundle, the B component, Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT), focuses on setting a time(s) each day to stop sedative medications, orient the patient to time and day, and conduct an SBT in an effort to liberate the patient from the ventilator.

ICU sedation can help reduce anxiety and agitation for patients, facilitate mechanical ventilation, and decrease traumatic memories. But deep sedation has been found to reduce six-month survival and increase hospital mortality, ICU lengths of stay, ventilator duration and physiologic stress.

Studies have shown that using SAT and SBT synergistically helps decrease mechanical ventilation days, hospital lengths of stay and delirium.

Implementing the B component of the ABCDEF Bundle

Search B Element Resources
 
Both SATs and SBTs are incorporated into the Wake Up and Breathe Protocol, a two-step process that focuses on creating a synergy between SAT and SBT protocols. These protocols typically incorporate safety screens and failure criteria. 
 
The SAT safety screen includes the absences of seizures, alcohol withdrawal, paralysis and increased intracranial pressure. SAT failure criteria focus attention on the signs of pain, agitation and delirium (PAD), along with signs common to respiratory distress in aroused patients. 
 
The SBT safety screen includes evaluation of the need for ventilator support; this helps facilitate ventilation weaning and decreases reintubation rates. 
 
To enable successful implementation of SATs and SBTs, it is important to create an interprofessonal team. The  
 
ABCDEF bundle is most effective when implemented by a team that includes a physician, a nurse, a respiratory therapist, and a physical therapist at all levels of care. 
 
Wake Up and Breath Protocol
The PAD guidelines recommend that: 
  • Depth and quality of sedation should be routinely assessed in all ICU patients. 
  • The Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are the most valid and reliable scales for assessing quality and depth of sedation in ICU patients. 
  • Objective measures of brain function should be used adjunctively to monitor sedation in patients receiving neuromuscular blocking agents. 
  • EEG monitoring should be used to either monitor nonconvulsive seizure activity in ICU patients at risk for seizures or titrate electrosuppressive medication to achieve burst suppression in ICU patients with elevated intracranial pressure.
Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS)
Citation: JAMA. 2003 Jun 11;289(22):2983-91
Population: Adult
Bundle: B Element
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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
Citation: Lancet. 2008 Jan 12;371(9607):126-34
Population: Adult
Bundle: B Element
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The preventability of ventilator-associated events. The CDC Prevention Epicenters Wake Up and Breathe Collaborative
Citation: Am J Respir Crit Care Med. 2015 Feb 1;191(3):292-301
Population: Adult
Bundle: B Element
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Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation
Citation: N Engl J Med. 2000 May 18;342(20):1471-7
Population: Adult
Bundle: B Element
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Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients
Citation: Send to Crit Care Med. 1999 Jul;27(7):1325-9
Population: Adult
Bundle: B Element
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The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients
Citation: Am J Respir Crit Care Med. 2002 Nov 15;166(10):1338-44
Population: Adult
Bundle: B Element
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Early deep sedation is associated with decreased in-hospital and two-year follow-up survival
Citation: Crit Care. 2015 Apr 28;19:197
Population: Adult
Bundle: B Element
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Analgesic, sedative, antipsychotic, and neuromuscular blocker use in Canadian intensive care units: a prospective, multicentre, observational study
Citation: Can J Anaesth. 2014 Jul;61(7):619-30
Population: Adult
Bundle: B Element
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Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project
Citation: Crit Care Med. 2013 Jun;41(6):1435-42
Population: Adult
Bundle: B Element
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Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials
Citation: Mayo Clin Proc. 2015 May;90(5):613-23
Population: Adult
Bundle: B Element
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Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients
Citation: Anesthesiology. 2006 Jan;104(1):21-6
Population: Adult
Bundle: B Element
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Diurnal sedative changes during intensive care: impact on liberation from mechanical ventilation and delirium
Citation: Crit Care Med. 2012 Oct;40(10):2788-96
Population: Adult
Bundle: B Element
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Early goal-directed sedation versus standard sedation in mechanically ventilated critically ill patients: a pilot study
Citation: Crit Care Med. 2013 Aug;41(8):1983-91
Population: Adult
Bundle: B Element
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Early intensive care sedation predicts long-term mortality in ventilated critically ill patients
Citation: Am J Respir Crit Care Med. 2012 Oct 15;186(8):724-31
Population: Adult
Bundle: B Element
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Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study
Citation: Intensive Care Med. 2013 May; 39(5): 910–918
Population: Adult
Bundle: B Element
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Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study
Citation: Crit Care. 2014 Jul 21;18(4):R156
Population: Adult
Bundle: B Element
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Protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial
Citation: JAMA. 2015 Jan 27;313(4):379-89
Population: Pediatrics
Bundle: B Element
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