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The aim of sedation is to provide comfort and minimize anxiety. However, adverse effects are noteworthy, and the optimal end point of sedation in intensive care unit patients is still debated. We analyzed if a level 2 on the Ramsay Scale (ie, awake, cooperative, oriented, tranquil patient) is suitable for an invasive therapeutic approach. Forty-two patients requiring respiratory support and sedation for at least 4 days were enrolled in a prospective interventional cohort study aiming at maintaining patients awake and collaborative. The Ramsay score was recorded 3 times a day. Once a day, the nurse in charge evaluated adequacy of sedation according to the compliance with nursing care and therapeutic maneuvers in the previous 24 hours. Data were collected until patients were ventilated. Overall, 264 of 582 days were classified as conscious. Sedation was adequate in 93.9% of them. In conscious days, a higher Simplified Acute Physiology Score II score and male sex significantly correlated with inadequate sedation. In a population of severe intensive care unit patients, conscious sedation was achieved in almost half of the days spent on ventilation. The positive implications (eg, on length of weaning and cost of sedation) of a conservative sedation strategy may be highly relevant.

Previously we have shown that optimal pulmonary gas exchange can be sustained at normal airway pressures in a model of severe acute respiratory failure (ARF), using intratracheal pulmonary ventilation (ITPV), with weaning to room air. In an identical model of ARF, we have now explored whether ITPV, combined with continuous positive airway pressure (CPAP), can sustain adequate ventilation, with weaning to room air. Randomized study in sheep. Animal research laboratory at the National Institutes of Health. ARF was induced in 12 sheep, using mechanical ventilation at peak inspiratory pressure of 50 cm H2O, but excluding 5 to 8% of lungs. Sheep were then randomized into two groups: the CPAP-ITPV group (n=6), in which ITPV was combined with a novel CPAP system; and a control group (n=6) in which the same CPAP circuit was used, but without ITPV. All sheep in the CPAP-ITPV group were weaned to room air in 38.7±14 h. PaO2/fraction of inspired oxygen (FIo2) progressively increased from 108.8±43 to 355.7±93.1; PaCO2 remained within normal range; respiratory rate (RR) ranged from 18 to 120 breaths/min, and tidal volume (Vt) was as low as 1.1 mL/kg. All sheep in the control group (CPAP alone) developed severe respiratory acidosis and hypoxemia after 4.8±4 h. PaO2/FIo2 decreased from 126.6±58.2 to 107.2±52.5 mm Hg, with a final PaCO2 of 166.8±73.3 mm Hg. All sheep treated with CPAP-ITPV maintained good gas exchange without hypercapnia at high RR and at low Vt, with weaning to room air. All control animals treated with CPAP alone developed severe hypercapnia, respiratory acidosis, and severe hypoxemia, and were killed.