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Effect of sleep quality on weaning from mechanical ventilation: A scoping review Cover

Effect of sleep quality on weaning from mechanical ventilation: A scoping review

The Journal of Critical Care Medicine
Volume 11 (2025): Issue 1 (January 2025)
By: ,  ,  ,  ,  ,   and    
Open Access
|Jan 2025
Figures & tables

Figures & Tables

Table 1

Study characteristics – effect of hospitalized patient’ sleep quality (objectively measured) on weaning from mechanical ventilation

Author(s), year, countryObjective(s)Study design/patients Definitions of groupsMethods (parameters assessed)Use of an alternative classification for sleep assessmentUse of sedation during patient monitoringResultsSleep and weaning outcomeOther weaning predictorsConclusion (sleep concerning weaning)
Huttmann et al., 2017, GermanyTo assess sleep quality in tracheotomized patients undergoing prolonged weaning

  • A cross-sectional study of 19 patients undergoing prolonged weaning at a specialized weaning unit of a pneumology department

  • Groups: “successful weaning” and “unsuccessful weaning”

  • Objective measurements: PSG (10 pm – 6 am)

  • Gas exchange monitoring Subjective evaluation: Sleep quality and SRI

  • Other parameters assessed: Days on invasive MV

NONO

  • 7 patients (36.8%) successful weaning vs. 12 (63.2%) unsuccessful weaning

  • Days on MV: 39 (SD 22) successful weaning vs. 187 (SD 335) unsuccessful weaning; p = 0.473

  • No significant difference in sleep quality between the successful weaning and unsuccessful weaninggroups in PSG

  • A decreased amount of REM sleep: 9.1 (SD 6.3) vs. 5 (SD 8.4), respectively

No significant difference in nocturnal gas exchange between the groupsThere was no difference between successful and unsuccessful weaning groups of patients undergoing prolonged weaning.
Dres et al., 2019, CanadaTo determine whether abnormal sleep or wakefulness is associated with SBT outcome

  • A prospective multicenter study of 44 (enrolled; 37 with adequate signals) intubated mechanically ventilated patients with an SBT planned for the next day at 3 ICUs

  • Groups: “failed SBT,” “successful SBT (extubation),” and “successful without extubation”

  • Objective measurements: PSG (5 pm – 8 am)

  • EEG markers (ORP index + hemispheric correlation [ICC R/L ORP])

  • Subjective evaluation: Delirium (CAM-ICU)

  • Other parameters assessed: SOFA score, days on MV, length of ICU stay

YESYES

  • 11 patients (30%) successful SBT (extubation) vs. 8 (21%) successful without extubation vs. 18 (49%) failed SBT

  • Days on MV: 10.4 (SD 8.6) successful SBT (extubation) vs. 5.0 (SD 2.5) successful without extubation vs. 4.4 (SD 3.2) failed SBT; p < 0.01

  • No significant difference in sleep architecture between the groups shown by PSG

  • Abnormal sleep patterns are present but not significant

  • More time with ORP > 2.0 and > 2.2 in the successful SBT (extubation) group than in the other two; p < 0.01.

  • Differences in R/L ORP ICC: 0.80 (SD 0.16) successful SBT (extubation) vs. 0.80 (SD 0.15) successful without extubation vs. 0.54 (SD 0.26); p = 0.006

  • SOFA score: 7 (SD 3) successful SBT (extubation) vs. 8 (SD 3) successful without extubation vs. 6 (SD 3) failed SBT; p = 0.32

  • Delirium: 3 (27%) successful SBT (extubation) vs. 2 (25%) successful without extubation vs. 0 (0%)failed SBT; p = 0.06

Although abnormal sleep patterns were noted, there was no association between sleep architecture changes and weaning. However, a detailed analysis of derived EEG markers (ORP, R/L ORP ICC) identified these parameters helpful in predicting SBT success.
Thille et al., 2018, FranceTo assess the impact of sleep alterations on weaning duration

  • A prospective single-center study of 45 intubated patients with at least one SBT failure at a medical ICU

  • Groups: “short weaning” (< 3 days) and“prolonged weaning” (> 3 days)

  • Objective measurements: PSG (1–4 nights)

  • EEG reactivity at eyes opening during wakefulness assessed by a neurologist

  • Subjective evaluation: Delirium (ICDSC) ICU-AW (MRC score < 48)

  • Other parameters assessed: SOFA score, days on MV, length of ICU stay, mortality in ICU

YESYES

  • 27 patients (60%) short weaning vs. 18 (40%) prolonged weaning

  • Days on MV (median, IQR): 8 (4–13) short weaning vs. 13 (15–20) prolonged weaning; p = 0.19

  • Weaning duration is significantly longer in patients with atypical sleep compared with those with normal sleep (median, IQR): 5 (2–8) vs. 2 (1–2); p < 0.001 and independently associated with prolonged weaning: OR = 13.9, 95% CI 3.2–85.7; p = 0.001

  • Weaning duration is significantly longer in patients with no REM sleep compared with the others (median, IQR): 4 (2–7) vs. 2 (1–2); p = 0.03

  • Delirium: 10 (37%) short weaning vs. 6 (33%)prolonged weaning; p > 0.99 SOFA score (median, IQR): 3 (2–3) short weaning vs. 4 (3–6) prolonged weaning; p = 0.02

  • ICU-AW: 9 (33%) short weaning vs. 12 (71%) prolonged weaning; p = 0.03

Patients with atypical sleep or no REM sleep had markedly longer weaning duration than those with normal sleep. Atypical sleep was associated with prolonged weaning (a strong predictor).
Thille et al., 2021, FranceTo assess whether sleep alterations after extubation are associated with an increased risk of reintubation

  • A prospective observational single-center study of 52 extubated patients at a medical ICU

  • Groups: “extubation success” and “reintubation”

  • Objective measurements: PSG (afternoon to next morning)

  • Subjective evaluation: ICU-AW (MRC score < 48) Delirium (ICDSC)

  • Other parameters assessed: Mortality, SOFA

YESYES

  • 44 patients (85%) extubation success vs. 8 (15%) reintubation

  • Days on MV (median, IQR): 3 (2–7) extubation success vs. 9 (5–15) reintubation; p = 0.043

  • Reintubation rates 21% (7/33) in patients with no REM sleep and 5% (1/19) in patients with REM sleep, difference −16% (95% CI −33% to 6%); p=0.23

  • No statistically significant changes in the other PSG sleep parameters between the groups

  • SOFA score (median, IQR): 3 (2–4) extubation success vs. 3 (2–5) reintubation; p = 0.919

  • Delirium: 4 (10%) extubation success vs. 4 (33%) reintubation; p = 0.08 ICU-AW: 11/36 (30%) extubation success vs. 6/8 (86%) reintubation; p = 0.009

Absence of REM sleep influenced the risk of reintubation in the ICU.
Dessap et al., 2015, FranceTo assess the impact of delirium during weaning and associated alterations in the circadian rhythm

  • An observational multicenter study of 70 patients intubated for over 24 hours in an ICU

  • Groups: “successful extubation with delirium” and “successful extubation without delirium”

  • Objective measurements: Excretion of the melatonin urinary metabolite 6-SMT during weaning

  • Subjective evaluation: Delirium (CAM-ICU)

  • Other parameters assessed: SOFA score, days on MV, mortality in ICU

NOYES

  • 43 patients (61.4%) successful extubation with delirium vs. 24 (34.3%) successful extubation without delirium; 3 comatose patients (4.3%)

  • Days on MV (median, IQR): 4.1 (2.6–7.4) successful extubation with delirium vs. 2.8 (1.6–6.9) successful extubation without delirium; p = 0.133

Reduced excretion of 6-SMT (ng) in patients with delirium (median, IQR): 20.212 (23.207–39.920) vs. 18.880 (11.462–27.325); Interaction between delirium and 6-SMT secretion: F statistic = 2.65; p = 0.019

  • SOFA score (median, IQR): 8.0 (6.0–11.0) successful extubation with delirium vs. 5.5 (4.0–7.8) successful extubation without delirium; p = 0.1

  • More complications during weaning in patients with delirium: 40 (93%) vs. 15 (63%); p = 0.02 (OR 5.95, 95% CI 1.26–28.13; p = 0.021)

  • Successful extubation is less likely in patients with delirium: HR 0.54, 95% CI 0.30–0.95; p = 0.02

  • Alcohol abuse (median, IQR): 11 (25.6%) successful extubation with delirium vs. 1 (4.2%) successful extubation without delirium; p = 0.044

Urinary 6-SMT was associated with alterations in the circadian rhythm in patients with delirium and was identified as a measurable marker of the circadian rhythm.

[i] CAM-ICU: Confusion Assessment Method for the Intensive Care Unit, CI: confidence interval, EEG: electroencephalogram, HR: hazard ratio, ICC: intraclass correlation coefficient, ICDSC: Intensive Care Delirium Screening Checklist, ICU: intensive care unit, ICU-AW: intensive care unit-acquired weakness, IQR: interquartile range, MRC: Medical Research Council, MV: mechanical ventilation, ng: nanogram, OR: odds ratio, ORP: odds ratio product, PSG: polysomnography, REM: rapid eye movement, R/L: right/left, SBT: spontaneous breathing trial, SD: standard deviation, SOFA: Sequential Organ Failure Assessment, SRI: Severe Respiratory Insufficiency, 6-SMT: 6-sulfatoxymelatonin

Table 2.

Study characteristics – effect of hospitalized patient' sleep quality (subjectively evaluated) on weaning from mechanical ventilation

Author(s), year, countryObjective(s)Study design/patients Definitions of groupsMethods (parameters assessed)Use of sedation during patient monitoringResultsSleep and weaning outcomeOther weaning predictorsConclusion (sleep concerning weaning)
Chen et al., 2015, TaiwanTo investigate the predictors of sleep quality and successful weaning

  • A cross-sectional study of 94 patients in the process of weaning from MV at 3 respiratory care centers

  • Groups: “weaned group” (successfully weaned within 72 hours) and “nonweaned group“

  • Subjective evaluation:

  • The first two parts of a questionnaire: demographic (age, gender) and clinical (co-existing chronic illnesses, alcohol drinking, use of hypnotics, tracheotomy, albumin, days on MV) information

  • Third part: disease severity (APACHE II and GCS scores)

  • Fourth part: sleep (VSH score)

  • Other parameters assessed: Days on MV

YES

  • 53 patients (56.4%) weaned group vs. 41 (43.6%) non-weaned group

  • Days on MV: 37.9 (SD 17.8) weaned group vs. 42.5 (SD 20.4) non-weaned group; p = 0.240

  • Sleep quality was better in the weaned group than in the non-weaned group: 45.9 (SD 15.3) vs. 36.1 (SD 16.5); p = 0.004

  • Sleep quality negatively influenced by disease severity (APACHE II score: b = −1.323, 95% CI −2.052 to −0.593; p < 0.001), use of hypnotics (b = −10.707, 95% CI −16.718 to −4.696; p < 0.001), and 3–4 co-existing illnesses (b = −9.905, 95% CI −17.734 to −2.077; p < 0.14

  • The weaned group characterized by younger patients (p = 0.038) with higher GCS scores (p = 0.05) and less severe disease (p < 0.001)

  • Other factors identified as independent predictors of weaning (based on regression analysis): APACHE II score (OR = 1.644, 95% CI 1.150–2.351; p < 0.06), GCS score (OR = 0.810, 95% CI 0.695–0.944; p < 0.07), and alcohol use (OR = 0.208, 95% CI 0.063–0.689; p < 0.09)

Sleep quality was identified as a significant predictor of successful weaning from MV.
Huttmann* et al., 2017, GermanyTo assess sleep quality in tracheotomized patients undergoing prolonged weaning

  • A cross-sectional study of 19 patients undergoing prolonged weaning at a specialized weaning unit of a pneumology department

  • Groups: “successful weaning” and “unsuccessful weaning”

  • Objective measurements:

  • PSG (10 pm – 6 am)

  • Gas exchange monitoring

  • Subjective evaluation: Sleep quality and SRI

  • Other parameters assessed: Days on invasive MV

NO

  • 7 patients (36.8%) successful weaning vs. 12 (63.2%) unsuccessful weaning

  • Days on MV: 39 (SD 22) successful weaning vs. 187 (SD 335) unsuccessful weaning; p = 0.473

No significant difference in sleep quality or any items of the questionnaire between the groupsNo difference was identified in sleep quality or questionnaire items between the successful and unsuccessful weaning groups.

* The study by Huttmann et al. (2017) objectively evaluated sleep before weaning initiation; additionally, subjective evaluation was performed in the morning following the termination of nocturnal measurements. APACHE II: Acute Physiology and Chronic Health Evaluation II, CI: confidence interval, GCS: Glasgow Coma Scale, MV: mechanical ventilation, PSG: polysomnography, SD: standard deviation, SRI: Severe Respiratory Insufficiency, VSH: Verran and Snyder-Halpern Sleep Scale

DOI: https://doi.org/10.2478/jccm-2024-0043 | Journal eISSN: 2393-1817 | Journal ISSN: 2393-1809
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Language: English
Page range: 23 - 32
Submitted on: Jul 8, 2024
Accepted on: Oct 30, 2024
Published on: Jan 31, 2025
Published by: University of Medicine, Pharmacy, Science and Technology of Targu Mures
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
extubation,
mechanical ventilation,
scoping review,
sleep-weaning
Related subjects:
Medicine,
Clinical medicine,
Internal medicine,
Internal medicine, other,
Surgery,
Surgery, other,
Anaesthesiology,
Emergency medicine and intensive-care medicine

© 2025 Hana Locihová, Darja Jarošová, Karolína Šrámková, Jana Slonková, Renáta Zoubková, Klára Maternová, Karel Šonka, published by University of Medicine, Pharmacy, Science and Technology of Targu Mures
This work is licensed under the Creative Commons Attribution 4.0 License.

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