March 2, 2020

Signs of discomfort after mechanical ventilation withdrawal

An observational study of sedation practice and discomfort

Robert et al. Intensive Care med 2020; 45:1-12


A substantial number of patients die in the ICU, often after withdrawal of invasive mechanical ventilation. Even though quality of dying is a focus area, discomfort at end-of-life is often reported. The aim of the study was to identify risk factors for discomfort, to analyse how sedation and opioate were managed in withdrawal situations, and to analyse the impact of discomfort on family psychological disorders.

The study was a post-hoc analysis of an observational study including 458 patients from 43 French ICUs. For all patients, a decision to withdraw invasive mechanical ventilation by immediate extubation or terminal weaning was made. Use of sedatives and analgesia were recorded from initiation of withdrawal to death.

Discomfort was defined by the occurrence of one of three: at least one gasp, significant bronchial obstruction, or a behavioural pain score (BPS) of at least thee. Discomfort was registered at initiation of withdrawal, and then after 15 min, 60 min, every six hours until 120 hours, and then every day until death. Level of sedation was monitored using Richmond Agitation-Sedation Scale (RASS).

A total of 226 (50%) patients showed signs of discomfort (gasps=138; bronchial obstruction=96; BPS> 3=125). Immediate extubation was independently associated with discomfort, whereas profound sedation (RASS of -5) and vasoactive drugs were associated with less discomfort. Family psychological disorders were not associated with patient discomfort.

The study suggests that physicians may underestimate the potential burden of ICU patients, and that a high proportion of patients do not receive enough sedation and analgesia at end-of-life. One of the reasons may be a fear of hastening death.



Strengths of the study include multicentre participation and prospective registration of data. Limitations include the non-randomized design, the post-hoc analyses (the study was not designed to investigate discomfort and sedation practice) and the inclusion of only French centres.


  • Monitoring and treatment of discomfort at end-of-life is essential, and sedation and opioids should be initiated and adjusted to meet the individual patient’s need.

This article review was prepared and submitted by Associate Professor Hanne Irene Jensen, member of the ESICM Ethics Section, on behalf of the ESICM Journal Review Club.


1) Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study Intensive. Care med 2020; 45:1-12. Robert et al. Intensive Care med 2020; 45:1-12

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