Key messages
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Stopping sedation each day may reduce the time people spend on a ventilator, probably reduces the number who die, and probably reduces the time people spend in intensive care and hospital, compared to sedation methods that do not include daily stopping.
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Stopping sedation each day may make little or no difference to the risk of the breathing tube or other tubes being accidentally pulled out, and probably reduces the need for a breathing tube (tracheostomy) inserted in the neck. It may have little to no effect on the amount of sedative medication, but probably increases the amount of pain medication (morphine) people receive while in intensive care.
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We need more studies in children. Future studies should measure the total amount of sedation and pain medications given and people's quality of life.
What is daily sedation interruption?
Critically ill infants, children, and adults in intensive care may need a machine for breathing (mechanical ventilation), which requires a tube to be inserted into their windpipe (intubation). People receiving ventilation may also require sedative medication to help them tolerate the breathing tube and make them more comfortable. Sedatives are usually given as a drip into a vein.
Because people's bodies may respond differently to medicine when they are critically ill, medications for sedation and pain can build up in the body. This can make it difficult to wake people when they are getting better and might extend the time they are on a ventilator. Stopping the sedative medication each day is done to see if a person wakes up and no longer needs sedation. People who are uncomfortable and still need sedation have medication restarted at a lower dose. If they are comfortable when awake and able to breathe safely without the ventilator, the healthcare team can assess whether the breathing tube can be removed.
What did we want to find out?
We wanted to know if stopping sedation each day was better than other sedation strategies for reducing:
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the length of time people require ventilation;
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death;
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the length of intensive care and hospital stays;
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sedation-related unwanted events, including: the breathing tube (or other lines or tubes) being accidentally pulled out; being unable to come off the ventilator and needing a breathing tube (tracheostomy) inserted in the neck; or developing delirium (a sudden change in how a person thinks, understands things, and pays attention);
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the amount of sedation and pain medication given.
We also wanted to know which was better at improving people's quality of life.
What did we do?
We looked for studies in adults and children that compared daily stopping of sedation with other sedation management methods that did not include daily stopping. We compared and summarised their results and rated our confidence in the evidence based on factors such as study methods and number of people included.
What did we find?
We found 23 studies involving 5987 people (3238 adults; 2750 children). Seven studies were conducted in North America; six in Europe; three in China; two in Egypt; and one each in Australia, Brazil, India, Indonesia, and Japan.
Daily stopping of sedation was compared to:
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step-by-step guidelines on sedation management;
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usual management, where healthcare teams decide how to manage sedation; or
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a strategy that prioritises pain management and only uses sedation if someone is very uncomfortable and a risk to themselves.
Main results
Compared with other sedation management methods, daily stopping of sedation:
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may reduce the time on the ventilator by around 14%, or 1 day in adults and 0.4 days in children (18 studies, 3815 participants);
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probably reduces the number of people who die by around 3.5% (18 studies, 4057 participants);
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probably reduces intensive care length of stay by around 11%, or 1.1 days in adults and 0.5 days in children (18 studies, 4477 participants);
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may make little or no difference to the number of times someone's breathing tube (16 studies, 4342 participants) or other tubes or lines (7 studies, 1536 participants) are accidentally pulled out;
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probably reduces the need for tracheostomy (8 studies, 2503 participants).
The evidence is very uncertain about the effect of daily sedation interruption on the amount of sedation medication people are given while in intensive care. It probably slightly increases the amount of pain medication (morphine) given. There may be little to no difference between sedation management strategies in terms of improving people's quality of life.
What are the limitations of the evidence?
We are moderately confident in the evidence about death and length of stay in intensive care and hospital, but have low confidence in the evidence about the length of time people required ventilation, occurrence of some unwanted events, and medication amounts given. Our confidence was reduced mainly because:
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the results sometimes varied between studies;
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they compared different ways of managing sedation;
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some outcomes were reported by too few studies to be certain about the size of the effect.
How up to date is this evidence?
This review updates our previous review. The evidence is current to 8 October 2025.
Read the full abstract
Background
Daily sedation interruption (DSI) is thought to limit drug bioaccumulation, promote a more awake state, and thereby reduce the duration of mechanical ventilation. Available evidence has shown DSI to either reduce, not alter, or prolong the duration of mechanical ventilation.
Objectives
To assess the effects of DSI versus sedation management without DSI on the duration of invasive mechanical ventilation, mortality, intensive care unit (ICU) length of stay, adverse events related to under- or oversedation (including accidental removal of endotracheal tube and tracheostomy), total doses of sedative and analgesic drug administered, and health-related quality of life, for critically ill people requiring intravenous sedation.
Search strategy
We used CENTRAL, MEDLINE All, Embase Classic+Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science Core Collection, and two trial registers, together with reference checking, citation searching, and contact with study authors to identify the studies included in the review. The latest search date was 8 October 2025.
Selection criteria
We included randomized controlled trials that compared DSI with sedation strategies that did not include DSI in mechanically ventilated, critically ill adults.
Data collection and analysis
Two authors independently extracted data and three authors assessed risk of bias. We contacted study authors for additional information as required. We combined data in forest plots using random-effects modelling. A priori subgroups and sensitivity analyses were performed.
Main results
Nine trials were used in the analysis (n = 1282 patients). These trials were found to be predominantly at low risk of bias. We did not find strong evidence of an effect of DSI on the total duration of ventilation. Pooled data from nine trials demonstrated a 13% reduction in the geometric mean, with relatively wide confidence intervals (CI) indicating imprecision (95% CI 26% reduction to 2% increase, moderate quality evidence). Similarly, we did not find strong evidence of an effect on ICU length of stay (-10%, 95% CI -20% to 3%, n = 9 trials, moderate quality evidence) or hospital length of stay (-6%, 95% CI -18% to 8%, n = 8 trials, moderate quality evidence). Heterogeneity for these three outcomes was moderate and statistically significant. The risk ratio for ICU mortality was 0.96 (95% CI 0.77 to 1.21, n = 7 trials, moderate quality evidence), for rate of accidental endotracheal tube removal 1.07 (95% CI 0.55 to 2.12, n = 6 trials, moderate quality evidence), for catheter removal 1.48 (95% CI 0.76 to 2.90, n = 4 trials), and for incidence of new onset delirium 1.02 (95% CI 0.91 to 1.13, n = 3 trials, moderate quality evidence). Differences in the doses of any drug used or quality of life score (Short Form (SF)-36) did not reach statistical significance. Tracheostomy was performed less frequently in the DSI group (RR 0.73, 95% CI 0.57 to 0.92, n = 6 trials, moderate quality evidence). Sensitivity analysis of unlogged data resulted in similar findings. Post hoc analysis to further explain heterogeneity, based on study country of origin, showed that studies conducted in North America resulted in a reduction in the duration of mechanical ventilation (-21%, 95% CI -33% to -5%, n = 5 trials).
Authors' conclusions
Based on low- and moderate-certainty evidence from 23 trials including nearly 6000 critically ill people, we found that DSI may reduce the duration of mechanical ventilation and probably reduces mortality, intensive care LOS, and hospital LOS compared with other sedation methods. Daily sedation interruption may have little to no effect on the adverse outcomes of accidental removal of the endotracheal tube or other lines or catheters, but probably reduces the need for tracheostomy. The evidence on sedation dosing is very uncertain; however, DSI probably increases opioid dosing. Given the evidence on the effect on sedation dosing is very uncertain, future trials should include data on total sedative and analgesic doses as well as delirium and health-related quality of life, as these remain under-evaluated.
Funding
This review received no funding.
Registration
Registration (CD009176) and previous version of the review: Cochrane Database of Systematic Reviews via DOI: 10.1002/14651858.CD009176.pub2.
Protocol available via DOI 10.1002/14651858.CD009176.pub1.
