Impact of Phenobarbital on Intubation Rates in Acute Alcohol Withdrawal

Introduction: Alcohol withdrawal syndrome (AWS) is commonly treated with benzodiazepines, though phenobarbital has emerged as a potential alternative. However, data are limited regarding the need for additional sedatives and mechanical ventilation when phenobarbital is used. This study aimed to evaluate the need for concomitant sedation and intubation in patients receiving phenobarbital for AWS.


Methods: This single-center, retrospective cohort study included patients aged ≥18 years who received at least one dose of phenobarbital for AWS between October 1, 2023, and October 31, 2024. Patients were excluded if phenobarbital was administered for other indications or if they left against medical advice. The primary outcome was the incidence of mechanical ventilation for agitation control after phenobarbital initiation. Secondary outcomes included additional sedation needs, hospital and ICU length of stay related to concomitant sedative use, and total phenobarbital dose administered.


Results: Of 39 patient encounters screened, 13 met inclusion criteria; 26 were excluded, primarily due to phenobarbital use for seizure disorders (n=18). The median cumulative phenobarbital dose was 745 mg (IQR: 354–1087 mg). Concomitant sedatives were administered in 84.6% (11/13) of patients, with 63.6% (7/11) of these requiring mechanical ventilation. Notably, the two patients treated with phenobarbital monotherapy did not require intubation.


Conclusions: In this cohort, patients receiving phenobarbital monotherapy for AWS avoided mechanical ventilation, whereas those receiving additional sedatives had higher intubation rates. These findings suggest a potential role for phenobarbital monotherapy in reducing sedation-related complications and improving clinical outcomes. Further studies are warranted to validate these findings and optimize sedation strategies in AWS management.