Unplanned extubation

OVERVIEW

• Unplanned extubation of mechanically ventilated patients is relatively common ( 0·5% to 14·2% of ICU patients in most studies, higher in a few outliers)
  • Self-extubation refers to the patient’s action, who deliberately removes the endotracheal tube (most common type of unplanned extubation, typically occur at night)
  • Accidental extubation is attributed either to personnel’s inappropriate manipulation of the tube during patient care or to a non-purposeful patient’s action, e.g. coughing (mostly occur in the morning)
• The event may occur without significant sequelae, but can also be life-threatening

RISK FACTORS

Patient factors

• Male
• Delirium
• Light sedation (note that most studies of daily interuppted sedation did not show increased rates of unplanned extubation)
• Difficulty securing tube (e.g. facial swelling, facial burns)
• previous unplanned extubation

Staff factors

• Junior staff
• Nurse-to-patient ratio
• Inadequately secured endotracheal tube and/or checks

Use of restraints and midazolam use are controversial risk factors for self-extubation, it may be that these are confounded by delirium

COMPLICATIONS

• effects of extubation with ETT cuff up
  • hemodynamic effects: hypotension, arrhythmias
  • laryngeal injury, bleeding or oedema
• airway obstruction
• acute pulmonary oedema due to loss of CPAP/PEEP in a patient with left ventricular failure
• respiratory failure
• aspiration
• reintubation and associated sequelae (e.g. prolonged stay, complications of mechanical ventilation, etc)

MANAGEMENT

• attend to potential life-threats using an ABC approach
• many patients (>50%) do not require reintubation if oxygenation and ventilation remains adequate (consider oxygen via NP or mask, high flow nasal prongs or NIV)
• check previous airway grade, obtain difficult airway trolley and call for assistance if likely difficult grade of intubation
• if stridor present, may need a smaller ETT than previously used due to laryngeal trauma/ oedema
• ensure the incident is documented and entered into a risk monitoring system; need to address cause of self-extubation

PREVENTION

• ensure endotracheal tube is well secured
• regular checks on endotracheal tube position and security
• identify patients appropriate for extubation as early as possible
• ensure appropriate analgesia, sedation and delirium management
• safe procedures should be established for performing oral care, renewing tube tapes and changing patient position on bed
• additional staff should be provided during high risk procedures e.g. transport
• use of restraints is controversial

References and Links

Journal articles

• Kiekkas P, Aretha D, Panteli E, Baltopoulos GI, Filos KS. Unplanned extubation in critically ill adults: clinical review. Nurs Crit Care. 2013 May;18(3):123-34. PMID: 23577947.