Unplanned extubation can be defined as the premature removal of ETT. It can be deliberate or accidental. Usually, it is caused by mechanical ventilation, which is the common process in neonatal intensive care unit (NICU). Unplanned extubations represents fourth most common adverse event in NICUs in North America. Unplanned extubation can result in several complications such as acute cardiorespiratory deterioration, bronchospasm, hypotension, ventilator-associated pneumonia, and subglottic stenosis. Duration of intubation, short length of ETT, less common use of sedatives and muscle relaxants, and time spent out of bed in the hand of parents, i.e. movements, are some of the factors responsible for unplanned extubation. Fortunately, this problem is preventable, and chances of complications could be reduced by removing these factors. This article deals with some important aspects of unplanned extubations such as its complications, factors responsible for unplanned extubations, and preventive strategies.
Introduction of unplanned extubation
Extubation, also referred to as detubation, is the process of removing the tube from a hollow organ or orifice in the body. Unplanned extubation can be defined as the premature removal of the endotracheal tube (ETT) by the patient, i.e. deliberate unplanned extubation, or by staff during nursing and medical care, i.e. accidental extubation (Silva, Reis, Aguiar, & Fonseca, 2013). This process usually takes place after the intubation of the larynx or trachea. It is generally considered as the final step in making the patient free from mechanical ventilation.
In infants, mechanical ventilation through the use of an ETT is a common process in neonatal intensive care unit (NICU). It is helpful in improving the survival rates of critically ill neonates by decreasing the chances of mortality in NICU. Usually, newborns delivered at less than 24 weeks of gestational age go through the process of ventilation more than mature newborn babies. Therefore, unplanned extubation can arise as an adverse effect of mechanical ventilation that is thought to help patients (Silva et al., 2013).
Unplanned extubations in the NICU is one of the most important issues that are related to patient safety as well as quality control. It is also a potentially damaging and costly incidence (Silva et al., 2013). Unplanned extubation rates are usually considered as a standard for quality of care (Razavi, Nejad, Mohajerani, & Talebian, 2013). It can also result in severe types of complications in patients. Many of these complications have been discussed here.
Incidences of Unplanned Extubations
Busy pediatric intensive care units (PICUs) and NICUs could be the common places for higher chances of unplanned extubation (Razavi et al., 2013). Extubation problems are found to be responsible for over 7% of all respiratory related injuries in the American Society of Anesthesiologists (ASA) Closed Claim Project database (Calder & Pearce, 2005). Unplanned extubations represent fourth most common adverse event in NICUs in North America (Merkel et al., 2014).
The incidences of unplanned extubation are reported as percentage, which is calculated from the ratio of the number of unplanned extubation and the number of ventilated patients. They can also be reported as the number of unplanned extubations per 100 intubation days. The later estimations can help in comparing different NICUs (Silva et al., 2013). Researchers are of opinion that the rate of less than1 per 100 patient-intubated days could be considered as the standard for unplanned extubation (Silva et al., 2013). Incidences of unplanned extubations in the NICU are from 1% to 80%, and the rates of unplanned extubations are from 0.14-6.6 per 100 patient-intubated days (Merkel et al., 2014). Unplanned extubations in neonatal patients are 2-3 times more common in neonates as compared to patients in PICU.
Adverse effects and Complications related to unplanned extubation
Coughing, bronchospasm and airway obstruction, hypotension, arrhythmias, and desaturation are comparatively common complications that occur after tracheal extubation (Calder & Pearce, 2005; Silva et al., 2013). However, there are many short-term and long-term adverse effects of unplanned extubation. Short-term problems may include trauma and inflammation of the supraglottic tissues, subglottic tissues and the glottis, and acute cardiorespiratory deterioration. There are also the chances of intraventricular hemorrhage in the initial days of life in the preterm infant. On the other hand, long-term problems may include more chances of ventilator-associated pneumonia, subglottic stenosis, and more days on ventilator, resulting in increased chances of chronic lung disease (Merkel et al., 2014). Subglottic stenosis can occur due to repeated intubations.
Unsuccessful management of unplanned extubation can result in worsening of the condition by exposing the patient to problems of premature elimination from ventilator support. It can also have a bad impact in other forms such as respiratory failure, mortality, issues in the duration of mechanical ventilation, and time-span of ICU and hospital stay. Morality rate is higher in patients with unsuccessfully managed unplanned extubation than those with successfully managed unplanned extubation (Razavi et al., 2013).
Unplanned extubation can, sometimes, result in emergency endotracheal reintubation, but repeated intubations during emergency situations can increase the chances of laryngeal or tracheal injury and scarring, intraventricular hemorrhage, pulmonary injury from excessive ventilation, ventilator-related pneumonia, and changes in some of the functions of the body such as hypercarbia, hypoxemia, increased intracranial pressure, and increased arterial pressure (Razavi et al., 2013; Silva et al., 2013).
Factors responsible for Unplanned Extubation
Among the factors responsible for increased incidences are prolonged duration of intubation, short length of ETT distal to the vocal cords in neonates as compared to the older children in PICUs, less common use of sedatives and muscle relaxants, and time spent out of bed in the hand of parents. Method of attachment of endotracheal tubes, excessive secretions in the body, nurse-patient ratio and procedures such as suctioning and weighing can also result in unplanned extubations in neonates (Merkel et al., 2014; Razavi et al., 2013).
Researchers have found that less than 2 years of age is one of the most important risk factor in unplanned extubation. This shows that nurses have to show close and continuous attention to such patients. Moreover, males are also found to have more chances of unplanned extubation. Some researches show that in females estrogen is probably involved in the regulatory role in secretion of tracheal goblet cells resulting in reduced secretion and less chances of unplanned extubation. More than normal secretions could increase the chances of unplanned extubation (Razavi et al., 2013).
Timing of staff can also affect the chances of unplanned extubation (Razavi et al., 2013). Poor attachment or fixation, i.e. the use of conventional tape, or loose or wet tape, and ETT manipulation, i.e. retaping of ETT but not securing product, and unsupported ventilator tubing, are also among the risk factors for unplanned extubation (Silva et al., 2013).
Prevention and Treatment strategies for unplanned extubations
Although, unplanned extubation is a severe type of incident but luckily it is preventable in most of the cases. In fact, preventive strategies are considered as the only options to decrease the chances of unplanned extubation and its complications. Close monitoring of patients by the nursing staff and the use of alarming devices could help in preventing the unplanned extubation, especially for those who are at increased risk of unplanned extubation (Razavi et al., 2013).
Researchers have reported that regular ETT suctioning can stop subsequent accumulation of fluids and secretions that can reduce chances of unplanned extubation especially in patients with over 5ml/hour of secretions. Uncuffed endotracheal tubes can increase the chances of unplanned extubation, whereas cuffed tubes are usually protected from the complications of unplanned extubations. However, further researches are required for the protective effects of cuffed tubes (Razavi et al., 2013).
Agitation of patients can also result in increased chances of unplanned extubation, but in infants this problem can be solved by the use of sedation protocols. Unexpected movements of patients are also found to increase the chances of unplanned extubation. So, patients have to be moved with extreme care in order to reduce the chances of unplanned extubation (Razavi et al., 2013), especially in their movement from one bed to the other bed or their movement in the hands of their parents.
In order to decrease the chances of mortality as a result of unplanned extubations, factors that can lead to unplanned extubations (mentioned above) have to be investigated in detail and related problems have to be resolved. Study of the important topics such as risk factors, incidences, and strategies to reduce or prevent unplanned extubations can also help clinicians in successful management of unplanned extubations (Razavi et al., 2013).
Change of culture in the NICU can be the most important factor that can help in avoiding and preventing unplanned extubation (Merkel et al., 2014). This change in culture can be achieved by the inclusion of quality improvement (QI) team, properly trained staff and better supervision. This change in culture can also help in knowing the importance of multiple unit-specific interventions to achieve the goal of systemic change. Properly trained staff members can help in proper placement and secure use of devices and tapes with endotracheal tubes. In this regard, in-service trainings and educational sessions can also help other staff members in making proper procedures (Merkel et al., 2014) such as standardized endotracheal tube taping practice. In this regard, it has to be noted that there is no significant retaping time difference between the YYY and YHY technique. However, nurses preferred to use YHY method (Chuo et al., 2014). Mannequin-based simulation and video-demonstration of appropriate placement of securing devices and tapes can help in better training of the staff. Mannequin-based simulation is commonly used by many hospitals such as that of Stanford School of Medicine. This technique involves the recreation of the real physical patient in a practical clinical environment (Stanford School of Medicine, 2014). Culture change has produced positive changes at Penn State Hershey Children's Hospital in Hershey, Pennsylvania, and drastically decreased the incidences of unplanned extubations.
Moreover, implementation of unplanned extubation care can also help in this case (Razavi et al., 2013). Proper care can be done with proper documentation of placement of endotracheal tube with every nursing assessment and ventilator check.
Researchers have reported that the presence of at least 2 licensed professional staff members such as MDs and therapists in different procedures such as retaping and securing endotracheal tubes of patients, who are going through the process of intubation, could reduce unplanned extubations (Merkel et al., 2014).
Researchers are of opinion that early extubation to decrease the period of mechanical ventilation, particularly once the weaning process has started, should be considered as another strategy to decrease unplanned extubation (Silva et al., 2013). Spontaneous mini-root cause analyses after unplanned extubations followed by plan-do-study-act improvement cycles including education and training, alarms and alert cards, can also be an important part of intervention targeting some of the above mentioned factors.
Overall, preventive strategies for adverse events in unplanned extubations need further studies (Silva et al., 2013). Further investigations are also required in estimating the rates of unplanned extubations in the NICUs. These investigations could help in developing guidelines and policies to reduce or prevent the incidences of unplanned extubations.
Chuo, J., Aftab, S., Heimall, L., Soorikian, L., Provost, L., & Ades, A. (2014). Impact of team building using a novel technique (planned experimentation) to standardize endotracheal tube taping practice in the NICU. Journal of Hospital Administration, 3(5), p135.
Calder, I., & Pearce, A. (2005). Core Topics in Airway Management: Cambridge University Press.
Merkel, L., Beers, K., Lewis, M. M., Stauffer, J., Mujsce, D. J., & Kresch, M. J. (2014). Reducing Unplanned Extubations in the NICU. Pediatrics, 133(5), e1367-e1372.
Razavi, S. S., Nejad, R. A., Mohajerani, S. A., & Talebian, M. (2013). Risk Factors of Unplanned Extubation in Pediatric Intensive Care Unit. Tanaffos, 12(3), 11-16.
Silva, P. S., Reis, M. E., Aguiar, V. E., & Fonseca, M. C. (2013). Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations. Respiratory care, 58(7), 1237-1245.
Stanford School of Medicine. (2014). Mannequin-based Patient Simulation. Retrieved from http://cisl.stanford.edu/what_is/sim_modalities/mannequin_sim.html