CE Article: Unplanned Extubation—An Underrecognized Complication

Objectives

• Identify the circumstances and consequences of unplanned extubation
• Outline evidence-based interventions for cases of unplanned extubation
• Describe preventive strategies for secure tube placement

EMS is called for an unknown medical problem. The first-responding ALS fire crew finds a 29-year-old male unconscious and unresponsive in his bed. He has extremely slow respirations and obvious peripheral and circumoral cyanosis. According to his girlfriend he has no health problems and has been recently healthy. An assessment finds no abnormalities beyond those noted. Further assessment and intervention: 

• Vitals: pulse 62, BP 132/60, respiratory rate 4;
• SpO₂: 68%; after appropriate preoxygenation with a BVM, it increases to 99%;
• He is orally intubated without difficulty. Tube position is confirmed using breath sounds, gastric sounds, and capnography. EtCO₂ is initially 72 with good waveform. BVM ventilation is initiated at a rate of 12 on 100% oxygen.
• An IV is started. 

The crew transfers care to the transporting ALS team. During transport the girlfriend volunteers the patient had oral surgery the previous day. During the night, in response to severe pain, he took several of his prescribed oxycodones, which allowed him to sleep. Upon learning this the crew administers 0.4 mg of naloxone. The patient immediately becomes agitated and requires restraints. As he struggles the IV is pulled out and has to be restarted. 

By arrival at the hospital, the man’s vitals are pulse 120, BP 104/70, and respiratory rate 34. His SpO₂ is 85% and EtCO₂ is 58.

Upon initial assessment there the ED physician expresses concern about the patency of the ET tube due to the continued elevation of the EtCO₂. A chest x-ray shows the distal tip of the endotracheal tube to be in the posterior pharynx, above the vocal cords. The patient is reintubated and stabilized prior to admission to ICU. 

What happened?

Losing the Tube

If you’ve worked in ground or air-medical transport very long, you’ve already envisioned several scenarios that could have resulted in this malpositioned endotracheal tube. It could have been pulled during the transfer into the ambulance, perhaps when the person managing the bag-valve mask got out of step with the patient during the lift onto the stretcher, movement out of the house, or lift into the ambulance. Or the tube could have been displaced by the patient himself during his episode of agitation. Another possibility is dislodgement during the transfer from the ambulance to the ED stretcher. Of course, it also could have been incorrectly positioned at initial insertion, but given the thoroughness of the initial tube confirmation, it’s pretty safe to assume this extubation occurred sometime during transport or transfer into the ED. The term for this is unplanned extubation, and it happens more often than you’d think.

Extubation is categorized as either planned or unplanned. Planned extubation refers to weaning from mechanical ventilation and removal of the endotracheal tube as planned by the medical team. It rarely occurs in the out-of-hospital setting. Unplanned extubation (UE) is defined as premature removal of the endotracheal tube by actions of the patient or during care, manipulation, or movement of the patient.^1–9 In EMS we have more manipulation and movement of patients than most patient care settings, so we’d be wise to be aware of the condition and alert for the signs. 

Like in this case, a hallmark of unplanned extubation is that it occurs with the ET tube cuff still inflated. A comprehensive guided review of the literature found unplanned extubation occurs in 7.3% (median) of all intubated adult ICU patients.⁶ Other studies have found adult ICU occurrence rates from 2%–10%.^5,10,11 The clear majority (62.8%–96.4%) of unplanned extubations in adult intensive care units are the result of patient self-extubation,^2,4,10,12 which may be what happened in this case. 

Obviously these data from well-controlled ICU environments may not apply to EMS. Information from our environment is scant, but two studies suggest the UE rate in emergency medical services is approximately 3%, although it’s likely higher since these studies relied solely on voluntary self-reporting.^13,14  

If you provide transport of high-risk neonates, the potential for unplanned extubation is even higher. Unplanned extubation is the fourth-most common adverse event in the neonatal intensive care unit.¹⁵ Incidence in the NICU is between 1–4.8 unplanned extubations per 100 ventilated days.^15,16 In a prospective study in a combined pediatric/neonatal ICU, Brazilian researchers found the unplanned extubation rate to be 18.7%.¹⁷ Self-extubation is the most frequent cause of unplanned extubation in neonates (60%); accidental extubation during retaping of the tube, suctioning, weighing, or ventilator circuit changes makes up the remainder.¹⁸ 

And it’s a big deal for the patient. Unplanned extubation creates a variety of complications. While the patient in the case study survived, he experienced a prolonged stay in the hospital complicated by delayed weaning and development of ventilator-acquired pneumonia. That isn’t surprising; patients who experience any unplanned extubation (even if it is recognized and resolved quickly) require substantially longer ICU (18 vs. 9 days) and hospital (30 vs. 18 days) length of stays. In addition, they have more than double the incidence of ventilator-acquired pneumonia (30% vs. 13.8%).¹⁰ These complications and prolonged ICU care result in a 41% increase in cost, from an average of $56,206 to $100,198 per patient.^19,20 

Similar complications are reported in pediatric and neonatal ICU studies. German investigators reported that unplanned extubation increased NICU length of stays from 9 to 51 days and total hours of mechanical ventilation from 52 to 345.²¹ A similar study in a pediatric ICU described increases in ICU (10 vs. 4.5 days) and hospital (16.5 vs. 10 days) LOS associated with unplanned extubation. The study attributed a 57% increase in cost associated with UE, from a median of $64,618 to $101,310.²²

Patients who require reintubation to maintain airway patency or ventilation following unplanned extubation experience an increase in complications and mortality. This is typical when an endotracheal tube moves during EMS care. An average of 45.8% of adults who experience an unplanned extubation required reintubation.⁶ Other authors report higher reintubation rates between 47%–79.6%.^5,10,11,23 The need for reintubation has been shown to be most likely in adults with pneumonia.²⁴ Pediatric and neonatal ICU patients have similar complications related to reintubation. One study reported that 43% of UE patients required reintubation, as compared to only 8% of patients weaned without UE. Patients requiring reintubation required two additional PICU days (4.6 vs. 2.6) compared to patients without reintubation.²⁵ One small retrospective study reported that 63% of pediatric UEs required reintubation and 20% of the reintubated patients experienced cardiovascular collapse, the majority requiring CPR.²⁶ 

Keeping Things Secure

Regardless of the setting, unplanned extubation can only occur when an endotracheal tube is inadequately secured, allowing either deliberate or accidental forces to pull the tube out of the trachea.^21,27 There are two broad categories of securing devices for endotracheal tubes.

Manual securement utilizes either twill or various types of adhesive tape to secure the tube. Typically twill tape is cinched around the tube and then wrapped and tied behind the neck to secure the cinch point at the mouth. Adhesive tape is usually wrapped around the tube and then taped to the cheek and neck or pulled together behind the neck, again with the purpose of securing the point where the tape goes around the tube at the mouth. 

Commercial devices are specifically designed to secure endotracheal tubes. These devices wrap behind the neck and connect to the endotracheal tube by either a cloth or plastic strip that surrounds the tube, a screw that squeezes the tube, or a channel the tube goes through. The Thomas Tube Holder, one of the more commonly used devices in EMS, fits into this category. 

Device effectiveness is typically measured by the amount of force required to displace the tube; ability to hold the endotracheal tube in place; ease of application; degree of pressure damage the device causes to oral mucosa, lips, and facial skin; and patient satisfaction or pain.^27,28 

There is limited literature available regarding the relative effectiveness and complications associated with various tube securement practices, but several themes can be identified. First, any securement device is more secure than having care providers manually hold the tube.¹³ In comparisons between twill and tape (manual methods), twill appears superior in providing security and minimizing damage to the oral mucosa, lips, and skin.^28,29 Twill also appears to compress the jugular veins less and is associated with less patient pain compared to tape.²⁹ The performance of tape appears to vary widely depending upon the type used.^30,31 Tape has been found to be an unnecessary source of hospital-acquired infection: An integrative review of the literature found 35%–74% of tape used in the ICU colonized significant bacteria, including MRSA and vancomycin-resistant enterococcus.³² 

When comparing commercial devices with manual methods, it appears commercial devices provide superior security and less tissue injury (skin and mucosa) than tape or twill.^28,33,34 Tape has also been associated with skin avulsion injury during extubation.³⁵ However, in the only study that has directly measured pressure exerted on the skin, commercial devices were shown to exert more pressure than tape or twill.²⁷ 

Commercial devices vary in their ability to maximize securement and minimize mucosal/skin damage. Overall, commercial devices that simply wrap around the endotracheal tube without utilizing adhesive, a screw device, or a security cylinder are less secure than those that do.³¹ The best securement is provided by devices that either have a positive way to attach to the endotracheal tube or are secured to the face using adhesive,³⁶ although adhesive has potential to increase damage to the face and lips.²⁷ Overall, several authors note there is currently no ideal device available for tube securement.^27,28 

In addition to tube securement, there are a few other factors associated with the risk of unplanned extubation. Patients who are restless or agitated are more likely to self-extubate.^6,18,23 In fact, one study found 61% of patients who self-extubated were agitated at the time.³⁷ Two additional risk factors are inadequate sedation^9,38 and the use of physical restraints, both presumably related to agitation.^38,39 So during transport, especially aeromedical transport, adequate sedation appears to be a useful tool for reducing the risk of unplanned extubation and may also reduce stress in high-risk patients. 

EMS organizations that provide critical care transport should keep in mind that neonates are especially likely to experience unplanned extubation related to movement. Neck extension has been reported to create as much as 0.9 cm movement toward the carina or 1.7 cm movement toward the vocal cords.²¹ The risk increases when caring for neonates at 30–36 weeks gestational age with a weight less than 1,000 g.⁴⁰ 

Prevention

Prevention of unplanned premature extubation begins with securement. As noted above multiple authors have described the absence of an optimal endotracheal tube stabilizer for patients of any age.^{14,21,27–29,31,33,34,36,41–44} Attributes of the optimal securement device include:^{27,28,32,45,46}

• Ease of application and maintenance; 
• Adequate stabilization of the tube against external forces that risk dislodgement; 
• Security is not compromised when the device is exposed to blood, saliva, or other fluids;
• Secures the endotracheal tube without compressing the tube and decreasing the internal diameter;
• Facilitates suctioning of the tube and oropharynx without risk of tube movement;
• Allows good visualization of the oral cavity;
• Minimizes or eliminates skin pressure;
• Cost- and time-effective;
• Enhances patient comfort.

In addition to providing optimal securement, unplanned extubation can be reduced through:⁷ 

• Process standardization and compliance related to sedation and restraint;
• Staff education on airway care, monitoring, and recognition of UE;
• Identification of every UE incident with careful root cause analysis and improvement and ongoing tracking of rates;
• Careful and appropriate restraint.

Intervention, Communication

Hopefully awareness of the problem will increase your vigilance when caring for intubated patients. In addition to continually monitoring capnometry and waveform capnography, be aware of any patient movement or treatment procedures that may inadvertently pull on the tube or ventilator circuit. If this occurs, immediately:

• Evaluate the EtCO₂ and capnograph waveform;
• Assess the tube position at the teeth; 
• Reassess the breath sounds to evaluate air movement and ascertain whether the tube may be either too deep in the right main stem or too shallow, with a risk for extubation.

If the tube is completely or nearly outside the mouth or there is evidence of impaired ventilation (based on abnormal capnography waveform, alterations in EtCO₂, and/or breath sounds), remove the tube completely. If in doubt, take it out! Determine whether the patient will require reintubation based on the following factors:

• Is the patient spontaneously ventilating? If so, assess the rate and depth. Ideally assess EtCO₂ using a cannula sensor to evaluate the waveform and determine the adequacy of air movement. Determine whether the patient is ventilating adequately. 
• Does the patient have significant risk for airway compromise and/or emesis and aspiration based on their underlying condition? (This may be why you intubated in the first place.)

Patients who are at risk of airway compromise or aren’t ventilating adequately need to be reintubated. Follow your usual procedures and be prepared for a potentially more difficult intubation. Forcible extubation with the balloon inflated may cause edema and/or laryngospasm.⁴⁷ Following reintubation return to careful monitoring of EtCO₂ and the waveform capnograph.

If the patient does not require reintubation, monitor airway patency and ventilation using a nasal cannula EtCO₂ sensor and be prepared to supplement ventilation and/or reintubate if necessary.

Regardless of whether the patient requires reintubation, it is critical that you clearly document and communicate the unplanned extubation to the receiving facility. This information will prompt additional airway assessment and ventilation monitoring and may also prompt prophylactic measures to prevent ventilator-acquired pneumonia. 

Summary

Unplanned extubation is a common, costly, and preventable complication that can result in prolonged ICU and hospital stays with increases in ICU costs, ventilator-acquired pneumonia, and even brain damage and death. Inadequate tube securement is a universal factor in all unplanned extubations. 

Prevention of UE in the EMS setting requires a comprehensive and intentional approach that effectively addresses these primary causes using the following principles: 

• Secure the endotracheal tube using a commercial device that is easy to apply and maintain, prevents the tube from moving when force is applied without compromising the internal tube diameter, enables oral care and suctioning, and minimizes or eliminates skin pressure and the use of adhesives that may cause skin tears. 
• Guidelines/protocols for care of intubated/ventilated patients should be evidence-based and provide clear parameters for use of sedation, patient restraint, and patient monitoring. All patient care team members should be well trained on use of the guidelines. 
• When unplanned extubation occurs, it should be documented, and the rate of incidence monitored as is done with other care complications. Review individual cases to identify causative factors, with changes in care guidelines and provider training as necessary. Always inform receiving facilities during the patient handoff report to enable monitoring or prophylactic care for complications. 

Adherence to these guidelines, combined with the development of improved securement devices and more reliable standards for documentation and tracking of unplanned extubation, offers promise for reducing the incidence of this serious and preventable complication.   

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Scott Bourn, PhD, RN, FACHE, is vice president of clinical quality and impact for Securisyn Medical. He has a diverse background in EMS, emergency and critical care nursing, and education.