A Common and Costly Complication of Airway Management
Endotracheal intubation and extubation are procedures routinely performed by clinicians who manage the airway of critically ill or injured patients (e.g., emergency physicians, anesthesiologists, and intensive care physicians) and patients undergoing general anesthesia (i.e., anesthesiologists and other anesthesia providers). Most of the time, extubation is a planned, intentional, and controlled event and in these circumstances the rate of complications related to extubation has been reported in the literature to be as high as 12%. The unplanned, unintentional, and uncontrolled removal of the endotracheal tube (ETT) can be either due to actions of the patient removing their own tube, defined as self-extubation, or due to an external force applied to the ETT during nursing care or movement of the patient that causes the dislodgement of the tube, defined as accidental extubation. Unplanned extubation is associated with significant complications, including aspiration pneumonia, hypoxemia, arrhythmias, vocal cord injury, brain damage, and death.
Asai T, Koga K, Vaughan RS. Respiratory Complications Associated With Tracheal Intubation and Extubation. Br J Anaesth. 1998;80(6):767-775.
Domino KB, Posner KL, Caplan RA, et al. Airway Injury During Anesthesia: A Closed Claims Analysis. Anesthesiology. 1999;91(6):1703-1711.
Ismaeil MF, El-Shahat HM, El-Gammal MS, et al. Unplanned Versus Planned Extubation in Respiratory Intensive Care Unit, Predictors of Outcome. Egyptian J Chest Dis Tuberc. 2014;63(1):219-231.
da Silva, PS, Reis, ME, Aguiar VE, et al. Unplanned Extubation on the Neonatal ICU: A Systematic Review, Critical Appraisal and Evidence-Based Recommendations. Resp Care, 2013.58 (7): p. 1237-45.
Bouza C, Garcia E, Diaz M, et al. Unplanned Extubation in Orally Intubated Medical Patients in the Intensive Care Unit: A Prospective Cohort Study. Heart Lung. 2007;36(4):270-276.
Cook T, Behringer EC, Benger J. Airway Management Outside the Operating Room: Hazardous and Incompletely Studied. Curr Opin Anaesthesiol. 2012;25(4):461-469.
Asai T. Airway Management Inside and Outside Operating Rooms—Cir-cumstances Are Quite Different. Br J Anaesth. 2018;120(2):207-209.
de Groot RI, Dekkers OM, Herold IH, et al. Risk Factors and Outcomes After Unplanned Extubations on the ICU: A Case-Control Study. Crit Care. 2011;15(1):R19.
de Lassence A, Alberti C, Azoulay E, et al. Impact of Unplanned Extubation and Reintubation After Weaning on Nosocomial Pneumonia Risk in the Intensive Care Unit: A Prospective Multicenter Study. Anesthesiology. 2002;97(1):148-156.
Phoa LL, Pek WY, Syap W, et al. Unplanned Extubation: A Local Experience. Singapore Med J. 2002;43(10):504-508.
McNett M, Kerber K. Unplanned Extubations in the ICU: Risk Factors and Strategies for Reducing Adverse Events. J Clin Outcomes Manag. 2015;22(7):303-311.
Kapadia FN, Bajan KB, Raje KV. Airway Accidents in Intubated Intensive Care Unit Patients: An Epidemiological Study. Crit Care Med. 2000;28(3):659-664.
Balon JA. Common Factors of Spontaneous Self-Extubation in a Critical Care Setting. Int J Trauma Nurs. 2001;7(3):93-99.
Meyers JM, Pinheiro J, Nelson MU. Unplanned Extubation in NICU Pa-tients: Are We Speaking the Same Language? J Perinatol. 2015;35(9):676-677.
Barber JA. Unplanned Extubation in the NICU. J Obstet Gynecol Neonatal Nurs. 2013;42(2):233-238.
da Silva PS, Reis ME, Aguiar VE, et al. Unplanned Extubation in the Neonatal ICU: A Systematic Review, Critical Appraisal, and Evidence-Based Recommendations. Respir Care. 2013;58(7):1237-1245.
Franck LS, Vaughan B, Wallace J. Extubation and Reintubation in the NICU: Identifying Opportunities to Improve Care. Pediatr Nurs. 1992;18(3):267-270.
Society of Critical Care Medicine. Critical Care Statistics. www.sccm.org/Communications/Critical-Care-Statistics. Accessed April 10, 2019.
Wunsch H, Wagner J, Herlim M, et al. ICU Occupancy and Mechanical Ventilator Use in the United States. Crit Care Med. 2013;41(12):2712-2719.
Rapheal J, Rosenthal-Ganon T, Gozal Y. Emergency Airway Management With a Laryngeal Mask Airway in a Patient Placed in the Prone Position. J Clin Anesth. 2004;16(7):560-561.
Hung MH, Fan SZ, Lin CP, et al. Emergency Airway Management With Fiberoptic Intubation in the Prone Position With a Fixed Flexed Neck. Anesth Analg. 2008;107(5):1704-1706.
Kiekkas P, Aretha D, Panteli E, et al. Unplanned Extubation in Critically Ill Adults: Clinical Review. Nurs Crit Care. 2013;18(3):123-134.
de Lassence A, Alberti C, Azoulay É, et al. Impact of Unplanned Extubation and Reintubation After Weaning on Nosocomial Pneumonia Risk in The Intensive Care Unit. A Prospective Multicenter Study. Anesthesiology. 2002;97(1):148-156.
Cosentino C, Fama M, Foà C, et al. Unplanned Extubations in Intensive Care Unit: Evidences for Risk Factors. A Literature Review. Acta Biomed. 2017;88(5S):55-65.
Ai ZP, Gao XL, Zhao XL. Factors Associated With Unplanned Extubation in the Intensive Care Unit For Adult Patients: A Systematic Review and Meta-Analysis. Intensive Crit Care Nurs. 2018;47:62-68.
Aydogan S, Kaya N. The Assessment of the Risk of Unplanned Extubation in an Adult Intensive Care Unit. Dimens Crit Care Nurs. 2017;36(1):14-21.
Piriyapatsom A, Chittawatanarat K, Kongsayreepong S, et al. Incidence and Risk Factors of Unplanned Extubation in Critically Ill Surgical Patients: The Multi-Center Thai University-Based Surgical Intensive Care Units Study (THAI-SICU Study). J Med Assoc Thai. 2016;99 suppl 6:S153-S162.
Danielis M, Chiaruttini S, Palese A. Unplanned Extubations in the Intensive Care Unit: Findings From A Critical Incident Technique. Intensive Crit Care Nurs. 2018;47:69-77.
Kwon E, Choi K. Case-Control Study on Risk Factors of Unplanned Extubation Based on Patient Safety Model in Critically Ill Patients With Mechanical Ventilation. Asian Nurs Res. 2017;11(1):74-78.
Metzner J, Posner KL, Lam MS, et al. Closed Claims’ Analysis. Best Pract Res Clin Anaesthesiol. 2011;25(2):263-276.
Cook TM, Woodall N, Frerk C. Major Complications of Airway Management in the UK: Results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617-631.
Chao CM, Sung MI, Cheng KC, et al. Prognostic Factors and Outcomes of Unplanned Extubation. Sci Rep. 2017;7(1):8636.
Kapadia F. Effect of Unplanned Extubation on Outcome of Mechanical Ventilation. Am J Respir Crit Care Med. 2001;163(7):1755-1756.
Lin PH, Chen CF, Chiu HW, et al. Outcomes of Unplanned Extubation in Ordinary Ward Are Similar to Those in the Intensive Care Unit. A STROBE-Compliant Case-Control Study. Medicine. 2019;98(11):e14841.
Mort TC. Unplanned Tracheal Extubation Outside the Operating Room: A Quality Improvement Audit of Hemodynamic and Tracheal Airway Complications Associated With Emergency Tracheal Reintubation. Anesth Analg. 1998;86(6):1171-1176.
Bhattacharya P, Chakraborty A, Agarwal P. Comparison of Outcome of Self-Extubation and Accidental Extubation in ICU. Indian J Crit Care Med. 2007;11(3):105-108.
Rosenthal VD, Udwadia FE, Muñoz HJ, et al. Time-Dependent Analysis of Extra Length of Stay and Mortality Due To Ventilator-Associated Pneumonia in Intensive-Care Units of Ten Limited-Resources
Countries: Findings of the International Nosocomial Infection Control Consortium (INICC). Epidemiol Infect. 2011;139(11):1757-1763.
Karvouniaris M, Makris D, Manoulakas E, et al. Ventilator Associated Tracheobronchitis Increases the Length of Intensive Care Unit Stay. Infect Control Hosp Epidemiol. 2013;34(8):800-808.
Gao F, Yang LH, He HR, et al. The Effect of Reintubation on Ventilator-Associ-ated Pneumonia and Mortality Among Mechanically Ventilated Patients With In-tubation: A Systematic Review and Meta-Analysis. Heart Lung. 2016;45(4):363-371.
Chuang ML, Lee CY, Chen YF, et al. Revisiting Unplanned Endotracheal Extubation and Disease Severity in Intensive Care Units. PLoS One. 2015;10(10):e0139864
Epstein SK, Nevins ML, Chung J. Effect of Unplanned Extubation on Outcome of Mechanical Ventilation. Am J Respir Crit Care Med. 2000;161(6):1912-1916.
Elmetwally R, Elshafey M, Zeidan A, et al. Predictors and Outcome of Unplanned Extubation in COPD Patients. Egypt J Anaesth 2010;26(1):1-11.
Veldman A, Trautschold T, Weiss K, et al. Characteristics and Outcome of Unplanned Extubation in Ventilated Preterm and Term Newborns on a Neonatal Intensive Care Unit. Paediatr Anaesth. 2006;16(9):968-973.
Kanthimathinathan HK, Durward A, Nyman A, et al. Unplanned Extubation in a Paediatric Intensive Care Unit: Prospective Cohort Study. Intensive Care Med. 2015;41(7):1299-1306.
Roddy DJ, Spaeder MC, Pastor W, et al. Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay. Pediatr Crit Care Med. 2015;16(6):572-575.
Klugman D, Berger JT, Spaeder MC, et al. Acute Harm: Unplanned Extubations and Cardiopulmonary Resuscitation in Children and Neonates. Intensive Care Med. 2013;39(7):1333-1334.
Lee JH, Lee HC, Jeon YT, et al. Clinical Outcomes After Unplanned Extubation in a Surgical Intensive Care Population. World J Surg. 2014;38(1):203-210.
Dasta JF, McLaughlin TP, Mody et al. Daily Cost of an Intensive Care Unit Day: The Contribution of Mechanical Ventilation. Crit Care Med. 2005;33(6):1266-1271.
Needham DM, Pronovost PJ. The Importance of Understanding the Costs of Critical Care and Mechanical Ventilation. Crit Care Med. 2005;33(6):1434-1435.
Vats A, Hopkins C, Hatfield K, et al. An Airway Risk Assessment Score for Unplanned Extubation in Intensive Care Pediatric Patients. Pediatr Crit Care Med. 2017;18(7):661-666.
Chao CM, Lai CC, Chan KS, et al. Multidisciplinary Interventions and Continuous Quality Improvement to Reduce Unplanned Extubation in Adult Intensive Care Units. A 15-Year Experience. Medicine. 2017;96(27):e6877.
Chiang AA, Lee KC, Lee JC, et al. Effectiveness of a Continuous Quality Improvement Program Aiming To Reduce Unplanned Extubation: A Prospective Study. Intensive Care Med. 1996;22(11):1269-1271.
Tripathi S, Nunez DJ, Katyal C, et al. Plan To Have No Unplanned: A Collab-orative, Hospital-Based Quality-Improvement Project To Reduce the Rate of Unplanned Extubations in the Pediatric ICU. Respir Care. 2015;60(8):1105-1112.
Fontanez-Nieves TD, Frost M, Anday E, et al. Prevention of Unplanned Extubations in Neonates Through Process Standardization. J Perinatol. 2016;36(6):469-473.
Kandil SB, EmersonBL, Hooper M, Ciaburri R et al. Reducing Unplanned Extubations Across a Children’s Hospital Using Quality Improvement Methods. Pediatr Qual Saf 2018;3: e114.
Galiote JP, Rodiore M, Carman J et al. Reduction in Unintended Extuba-tions in a Level IV Neonatal Intensive Care Unit. Pediatrics 2019;143; e20180897.
Scales DC, Dainty K, Hales B, et al. A Multifaceted Intervention for Quality Improvement in a Network of Intensive Care Units: A Cluster Randomized Trial. JAMA. 2011;305(4):363-372.
Bouadma L, Deslandes E, Lolom I, et al. Long-Term Impact of A Multifaceted Prevention Program on Ventilator-Associated Pneumonia in a Medical Intensive Care Unit. Clin Infect Dis. 2010;51(10):1115-1122.
Fisher DF, Chenelle CT, Marchese AD, et al. Comparison of Commercial and Noncommercial Endotracheal Tube-Securing Devices. Respir Care. 2014;59(9):1315-1323.
Gardner A, Hughes D, Cook R, et al. Best Practice in Stabilisation of Oral Endotracheal Tubes: A Systematic Review. Aust Crit Care. 2005;18(4):158, 160-165.
Mehta NM, Sharma S, Laussen PC. Unplanned Extubation: Securing the Tool of Our Trade. Intensive Care Med. 2015;41(11):1983-1985.
Umoren RA, Poore JA, Sweigart L, et al. TeamSTEPPS Virtual Teams: Interactive Virtual Team Training and Practice for Health Professional Learners. Creat Nurs. 2017;23(3):184-191.
Murphy M, Curtis K, McCloughen A. What is the Impact of Multidisci-plinary Team Simulation Training on Team Performance and Efficiency of Patient Care? An Integrative Review. Australas Emerg Nurs J. 2016;19(1):44-53.
Patel A, Nouraei SA. Transnasal Humidified Rapid-Insufflation Venti-lator Exchange (THRIVE): A Physiological Method of Increasing Apnoea Time in Patients With Difficult Airways. Anaesthesia. 2015;70(3):323-329.
Jaber S, Monnin M, Girard M, et al. Apnoeic Oxygenation Via High-Flow Nasal Cannula Oxygen Combined With Non-Invasive Ven-tilation Preoxygenation for Intubation in Hypoxaemic Patients in the Intensive Care Unit: The Single-Centre, Blinded, Randomised Controlled OPTINIV Trial. Intensive Care Med. 2016;42(12):1877-1887.
Neligan PJ, Malhotra G, Fraser M, et al. Continuous Positive Airway Pressure Via the Boussignac System Immediately After Extubation Improves Lung Function in Morbidly Obese Patients With Obstructive Sleep Apnea Un-dergoing Laparoscopic Bariatric Surgery. Anesthesiology. 2009;110(4):878-884.
Zoremba M, Kalmus G, Begemann D, et al. Short Term Non-Invasive Ventilation Post-Surgery Improves Arterial Blood-Gases in Obese Subjects Compared to Supplemental Oxygen Delivery—A Randomized Controlled Trial. BMC Anesthesiol. 2011;11:10.
Patient Safety Movement. Actionable Patient Safety Solutions. Chal-lenge 8: Airway Safety. https://patientsafetymovement.org/actionable-solu-tions/challenge-solutions/airway-safety/. Accessed April 10, 2019.