MORBIDITY & MORTALITY
CONFERENCE BLISS 11I
Omar Shahbaz - PGY 3
Bhavtosh Dedania - PGY 2
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Risk Factors Associated with
Unplanned Extubation
Patient-related factors
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Restlessness
Agitation
Confusion
Physical suffering
Nosocomial infection
Nasotracheal intubation
Nursing Related Factors
 Poor fixation of the endotracheal tube
 High patient to nurse ratios
 Night shift
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Physical Restraints:(1)
 (+) Restraining an unconscious/restless patient might
prevent self-extubation
 (-) Restraints might cause anxiety and increase the
possibility of unplanned extubation
 **Self-extubation occurs despite the use of restraints.
 Nonetheless remains first choice in high risk patients.
Sedation:(2)
 Sedation increases the risk for unplanned extubation
by prolonging mechanical ventilation and initiating
paradoxical agitation
1) Happ MB. Treatment interference in critically ill patients: an update on unplanned extubation.
Clin Pulmon Med. 2002; 9:81-86)
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2) Chang et al. Influence on physical restraint on unplanned extubation in adult
intensive care patients: a case-control study. Am J Crit Care 2008:17:408-415
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Among the 191 patients who were
physically restrained 82 had
unplanned extubation
Age, Apache II score, GCS scores,
restraint method, route of intubation,
sedative status DID NOT differ
significantly between the unplanned
extubation group and the control
group
The unplanned extubation group had
a higher rate of nosocomial infection
vs. control group (29.3% vs. 15.2%)
-------------------------------------------Among the 109 patients who were
never physically restrained, 18 had
unplanned extubation.
No significant difference in Age,
Apache II scores, route of intubation,
rates of nosocomial infection or
sedative status
The unplanned extubation group had
higher GCS scores on ICU
admission vs. control group (10.3%
vs. 8.3%)
Consequences of Unplanned Extubation
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Types of Self Extubation
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Accidental Extubation
Self Extubation
 Inappropriate
manipulation of tube
during patient care
 Cause : Non purposeful
patient’s action e.g cough
/ sneezing
 All NATURAL or
UNINTENTIONAL
causes
 Lower risk of adverse
outcomes than Self
extubation.
 Patient’s deliberate or
intentional action
 Reason –discomfort of
tube / pain / agitation /
no-restraints / delirium
/ encephalopathy /
inability to breathe on
their own etc
 Higher risk of adverse
outcomes than
accidental extubation.
Hypothetical Situation 2:30 AM on
Saturday night
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 85 year old demented male admitted since last 2
weeks for COPD exacerbation due to strep PNA
self extubated  noticed by
 RN call for 
 RT – starts bagging the pt 
 Intern / PA – o/n  stat page
 Secretary (“Anesthesia Stat Bliss 11i room 5” X 3)
 Resident admitting in red pod (finishing his H&P /
orders) runs from ED to 11i 
 Anesthetist & team ( whats the K+ , Mg+2, history,
meds) 
 Re-intubation 
 Stat CXR – for tube placement 
 Radiologist calls back 
 ICU attending notified in the middle of night 
Concerns
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 Chaotic situation  because its unplanned and pt. is
not ready
 Issue with patient safety
 ET removed with INFLATED cuff – higher damage
 Circulatory and reflex changes – Bradycardia /
Tachycardia / Hypotension
 Laryngospasm / Laryngeal Edema / Bronchospasm
(Coppolo and May, 1990; Atkins et al., 1997; Mort,
1998).
 Higher risk of Pneumonias (aspiration in particular)
with emergent intubation (de Lassence et al., 2002)
 Higher risk of injury – mechanical due to laryngoscope
/ ET tube – chance of bleeding & difficult re-intubation
due to edema
 Arrhythmias
 Adverse outcomes including death
Contd.
 Re-intubated patients demonstrate up to sevenfold
higher ICU or hospital mortality rates compared
with those who successfully tolerate UE (Epstein et
al., 1997; Robin and Trieger, 2002; Bouza et al.,
2007)
 Besides mortality, re-intubation is associated with
significantly higher incidence of ICU-acquired
urinary tract infections (de Lassence et al., 2002;
Krinsley and Barone, 2005)
 Prolonged duration of mechanical ventilation, ICU
and hospital length of stay (Epstein et al., 2000;
Johan, 2000; Bouza et al., 2007)
 Higher resource utilization (Krinsley and Barone,
2005).
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Immediate Complications :
Breaking it down
Hypotension - 35%
Tachycardia - 30%
Hypertension - 14%
Multiple laryngoscopy attempts - 22%
Difficult laryngoscopy - 16%
Difficult intubation - 14%
Hypoxemia - 14%
Esophageal intubation - 14%
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(Anesth Analg 2012;114:1003–14)
Data
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 Unplanned Extubation (UE) is expressed as the
number of episodes observed per 100 ventilated days.
 National average 3 to 16%
 Our Hartford Hospital average 4.14 % 
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 Most patients were reintubated within 1 hour of
unintentional extubation.
 Reintubation rates were slightly higher in medical
patients than surgical patients.
 Reintubation was less frequent during weaning from
mechanical ventilation, compared with patients on
continuous ventilatory support
 Patients who extubated themselves had lower
reintubation rates than accidental extubation
Courtesy : Dr. Shore & RT staff
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1. Physical Restraints
 A prospective study by Tominaga et al assessing 2
time periods found that decreased use of hand
restraints increased the incidence of unplanned
extubations (2% vs 6%, P 0.001)
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Carrion et al.31 suggested keeping patients’ hands at
least 20 cm away from endotracheal tubes to prevent
unplanned extubation.
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The most common type of restraint was the wrist
belt, but use of chest restraint ,4-point, arm, and hand
restraints were also described
(Anesth Analg 2012;114:1003–14)
2. Securing the ET tube
 Tominaga et al.19 found fewer unplanned extubations
when tubes were secured with waterproof tape around
the tube, upper lip, and face compared with an
endotracheal tube secured via a cloth or Velcro tie
around the back of the head (15% vs 4%, P 0.001).
 Barnason et al.28 showed that securing the
endotracheal tube using twill or adhesive tape was
comparable in preventing unplanned extubations and
maintaining oral mucosa and facial skin integrity.
 Richmond et al.5 found that securing endotracheal
tubes with a Comfit or Hollister holder reduced the
incidence of unplanned extubations.
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(Anesth Analg 2012;114:1003–14)
3. Sedation
 Two studies associated the use of benzodiazepines,
particularly midazolam, with an increased occurrence of
unplanned extubations. Although a paradoxical
excitatory effect or delirium associated with midazolam
has been identified as a probable explanations for this
finding.
 IV boluses of morphine sulfate, benzodiazepines
(diazepam, midazolam, or lorazepam), and haloperidol
given “as needed” were found to increase the incidence
of unplanned extubations.
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 ‘Powers’ reported that the introduction of a sedation
protocol linked to the RAAS reduced the incidence of
unplanned extubation from 7% to 3% in 1 year.
4. Nursing care
 Six studies found a correlation between higher
unplanned extubation rate and
 Increased nursing workload
 Nurse experience of 5 years or less
 Nurse absence from the room.
 The health care provider was not at the bedside at
the time of unplanned extubations in 71% to 89%of
cases.
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(Anesth Analg 2012;114:1003–14)
5. Weaning
 Thirteen studies recommended prompt identification
of patients ready for weaning from mechanical
ventilation as a strategy to reduce unplanned
extubation.
 This recommendation was based on the finding that
most patients who successfully tolerated unplanned
extubation, suggesting they were eligible for elective
extubation within the ensuing few hours.
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(Anesth Analg 2012;114:1003–14)
Summary
 Be prepared
 Identify high risk patient by using risk assessment tool
 Artificial manual breathing unit (AMBU) bag in room
of all intubated patients
 Respiratory Therapist in ICU
 Oral Care
 Adequate & frequent suctioning
 Appropriate size of tube holders & tube fixation
techniques
 Securing the ET tube while patient positioning or
bathing
 Ix & Rx of agitation – sedatives, analgesics, improved
orientation, behavior therapy , visits of relatives.
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Nursing in Critical Care © 2012 British Association of Critical Care Nurses
Intensive and Critical Care Nursing (2007) 23, 249—255
Summary
 Increased RN staffing esp. for sick high risk pts , 1:1
 Implementation of CME for nursing education
 Weaning protocol – wake up and breath, to extubate
before UE event
 Judicious use of physical restraints, as can be harmful
 Protocols for patient transport
 The use of non-invasive positive pressure ventilation
in patients whose UE occurred during the weaning
period has the potential to considerably decrease the
need for re-intubation
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Nursing in Critical Care © 2012 British Association of Critical Care Nurses
Intensive and Critical Care Nursing (2007) 23, 249—255
THANK YOU!
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