Skip to main content
Patient Care

CE Article: Unplanned Extubation—An Underrecognized Complication

Editor's note: CE credit is available for $6.95 after reading this article and taking a post-test here.

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 sedation9,38 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.   

References

1. Ismaeil MF, El-Shahat HM, El-Gammal MS, Abbas AM. Unplanned versus planned extubation in respiratory intensive care unit, predictors of outcome. Egyptian J Chest Dis Tuberculosis, 2014 Jan; 63(1): 219–31.

2. Yoon HK, Park HS, Park HP. Clinical outcomes after unplanned extubation in a surgical intensive care population: reply. World J Surg, 2014; 38(8): 2,191.

3. Thiel D, Houten J, Wecksell M. Accidental tracheal extubation of a patient in the prone position. A A Case Rep, 2014; 2(2): 20–2.

4. Moons P, Boriau M, Ferdinande P. Self-extubation risk assessment tool: predictive validity in a real-life setting. Nurs Crit Care, 2008; 13(6): 310–4.

5. de Groot RI, et al. Risk factors and outcomes after unplanned extubations on the ICU: a case-control study. Crit Care, 2011; 15(1): R19.

6. da Silva PS, Fonseca MC. Unplanned endotracheal extubations in the intensive care unit: systematic review, critical appraisal, and evidence-based recommendations. Anesth Analg, 2012; 114(5): 1,003–14.

7. 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 (Baltimore), 2017; 96(27): e6877.

8. Bouza C, et al. Unplanned extubation in orally intubated medical patients in the intensive care unit: a prospective cohort study. Heart Lung, 2007; 36(4): 270–6.

9. 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.

10. de Lassence A, 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): 148–56.

11. Phoa LL, et al. Unplanned extubation: a local experience. Singapore Med J, 2002; 43(10): 504–8.

12. Kiekkas P, et al. Unplanned extubation in critically ill adults: clinical review. Nurs Crit Care, 2013; 18(3): 123–34.

13. Wang HE, et al. Preliminary experience with a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation. Resuscitation, 2003; 58(1): 49–58.

14. Kupas DF, Kauffman KF, Wang HE. Effect of airway-securing method on prehospital endotracheal tube dislodgment. Prehosp Emerg Care, 2010; 14(1): 26–30.

15. Meyers JM, Pinheiro J, Nelson MU. Unplanned extubation in NICU patients: Are we speaking the same language? J Perinatol, 2015; 35(9): 676–7.

16. Barber JA. Unplanned extubation in the NICU. J Obstet Gynecol Neonatal Nurs, 2013; 42(2): 233–8.

17. Silva PS, Reis ME, Aguiar VE, Fonseca MC. Unplanned extubation in the neonatal ICU: a systematic review, critical appraisal, and evidence-based recommendations. Respir Care, 2013; 58(7): 1,237–45.

18. Franck LS, Vaughan B, Wallace J. Extubation and reintubation in the NICU: identifying opportunities to improve care. Pediatr Nurs, 1992; 18(3): 267–70.

19. Dasta JF, McLaughlin TP, Mody SH, Piech CT. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med, 2005 Jun; 33(6): 1,266–71.

20. Needham DM, Pronovost PJ. The importance of understanding the costs of critical care and mechanical ventilation. Crit Care Med, 2005; 33(6): 1,434–5.

21. Veldman A, 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): 968–73.

22. Roddy DJ, et al. Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay. Pediatr Crit Care Med, 2015; 16(6): 572–5.

23. 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 (Korean Soc Nurs Sci), 2017; 11(1): 74–78.

24. Chen CZ, et al. Factors predicting reintubation after unplanned extubation. J Formos Med Assoc, 2002; 101(8): 542–6.

25. Kanthimathinathan HK, et al. Unplanned extubation in a paediatric intensive care unit: prospective cohort study. Intensive Care Med, 2015; 41(7): 1,299–306.

26. Klugman D, et al. Acute harm: unplanned extubations and cardiopulmonary resuscitation in children and neonates. Intensive Care Med, 2013; 39(7): 1,333–4.

27. Fisher DF, et al. Comparison of commercial and noncommercial endotracheal tube-securing devices. Respir Care, 2014; 59(9): 1,315–23.

28. Gardner A, et al. Best practice in stabilisation of oral endotracheal tubes: a systematic review. Aust Crit Care, 2005; 18(4): 158, 160–5.

29. Mohammed H, Hassan MS. Endotracheal tube securements: Effectiveness of three techniques among orally intubated patients. Egyptian Journal of Chest Diseases and Tuberculosis, 2014; 64: 183–96.

30. Fenje N, Steward DJ. A study of tape adhesive strength on endotracheal tubes. Can J Anaesth, 1988; 35(2): 198–201.

31. Lovett PB, et al. The insecure airway: a comparison of knots and commercial devices for securing endotracheal tubes. BMC Emerg Med, 2006; 6: 7.

32. Krug L, Machan M, Villalba J. Securing the endotracheal tube with adhesive tape: an integrative literature review. AANA J, 2014 Dec; 82(6): 457–64.

33. Buckley JC, et al. Comparison of the Haider Tube-Guard Endotracheal Tube Holder Versus Adhesive Tape to Determine if This Novel Device Can Reduce Endotracheal Tube Movement and Prevent Unplanned Extubation. Anesth Analg, 2016; 122(5): 1,439–43.

34. Carlson J, et al. Extubation force: tape versus endotracheal tube holders. Ann Emerg Med, 2007; 50(6): 686–91.

35. Yilmaz B, Colakoglu K, Gurunluoglu R. Skin avulsion injury during endotracheal tube extubation—case report of an unusual complication. Patient Saf Surg, 2008; 2: 12.

36. Wagner JL, Shandas R, Lanning CJ. Extubation force depends upon angle of force application and fixation technique: a study of 7 methods. BMC Anesthesiol, 2014; 14: 74.

37. Boulain T. Unplanned extubations in the adult intensive care unit: a prospective multicenter study. Association des Reanimateurs du Centre-Ouest. Am J Respir Crit Care Med, 1998; 157(4 Pt 1): 1,131–7.

38. McNett M, Kerber K. Unplanned extubations in the ICU: Risk factors and strategies for reducing adverse events. J Clin Outcomes Management, 2015; 22(7).

39. Chang LY, Wang KW, Chao YF. Influence of physical restraint on unplanned extubation of adult intensive care patients: a case-control study. Am J Crit Care, 2008; 17(5): 408–15; quiz 416.

40. Oliveira PC, et al. Incidence and primary causes of unplanned extubation in a neonatal intensive care unit. Rev Bras Ter Intensiva, 2012; 24(3): 230–5.

41. Mehta NM, Sharma S, Laussen PC. Unplanned extubation: securing the tool of our trade. Intens Care Med, 2015; 41(11): 1,983–5.

42. Murdoch E, Holdgate A. A comparison of tape-tying versus a tube-holding device for securing endotracheal tubes in adults. Anaesth Intensive Care, 2007; 35(5): 730–5.

43. Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care, 2010; 14(1): 31–5.

44. Barnason S, et al. Comparison of two endotracheal tube securement techniques on unplanned extubation, oral mucosa, and facial skin integrity. Heart Lung, 1998; 27(6): 409–17.

45. Patient Safety Movement. Actionable Patient Safety Solutions. Challenge 8B: Unplanned Extubation, https://patientsafetymovement.org/actionable-solutions/challenge-solutions/airway-safety/unplanned-extubation/. 

46. Hampson J, et al. Impact of the introduction of an endotracheal tube attachment device on the incidence and severity of oral pressure injuries in the intensive care unit: a retrospective observational study. BMC Nurs, 2018; 17: 4.

47. Artime CA, Hagberg CA. Tracheal extubation. Respir Care, 2014 Jun; 59(6): 991–1,002; discussion 1,002–5.

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. 

 

Back to Top