Outcomes of Unplanned Extubations in a Large Children's Hospital

Cheryl L Dominick; Brooke N Blanke; Emily M Simmons; Danielle M Traynor; Madeline Fowler; Akira Nishisaki; Natalie Napolitano

doi:10.4187/respcare.10904

Outcomes of Unplanned Extubations in a Large Children's Hospital

Respir Care. 2024 Jan 24;69(2):184-190. doi: 10.4187/respcare.10904.

Authors

Cheryl L Dominick¹, Brooke N Blanke², Emily M Simmons², Danielle M Traynor³, Madeline Fowler⁴, Akira Nishisaki⁵, Natalie Napolitano²

Affiliations

¹ Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania. defalco@chop.edu.
² Department of Respiratory Care, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
³ Critical Care Center for Evidence and Outcomes, Pediatric Intensive Care Unit, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
⁴ College of Nursing and Health Professionals, Drexel University, Philadelphia, Pennsylvania.
⁵ Division of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

PMID: 38164617
PMCID: PMC10898459 (available on 2025-02-01)
DOI: 10.4187/respcare.10904

Abstract

Background: Unplanned extubation (UE) is defined as unintentional dislodgement of an endotracheal tube (ETT) from the trachea. UEs can lead to instability, cardiac arrest, and may require emergent tracheal re-intubation. As part of our hospital-wide quality improvement (QI) work, a multidisciplinary committee reviewed all UEs to determine contributing factors and evaluation of clinical outcomes to develop QI interventions aimed to minimize UEs. The objective was to investigate occurrence, contributing factors, and clinical outcomes of UEs in the pediatric ICU (PICU), cardiac ICU (CICU), and neonatal ICU (NICU) in a large academic children's hospital. We hypothesized that these would be substantially different across 3 ICUs.

Methods: A single-center retrospective review of UEs in the PICU, CICU, and NICU was recorded in a prospective database for the last 5 y. Consensus-based standardized operational definitions were developed to capture contributing factors and adverse events associated with UEs. Data were extracted through electronic medical records by 3 respiratory therapists and local Virtual Pediatric Systems (VPS) database. Consistency of data extraction and classification were evaluated.

Results: From January 2016-December 2021, 408 UEs in 339 subjects were reported: PICU 52 (13%), CICU 31 (7%), and NICU 325 (80%). The median (interquartile range) of age and weight was 2.0 (0-4.0) months and 5.3 (3.0-8.0) kg. Many UE events were not witnessed (54%). Common contributing factors were routine nursing care (no. = 70, 18%), ETT retaping (no. = 62, 16%), and being held (no. = 15, 3.9%). The most common adverse events with UE were desaturation < 80% (33%) and bradycardia (22.8%). Cardiac arrest occurred in 12%. Sixty-seven percent of UEs resulted in re-intubation within 72 h. The proportion of re-intubation across 3 units was significantly different: PICU 62%, CICU 35%, NICU 71%, P < .001.

Conclusions: UEs occurred commonly in a large academic children's hospital. Whereas UE was associated with adverse events, re-intubation rates within 72 h were < 70% and variable across the units.

Keywords: ICUs; airway extubation; critical care; intratracheal; intubation; neonatal ICU; pediatric ICU; pediatrics; risk factors.

MeSH terms

Airway Extubation* / methods
Child
Heart Arrest* / therapy
Humans
Infant, Newborn
Intensive Care Units, Neonatal
Intensive Care Units, Pediatric
Intubation, Intratracheal / adverse effects
Risk Factors