Self/Unplanned Extubation

Safety, Surveillance, and Monitoring of the Mechanically Ventilated Patient

For some must watch, while some must sleep.

                       William Shakespeare, “Hamlet”

The goals of health care professionals seem simple; provide quality care while preserving patient safety and well-being. For this goal to be possible, corrective and preventive measures to assure patient safety must be developed; in other words, protecting the patient against possible injury and negative outcomes.

Problems associated with mechanical ventilation (ie, ventilator-induced lung injury, barotrauma, volutrauma, atelectrauma, biotrauma, oxygen toxicity, and ventilator-associated pneumonia) have been well-studied. Achieving the goal of maintaining airway patency and assuring adequate oxygenation and ventilation is sometimes disrupted, resulting in one of the least desirable outcomes, premature loss of airway due to unplanned extubation (UE).

UE is a serious concern to health care providers in the intensive care unit (ICU). UE is defined as a premature removal of the endotracheal tube (ETT)¹ by action of the patient (deliberate/self-extubation) or inadvertently during nursing care and manipulation of the patient.² UE is an event often considered to be an indicator of quality of care of mechanically ventilated patients.³ UE often leads to adverse effects such as tracheal/laryngeal spasm or injury, inducing pulmonary or cardiac failure.⁴

The incidence of UE is reported to vary from .1 to 3.6 events per 100 events per 100 intubation days.⁵ Of the UEs studied, deliberate self-extubations per 100 intubation days accounted for the majority of unplanned extubations, occurring at a rate of 50 to 100 unplanned extubations per 100 ventilated patients.⁵ In one study, inadvertent/accidental UEs accounted for approximately 10% (range 3%–6%) of the cases.⁶ Of these UEs, 60% of the cases required reintubation.^3,7

There are numerous factors that have been shown to contribute to UE (self or inadvertent) including the location and cultures of the hospital. In a review of studies in the 1990s, UE was reported to be dependent on factors such as nursing care, timing of restraints, patient’s level of consciousness, use of sedation, distribution of nursing labor, working hours, the physical setup of the ventilator, and delayed extubation.⁸ A separate study of UEs in 122 patients showed that 55% of the patients were conscious, 68% of the patients were restrained. 46% of the patients required reintubation, and 7.3% of the patients incurred adverse effects, such as difficulties in intubation and tracheal spasm after UE.⁴ An extensive review was performed of international and local studies. In a study of 139 patients in southern Taiwan, many factors were found to result in increased risk for UE such as gender, age, types of illness, duration of intubation, level of consciousness at extubation, anatomic route of intubation (oral greater than nasotracheal), use of restraints, and use of sedatives.³ This study also identified a rate of UE at 6.4%. It was recommended that the medical provider and nurse should fully evaluate a patient’s oxygenation status, decrease the length of the weaning for possible extubation, and remove the ETT promptly when extubation criteria are met.³ Additionally, patients who are in the process of being weaned from the ventilator are more likely to sustain UE. Of noted importance, multiple investigators documented that UE was associated with prolonged duration of mechanical ventilation, ICU stay, and hospital stay compared with patients not having experienced UE.^3,7,9,10

Prevention of Unplanned Extubation

Patient Screening for Risk Factors

Given the numerous risk factors that can lead to UE, it is vital to develop a screening tool for mechanically ventilated patients to identify patients who are at increased risk. Early identification and treatment of modifiable factors may potentially lead to decreased incidence of UE and subsequently enhance quality of care.

A risk assessment tool (Fig. 1), called the Self-Extubation Risk Assessment Tool (SERAT) developed based on Bloomsbury Sedation Score and Glasgow Coma Scale (GCS) has been shown to have100% sensitivity and negative predictive values and 79% specificity.¹³ This tool was therefore very good at identifying patients at risk for UE. However, it also had a high number of false-positives, which could lead to invasive therapies for patients who screened positive and might not necessarily go on to have UE. The SERAT tool in combination with early screening for factors noted by Fang and colleagues⁸ could possibly be used in future research to develop a tool with both negative and positive predictive abilities.

Fig. 1 Self Extubation Risk Assessment Tool (SERAT).

(From 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; with permission.)

Analgesia and Sedation

ICU patients typically have physical discomfort and anxiety related to multiple sources including disease physiology, invasive procedures, monitoring or therapeutic devices, nursing and respiratory care procedures, as well as prolonged immobility. Uncontrolled pain and anxiety have many negative effects on quality of care, including increased agitation and incidence of UE.¹⁴ The goals of analgesia and sedation must be clearly established for each patient to ensure consistency among caregivers.

Current analgesia guidelines from the American College of Critical Care Medicine are summarized as follows¹⁴:

• Pain and response to analgesic therapies should be assessed via patient reporting on a numeric rating scale (0–10). For patients who cannot communicate, a subjective behavioral/physiologic rating tool should be used.

• Nonpharmacologic analgesic strategies (including heat/cold, massage, optimal positioning, and elimination of unnecessary devices, alarms, lights, noises, and so forth) should be used whenever possible to supplement pharmacologic analgesia such as including acetaminophen, nonsteroidal antiinflammatory drugs (NSAIDs), and opioids.

• Scheduled medication doses or a continuous infusion are preferable to “as-needed” dosing to ensure consistent analgesia.

• A patient who has the capacity to understand and operate a patient-controlled analgesia device will likely experience good quality of analgesia, less sedation, and less opioid consumption.

• NSAIDs or acetaminophen may be used as adjuncts to reduce overall opioid requirements.

Agitation and anxiety are commonly experienced by the patient requiring mechanical ventilation, affecting up to 50% to 74% of patients.^15,16 Agitation has been found to be a characteristic of patients with UE.^1,2,17,18 Frequent sources of anxiety in critically ill patients are related to an inability to communicate, lack of control, emotional distress regarding medical condition, unfamiliar noises and personnel, excessive stimulation, inadequate analgesia, frequent medical and nursing interventions, lack of mobility, and sleep deprivation. Administration of anxiolytics and sedating medications such as benzodiazepines, propofol (Diprivan), and dexmedetomidine (Precedex) are effective in relieving symptoms of anxiety and agitation.¹⁴ Avoiding oversedation should be made a priority because it has been associated with prolonged mechanical ventilatory support, increased ICU length of stay, increased incidence of nosocomial infections, increased need for diagnostic testing, and overall increase in health care costs.¹⁹ The practice of using intermittent, as-needed, boluses of sedation is a common factor in UE, and it has been shown that sedation and analgesia administered via continuous infusion may prevent UE in intubated patients who are alert.²⁰

Nurse-driven sedation protocols based on frequent use of validated assessment tools such as the Ramsay Scale, Riker Sedation-Agitation Scale, Motor Activity Assessment Scale, and so forth, improve patient outcomes by reducing oversedation, duration of ventilator support, ventilator-associated pneumonia, and ICU length of stay.^19,21 Powers²² showed that the use of a sedation protocol based on the Ramsay Scale significantly reduced UE.

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