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Year : 2019  |  Volume : 68  |  Issue : 3  |  Page : 346-350

Incidence, risk factors, and consequences of unplanned extubation

Department of Chest, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission26-Oct-2018
Date of Acceptance01-Jan-2019
Date of Web Publication4-Sep-2019

Correspondence Address:
MD Ahmad Abbas
Port Said Street, Mit-Ghamr 35611, Dakahlia Governorate
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejcdt.ejcdt_165_18

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Background Unplanned extubation (UE) is associated with prolonged duration of mechanical ventilation and ICU and hospital stay. Although UE has been studied regularly, many questions about incidence, determinants, and outcomes have not been answered in details. Moreover, inconsistent findings exist regarding outcomes. This study aimed at defining risk factors associated with UE with respect to consequences in relation to reintubation and mortality.
Patients and methods Invasively mechanically ventilated patients were enrolled and classified into planned extubation and UE groups according to the type of extubation. All patients were subjected to calculation of Simplified Acute Physiology Score on admission and Glasgow Coma Score, observed for presence of agitation, wrist restrains, use of sedation, and degree of sedation using Ramsay Sedation Score. Duration of mechanical ventilation before UE, patient-to-nurse ratio, timing of UE, total ICU length of stay, and mortality were recorded. Satisfaction question was applied to both responsible nurse and resident.
Results Overall, 11.02% of the studied patients experienced UE. UE was more prevalent in patients who were physically restrained, agitated, less sedated, with lower Ramsay score, and with unsatisfied loaded nurses and junior resident who were unsatisfied. In all, 55.6% of UE occurred in night shifts. UE had prolonged length of stay (13.28±3.92 days), higher reintubation rate (44.5%), and higher mortality (29.6%).
Conclusion This work identified four independent risk factors for UE: agitated patient, managed by a junior resident and loaded nurse particularly in a night shift.

Keywords: mortality, reintubation, unplanned extubation

How to cite this article:
Abbas A, Lutfy SM. Incidence, risk factors, and consequences of unplanned extubation. Egypt J Chest Dis Tuberc 2019;68:346-50

How to cite this URL:
Abbas A, Lutfy SM. Incidence, risk factors, and consequences of unplanned extubation. Egypt J Chest Dis Tuberc [serial online] 2019 [cited 2019 Oct 15];68:346-50. Available from: http://www.ejcdt.eg.net/text.asp?2019/68/3/346/266022

  Introduction Top

Planned extubation (PE) refers to endotracheal tube (ETT) removal by a physician or nurse according to a schedule or protocol. In contrast, unplanned extubation (UE) is defined as accidental or patient-induced ETT removal and occurs in 3–16% of patients on mechanical ventilation (MV) [1],[2],[3],[4],[5],[6]. This variation depends on patient characteristics, the characteristics of the ICUs surveyed, and the duration of MV of the patients. Furthermore, experiencing an UE is associated with prolonged duration of MV, ICU stay, and hospital stay [7].

Reasons for self-extubation include discomfort or pain caused by the artificial airway, and anxiety owing to patients’ inability to talk or breathe on their own. Accidental extubation is attributed either to personnel’s inappropriate manipulation of the tube during patient care or to a nonpurposeful patient’s action, for example, coughing [8],[9].

UE can provoke injuries of the upper respiratory tract, aspiration of gastric or tracheal substances, and severe hypoxia consequent to respiratory failure. In addition, complications such as a failure to reintubate, acute respiratory failure, healthcare-associated pneumonia, and infection occur frequently in patients requiring reintubation [10].

Although UE has been studied regularly, many questions about incidence, determinants, and outcomes of UE have not been answered in all detail. Moreover, inconsistent findings exist, especially with respect to outcomes after UE, with some authors reporting improved outcomes after UE [11]. This study aimed at defining risk factors associated with UE and highlightening consequences of such event in relation to reintubation and mortality.

  Patients and methods Top

This study was carried out in Respiratory ICU, Zagazig University, from March 2016 to June 2018. This study was approved by IRB- Zagazig University Ethical Committee. Written informed consent was obtained from patient’s relatives.

Patients who were invasively MV during period of the study were enrolled .They were classified according to the type of extubation into two groups: PE group, which fulfilled weaning criteria and tolerated 2-h spontaneous breathing trial through T-tube without signs of distress and followed by extubation [12], and UE group (whether accidental or self-removed). Patients with tracheostomy or refusing to participate were excluded.

All the following variables were assessed:
  1. Calculation of Simplified Acute Physiology Score II on admission [13].
  2. Assessment of Glasgow Coma Score each shift [14].
  3. Assessment of agitation (defined as excessive nonpurposeful motor activity) [15].
  4. Reporting use of sedatives. The use of sedation was considered positive when sedative drug was used more than 24 h [16].
  5. Degree of sedation using Ramsay Sedation Scoring System [17].
  6. Presence of any physical restrains (Wrist restrains).
  7. Duration of MV before UE.
  8. Nurse-to-patient ratio at the time of event.
  9. Whether the resident on duty was junior or senior.
  10. Satisfaction question was applied to both responsible nurse and resident. Parameters of satisfaction included financial issue, ability to choose day off, availability of ICU resources, conflicts with other staff, and schedule load. Score ranged from 0 to 5 according to number of parameters fulfilled.
  11. Recording timing of UE.
  12. Type of UE either self-inflicted or accidental and the need for reintubation.
  13. Total ICU length of stay (LOS).
  14. Mortality.

Statistical analysis

Categorical variables were shown as number (%) and continuous variables were shown as the mean (SD). Independent samples Student’s t-tests were used to compare between two groups of normally distributed data. Pearson’s χ2-test was used to compare percentage of categorical variables. Risk estimation [odds ratio (OR) and their 95% confidence interval] was done by binary logistic regression. All tests were two sided. A P-value less than 0.05 was considered significant. All statistics were performed using SPSS 22.0 for Windows (Microsoft Corp., Redmond, Washington, USA).

  Results Top

A total of 245 MV patients were enrolled, with mean age of 57.46±1.4 years. Overall, 55.1% were males. In all, 218 (88.97%) patients had PE, whereas 27 (11.02%) patients experienced UE. [Table 1] and [Table 2] show that UE was more prevalent in patients who were physically restrained (P<0.001), agitated (P<0.001), less sedated (P=0.002), lower Ramsay score (P<0.001), had unsatisfied nurses (P=0.004) who managed more patients (nurse-to-patient ratio, P<0.001), and junior resident (P=0.003) who were unsatisfied (P=0.01). More than 50% of UE events occurred in night shifts (P<0.001). Multivariate logistic regression of potential predictors of UE revealed four independent predictors: agitation (OR=1.7, P<0.001), high patient-to-nurse ratio (OR=1.05, P=0.002), night shifts (OR=1.8, P=0.003), and junior responsible residents (OR=1.4, P=0.06). [Table 2] Consequences of UE are evaluated in ([Table 3]). UE (in comparison to PE) had prolonged LOS (13.28±3.92 vs. 11.87±2.47 days, P<0.001), higher reintubation rate (44.5 vs. 13.7%, P<0.001), and higher mortality (29.6 vs. 5.05%, P<0.001).
Table 1 Comparison between both groups regarding different risk factors

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Table 2 Multivariate logistic regression of potential predictors of unplanned extubation

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Table 3 Consequences of unplanned extubation

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  Discussion Top

This work reported 11% incidence of UE (27 patients out of 245). The incidence of UE among intubated patients is reported to vary from 0.3 to 14% [18],[19].

The variation of reported incidence may be owing to different indicators used to define UE incidence, different patient characteristics, and severity of illness, with varied incidence between medical ICUs and surgical ICUs. The elective nature of some surgical procedures to patients entering surgical ICUs tends to make them better prepared for admission and thus may be weaned more optimally [20],[21],[22].

Growing reports clarifying different possible risk factors of UE include patient-related risk factors and medical staff-related or ICU-related risk factors, for example, agitation, use of physical restraints, use of sedation and its effectiveness, job satisfaction, and loaded ICU schedules [22],[23],[24],[25],[26].

In this work, UE is more frequent in agitated patients (63 vs. 39.9%), physically restrained (66.7 vs. 22%), with less use of sedation (33.3 vs. 63.3%), or ineffective sedation detected by lower Ramsay score (1.49±0.75 vs. 3.01±1.03).

In agreement with this study, Phoa et al. [26], Birkitt et al. [24] and Elmetwally et al. [27] found agitation in 75, 60, and 72.5% of their studied UE patients, respectively. Agitation is the most important patient-related factor associated with significantly higher risk for UE [8],[23],[28],[29],[30].

More than half of patients may manifest agitative behavior during ICU stay, which includes alertness or restlessness and can be present for a long period preceding UE. The main cause of agitation in critically ill patients includes inability to communicate, continuous stimulation with noise (e.g. equipment’s alarms), lack of mobility, sleep deprivation, and some treatable causes such as electrolyte disturbance and ICU psychosis [26],[30],[31].

Beyond agitation, UE incidence depends on patients’ consciousness level, being higher in those with Glasgow Coma Scale score of 9–15 points. It was reported that only 37% of UE patients were sedated, whereas in PE patients, the ratio reached 76%. Moreover, there was a lower Ramsay score in UE compared with PE group (1.56±.35 and 2.98±1.4, respectively) [15],[20].

In respect to physical restraints, hand restrains may increase the ability to develop UE by increasing the anxiety of the patients owing to impossibility of expressing their selves by gestures or in writing. Moreover, restraints mean in most conditions that the patient is agitated, and the patient can remove the ETT tube by moving his/her hand to reach and pull out the tube [15],[25].

As work environment stands to reason for adverse ICU outcomes, our study supported that theory. In UE group, both responsible resident physicians and nurses were less satisfied with their job, and also high patient-to-nurse ratio was associated significantly with UE (more patients were cared by one nurse). Job satisfaction was assessed by satisfaction question (are you satisfied with your job?). Items of satisfaction included financial issues, ability to choose days off, how loaded is your job schedule, conflicts with other ICU staff, and availability of ICU resources.

It was stated that the frequency of UE increases when nurse staffing was reduced. Indeed, the busier is the nurse, the less concentration and attention to patients [2],[32].

The most commonly used unit-level workload measure is the nurse-to-patient ratio. The nurse–patient ratio can be used to compare units and their patient outcomes in relation to nursing staffing. Regarding improving patient care, it should increase the number of nurses in a unit or decrease the number of patients assigned to each nurse. Most adverse outcomes occurs when nurse-to-patient ratio is more than three patients for each nurse [33]. Indeed job dissatisfaction and heavy working schedules with limited resources are associated with poor performance, and when it comes to critical care setting, this may lead to adverse outcome, including UE, and may reach to patient mortality.

In respect to timing of extubation, more than half of UE events occurs in night shift, which is in agreement with previous reports [25],[34]. The distraction of nurses may be more in mid and night shifts because nurses had more additional jobs like answering questions to the relatives about the current state of their related patients and the expected prognosis in addition to the deficient number of nursing in these shifts; moreover, night shifts may increase the anxiety of already agitated patient by sleep deprivation and equipment alarms. In contrast, Chevron et al. [25] in their study found the time between 7 : a.m. and 7 : p.m. is the rush hour of developing UE, and they explained this observation by the fact that this is the period when the ICU is the busiest, and the nurses may be distracted from their frequent monitoring of the intubated patients by other duties.

In this work, the responsible physician in 66.7% of UE event was a junior staff. It is possible that caregivers with less seniority are still learning to cope with high workload demands when faced with stressors and less able to schedule days off or asked to work more night shifts, which may have led to the higher frequency of UE and other ICU-related adverse events. There is an association between ICU complications (including UE) and years of working experience. Some results have indicated that experienced staff became more skilled and committed to their work, therefore staying more calm and controlled when facing unpredictable situations and feeling more successful in their profession.

This work identified four independent risk factors for UE: an agitated patient who was managed by a junior resident physician in ICU with high patient-to-nurse ratio especially in night shifts was more likely to experience UE.

Outcome of UE was evaluated in relation to reintubation and further for mortality. UE (in comparison with PE) had prolonged LOS (13.28±3.92 vs. 11.87±2.47 days, P<0.001), higher reintubation rate (44.5 vs. 13.7%, P<0.001) and higher mortality (29.6 vs. 5.05%, P<0.001). Premature cessation of ventilator support in patients with failed UE may yield a deterioration of respiratory functioning and hypoxemia; moreover, it may cause upper airway injuries, aspiration of oral and gastric secretions, and fatal arrhythmias [20]. The second intubation is often difficult and forcible, and this may lead to oral complications such as injury to the teeth, lips, gums, and tongue. Moreover, the patients needing reintubation had significantly increased duration of MV as well as ICU and hospital LOS and mortality. The reported mortality rates in patients with extubation failure vary between 30 and 40% [35],[36].

  Conclusion Top

The reported incidence of UE in this work was 11%. This work identified four independent risk factors for UE. A patient who is agitated managed by a junior resident physician in ICU with high patient-to-nurse ratio especially in night shift is more likely to experience UE. Further studies should be implemented to identify predictors of reintubation in UE to help in reducing adverse outcome and mortality.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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