Accidental Extubation

Accidental extubation occurs most commonly when 1 or more of the following conditions
exist:
Risk factors
1. Persistent chewing or “mouthing” the tube.
2. Prolonged intubation.
3. ET tube is “high”
4. Airway pressures/PEEP are high.
5. Baby is having good weight.
6. Patient is agitated and/or loosely restrained.
7. Excessive oral secretions.
8. The patient is being turned or moved.
Recognition
Clinical indicators
1. Gross air leak occurs from the mouth (or the cry is audble).
2. Airway pressures change abruptly (higher or lower). (This may not be evident in PCV)
3. Exhaled tidal volume decreases or becomes erratic.-Note: an ET tube in the
esophagus will return a Vt.
4. Patient becomes agitated and may not be able to trigger the ventilator.
5. SpO2 falls by >3 - 5% ( or > 90% for < 1 min.)
6. HR and or BP increase or decrease (but not at first)
7. Chest movements are not visible or not rhythmic
8. ETCO2 monitor shows

Response
If a partial or accidental extubation is suspected, a rapid response is vital.
Re-intubate &position it at the previous cm markings at the teeth.
Verify tracheal intubation with a CO2 detector.
Assessment of ET Tube Placement
1. Breath Sounds - UNRELIABLE - Pt’s with esophageal intubation may have “normal”
breath sounds. Breath sounds are unreliable in ELBWs, severe HMD, or
subcutaneous emphysema.
 2. Tidal Volume & PIP - UNRELIABLE - Vt and Pip may be erratic due to agitation &
gastric ventilation.
3. ETT Tube Position and/or CXR - UNRELIABLE -Neither confirm tracheal placement.
4. Chest Wall Movement -UNRELIABLE-difficult to make out subtle differences esp in
ELBWs
5. HR & SPO2 Changes & ETCO2 detector - RELIABLE -

Always confirm tracheal placement promptly with an ETCO2 detector

If there is no indication of exhaled CO2, remove the tube and mask ventilate( donot allow
the Spo2 to drop to below 85% & reattempt(attempt duration <20 secs) if possible by more
experienced team member.
Prevention
1. Secure taping
2. Tying
3. ETT place holders -neofit

4.

5. neobar
6. preventing agitation – nursing in thermoneutral zone, adequate sedation & analgesia for
procedures,clearing secretions frequently, minimum handling, settings to ensure
ventilator-baby synchrony
7. surveilence by staff
8. standardized protocol for care of ventilated babies