2015 Summer Neonatal-Pediatrics Section Bulletin

Summer 2015 Neonatal-Pediatrics Section Bulletin

Natalie Napolitano, MPH, RRT-NPS, FAARC
The Children’s Hospital of Philadelphia
Philadelphia, PA 19104
Jenni L. Raake, RRT
CICU Clinical Manager
Children’s Hospital Medical Center
3333 Burnet Ave
MLC 1002
Cincinnati, OH 45229
(513) 636-4060
Jenni.RAAKE@cchmc.orgLisa Tyler, MS, RRT-NPS, CPFT
The Children’s Hospital of Philadelphia
Philadelphia, PA 19104
In this issue:

Notes from the Chair

Natalie Napolitano, MPH, RRT-NPS, AE-C, FAARC

As you all read this, I will have recently returned from the AARC Summer Forum and Board of Directors meeting. The board is working hard on the new strategic plan and plans to deliver the services and benefits our membership and profession need and want. As your representative for those caring for our pediatric patients, I am ensuring that the needs of our patients and our specialty are heard. As one of the largest sections in the AARC, we have quite a voice! Please keep sending me your questions, concerns, and ideas.

AARC Elections will be starting soon. We will be electing a new chair-elect and there will be two great candidates on the ballot for you to choose from, so please take the time to vote.

I look forward to seeing you all again at AARC Congress 2015 in Tampa, FL, Nov. 7-10. We are anticipating another lively section meeting, Sunday, Nov. 8, 9:35-10:05 a.m., and I hope everyone who comes to the Congress will attend.

Unplanned Extubations in Neonatal and Pediatric Patients

Jenni L. Raake, MBA, RRT-NPS, FAARC

Unplanned extubation is defined as “displacement or removal of the endotracheal tube (ET Tube) at a time other than that specifically chosen” and is considered an adverse event.”1 Adverse events that occur during an unplanned extubation can range from mild hypoxia/hypercarbia to sudden death. Efforts to reduce unplanned extubations must occur in order to improve patient outcomes.


Unplanned extubation rates range from 0.11 to 4.36 events per 100 airway days.2 According to national standards, an acceptable rate would be 1.0 unplanned extubations per 100 ventilated days.3 In the pediatric population, younger patients are likely to have a higher unplanned extubation rate than older patients.4 In neonates, the likelihood of an unplanned extubation is even higher — three times higher than in adults — possibly due to patient activity and less use of sedative or paralytic agents.5

Unplanned extubations can occur at any time. Some studies show rates are highest on the night shift, when fewer staff are on duty, followed by the day shift, when multiple activities are taking place. The evening shift has the lowest rate of unplanned extubations.6

Contributing factors

When reviewing unplanned extubations, it is important to identify the issues that surrounded the untoward event so prevention measures can be initiated. Statistics indicated that inadequate staffing has the highest association with unplanned extubations.7-8 Other identified factors include: copious secretions that cause the tape to lose its integrity, difficulty in fixating a securement device due to small features (especially in premature infants), inadequate sedations, inadequate restraints, malposition of the ET tube, inattentive support staff who may not notice that their activity with the patient is placing tension on the ET tube, and patient transport off the unit for a procedure.9-10


Unplanned extubations are rarely benign events. Complications that occur can include: hypoxemic events; injury to the pharynx, larynx, and vocal cords; increased likelihood of acquiring a ventilator associated respiratory infection; and potential for sudden death due to loss of a secure airway.11-12

Not every unplanned extubation results in a patient free from an artificial airway. Nearly one-fourth of patients who experience an unplanned extubation require reintubation.13 And for children who experience an unplanned extubation, there is a greater chance that they will endure mechanical ventilation for twice as long as their counterparts who did not suffer from an unplanned extubation. Their stay in the ICU is likely to double as well.6

Additionally, the act of re-establishing an airway can be challenging. Neonatal and pediatric patients have smaller airways than adults, requiring extra attention to detail during the process. There is also a higher likelihood of airway swelling, which creates an even greater challenge with ET tube placement. Sometimes this requires a smaller ET tube to be placed than the one that was inadvertently removed. Smaller ET tubes can be problematic during mechanical ventilation due a greater chance of air leak around the smaller tube.

Prevention strategies

Standardized care bundles are utilized by many hospitals across the country to improve patient outcomes.14 Establishing care bundles for unplanned extubations requires a two-fold approach: education and consistency in care.

Education should focus on all bedside providers: nursing, respiratory therapy, physicians, and any other disciplines that may be performing patient care. The education needs to reinforce the risks of an unplanned extubation along with mitigation strategies that include assessment of sedation levels, assessment of ET tube security, ET tube/ventilator circuit positioning, and appropriate interventions such as application of restraints and neutral head positioning during an x-ray to assess ET tube placement.

The second portion of the bundle should have a two-fold focus on interventions. First up are sedation protocols.15 These permit the bedside nurse to adjust sedatives to maintain appropriate levels, keeping the patient from self-extubating. The other intervention involves getting caregivers to secure the ET tube in a consistent fashion. Consistency in the application of the tape or other securement device should be instituted. Additionally, scheduled and PRN retaping should be considered to ensure the ET tube integrity remains intact.16


ET tube security is vital to patient outcomes. Unplanned extubations pose a risk to neonatal and pediatric patients. Initiatives to mitigate risks should be instituted to improve patient outcomes.


  1. Kurachek SC, Newth C, Quasney M, et al., Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 2003;31(11):2657-2664.
  2. Chevron V, Menard J, Richard J, Girault C, Leroy J, Bonmarchand G. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med 1998;26(6):1049-1053.
  3. Frank BS, Lewis RJ. Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries. Peds Pulmonology 1997;23(6):424-428.
  4. Scott PH, Eigen H, Moye LA, et al. Predictability and consequences of spontaneous extubation in a pediatric ICU. Crit Care Med 1985;13:228-232.
  5. Veldman A, Trautschold T, Weis K, Fischer D, Bauer K. Characteristics and outcome of unplanned extubation in ventilated preterm and term newborns on a neonatal intensive care unit. Peds Anesthesia 2006;(16):968-73.
  6. Sadowski R, Dechert R, Bandy K, Juno J, Bhatt-Mehta V, Custer J, Moler F, Bratton S. Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit. Pediatrics 2004;114(3):628-632.
  7. Marcin J, Rutan E, Rapetti P, Brown J, Rahnamayi R, Pretzlaff R. Nursing staff and unplanned extubation in the pediatric intensive care unit. Peds Crit Care Med 2006;6(3):254-257.
  8. Ream R, Mackey K, Leet T, Green C, Andreone T, Loftis L, Lynch R. Association of nursing workload and unplanned extubations in a pediatric intensive care unit. Peds Crit Care Med 2007;8(4):366-371.
  9. Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001;120:1262-1270.
  10. Kapadia FN, Bajan KB, Raje KV. Airway accidents in intubated intensive care unit patients: an epidemiological study. Crit Care Med 2000;28:659-664.
  11. Betbese A-J, Perez M, Bak E, Rialp G, Mancebo J. A prospective study of unplanned endotracheal extubation in intensive care unit patients. Crit Care Med 1998;26(7):1180-1186.
  12. de Lassence A, Alberti C, Azoulay E, 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;97:148-156.
  13. Listello D, Sessler CN, Unplanned extubation: clinical predictors for reintubation. Chest 1994;105(5):1496-1503.
  14. Rachman B, Watson R, Woods N, Mink R. Reducing unplanned extubations in a pediatric intensive care unit: a systematic approach. Int J Peds;2009:1-5.
  15. Marx CM, Smith PG, Lowrie LH, et al., Optimal sedation of mechanically ventilated pediatric critical care patients. Crit Care Med 1994;22(1):163-170.
  16. Da Silva L, Sergio P, de Carvalho W. Unplanned extubations in pediatric critically ill patients: a systematic review and best practice recommendations. Peds Crit Care Med 2010:11(2):287-294.

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