1. Ihlenfeld, Janet T. PhD, RN

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Sadowski R, Dechert RE, Bandy KP, et al. Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit. Pediatrics. 2004;114: 628-632.


Children who experience unplanned extubations (UEX) are at risk for developing serious consequences from the incident. Owing to the serious nature of the injury or illness that led to their intubation and need for mechanical ventilation, the sudden elimination of that airway poses a danger to the children in the pediatric intensive care unit. This 5-year prospective study investigated the factors relating to UEX and the outcomes of the children who experienced UEX, which was defined as the sudden dislodgement of the endotracheal tube (oral, nasal, tracheal, or tracheostomy).


From July 1996 through June 2001, all children admitted to the pediatric intensive care unit (PICU) in one hospital center were followed for UEX. Data were collected once an UEX occurred; over that time period there were 2192 children intubated and 141 of those experienced one or more UEX. Following each UEX, data were collected on the demographics of the child as well as the illness, activities that were occurring at the time of the extubation, and the consequences of the event. Other important variables gathered were the length of time on mechanical ventilation and the length of stay in the PICU.


Over the 5 years, data were gathered during the first and second years, a weaning plan policy was instituted in the third year, trends were assessed during the fourth year, and follow-up data were gathered in the fifth year.


The data showed that children who accidentally extubated were younger (less than age 5), were medical patients, were sicker, and were on ventilators longer than those who did not have an unintended extubation. A vast majority of the incidents (74%) occurred because the child did something to cause the extubation.


When looking at whether reintubation was required, 52% of the children had to be reintubated, mostly because they were on sedating medications that inhibited their respiratory states, or who had been on ventilators for a long period of time. However, 48% of the children did not need to be reintubated, indicating that they could have been successfully weaned from the ventilator prior to the incident.


The researchers concluded that the youngest and sickest pediatric patients tended to have UEX, probably due to their developmental status and the use of uncuffed endotracheal tubes in pediatrics making it easier for the tubes to be dislodged. Also, since almost half of the children did not have to be reintubated suggests that many children are left on mechanical ventilation longer than needed. Further research in this area is warranted.