Management of a Partial or Inadvertent Extubation A Multi-Disciplinary Clinical Competency

1. Management of a Partial or Inadvertent ExtubationA Multi-Disciplinary Clinical Competency New England Medical Center Respiratory Care Programs Rev 3 04-24-01

2. Inadvertent Extubation: Target Population Partial or accidental extubation occurs most commonly when one or more of the following conditions exist: • Persistent chewing or “mouthing” the tube. • Prolonged intubation. • ET tube is “high” ( 4 cm  the carina in adults). • Airway pressures/PEEP are high. • Patient is morbidly obese. • Patient is agitated and/or loosely restrained. • Excessive oral secretions. • The patient is being turned or moved.

3. Inadvertent Extubation: Clinical Scenario The clinician may observe the following circumstances preceding a partial or accidental extubation: • The tube may be being manipulated or is unstable. • The patient may cough or exhale forcefully. • Patient being turned for CPT, bath, or other reason. • The head may tip back (chin up). • The ET tube tip follows the chin and may move 2 cm up with chin up and 2 cm down with chin down. • The tube may be curled in the oral pharynx. • It may appear to be correctly placed at the teeth.

4. Inadvertent Extubation: Recognition • Gross air leak occurs from the mouth (or the patient speaks). • Airway pressures change abruptly (higher or lower). (This may not be evident in PCV/BiLevel mode) • Exhaled tidal volume decreases or becomes erratic. • Note: an ET tube in the esophagus will return a Vt. • Patient becomes agitated and may not be able to trigger the ventilator. • SpO2 falls by  3 - 5% ( or > 90% for < 1 min.) • HR and /or BP  or  (but not at first).

5. Inadvertent Extubation: Response If a partial or accidental extubation is suspected, a rapid response may be vital. • Re-intubate: Deflate the cuff & attempt to advance the ET tube back into the trachea. • Position it at the previous cm markings at the teeth. • Verify tracheal intubation with a CO2 detector. • Breath sounds are not a reliable indication of tracheal intubation. • If there is no indication of exhaled CO2, remove the tube and mask ventilate. • Call 6-5555 & page “Anesthesia STAT”

6. Inadvertent Extubation:Assessment of ET Tube Placement Many assessments provide false or unclear information • Breath Sounds - UNRELIABLE - • Pt’s with esophageal intubation may have “normal” breath sounds. • Breath sounds are unreliable in pts with morbid obesity, severe COPD, asthma, or subcutaneous air. • Tidal Volume & Pip - UNRELIABLE - • Vt and Pip may be erratic due to agitation and gastric ventilation. • ETT Tube Position and/or CXR - UNRELIABLE - • Neither confirm tracheal placement. • Chest Wall Movement - UNRELIABLE - • HR & BP Changes - UNRELIABLE - • These parameter changes may be slow.

7. Inadvertent Extubation: Assessment • If a partial or accidental extubation is suspected and you re-intubate (push the ETT tube back in) the “Gold Standard” assessment is to: confirm tracheal placement promptly with an ETCO2 detector.

8. Inadvertent Extubation: Mask Ventilation • Consider mask ventilation with the ventilator. • Capture the patient’s RR and Itime -   flowrate •  flow-by/use flow triggering for leak compensation •  the patient to sitting position if tolerated. If using a Self-inflating Resuscitator • Use two people to ventilate: • One holds on the mask • One squeezes the resuscitator