Unplanned Extubation in Neonatal Intensive Care Unit: A Systematic Review, Critical Appraisal and Evidence-Based Recommendations

Objective: The purpose of this study was to update the state of knowledge on unplanned extubations (UEs) in neonatal intensive care units (NICUs). This review focuses on the following topics: incidence, risk factors, reintubation after UE, outcomes, and prevention. Material and Methods: Electronic databases were searched for relevant publications from January 1, 1950 through January 30, 2012 on the MEDLINE, EMBASE, CINAHL, Scielo, Lilacs, and Cochrane systems. Fifteen articles were selected for data abstraction. . The search strategy included the following key words: “unplanned extubation,” “accidental extubation,” “self extubation,” “unintentional extubation,” “unexpected extubation,” “inadvertent extubation,” “unintended extubation,” “spontaneous extubation,” “treatment interference,” and “airway accident.” Study quality was assessed using the Newcastle-Ottawa Scale (NOS). Grades of recommendation were assessed according to the Oxford Centre for Evidence-Based Medicine. Studies with NOS score ≥ 5 that included appropriate statistical were deemed of high methodological quality. Results: The overall mean NOS score was 3.5. All selected studies were classified as level 4 of evidence. UE rates ranged from 0.14 to 5.3 UE/100 intubation days or 1% to 80.8%. Risk factors included restlessness/agitation (13%-89%), poor fixation of endotracheal tube (8.5%-31%), tube manipulation at the time of UE (17%-30%), and performance of a patient procedure at bedside (27.5%-50%). One study showed that every day on mechanical ventilation increased UE risk 3% (relative risk 1.03, p < 0.01). The association between birth weight/gestational age and UE is controversial. Reintubation rates ranged from 8.3% to 100%. There is still a gap of information about strategies addressed to reduce the incidence of UE. Best methods of endotracheal tube securement remain a controversial issue. RESPIRATORY CARE Paper in Press. Published on December 27, 2012 as DOI: 10.4187/respcare.02164 Epub ahead of print papers have been peer-reviewed and accepted for publication but are posted before being copy edited and proofread, and as a result, may differ substantially when published in final version in the online and print editions of RESPIRATORY CARE. Copyright (C) 2012 Daedalus Enterprises Conclusions: Despite numerous publications on UE, there are few studies assessing preventive strategies for adverse events and a lack of randomized clinical trials. Recommendations are proposed based on the current available literature. RESPIRATORY CARE Paper in Press. Published on December 27, 2012 as DOI: 10.4187/respcare.02164 Epub ahead of print papers have been peer-reviewed and accepted for publication but are posted before being copy edited and proofread, and as a result, may differ substantially when published in final version in the online and print editions of RESPIRATORY CARE. Copyright (C) 2012 Daedalus Enterprises