Unplanned extubation, a life-threatening complication, can occur at any time. We must have a high index of suspicion and be ready at all times. (Note, a version of this discussion appeared as part of the 2020 review article Boredom Interrupted: 10 Causes of Airway Complications and How to Avoid Them )
Case #1:
The 40 year-old man had Ludwig’s Angina. It is a serious and sometimes life-threatening cellulitis infection affecting the tissues of the floor of the mouth. It often occurs in an adult with a dental infection. This gentleman had swelling so bad that it was hard to tell where his chin ended and his neck began. He was a big man, well over 6 ft tall and 110 kg (240 lbs.).
After 5 mg of valium and 50 mcg of fentanyl and an aerosolized lidocaine/pontocaine mixture he was ready. We did not perform injected nerve blocks because of concern of injecting into infected tissue. We needed to be gentle to avoid rupturing an abscess into the oropharynx.
The nasal fiberoptic intubation went gratifyingly easily. The patient cooperatively took deep breaths on command as I pulled his tongue outward with a gauze pad. My resident expertly intubated him in less than 2 minutes.
We taped the tube. With the airway secure and the anesthetic proceeding uneventfully I left OR 3. I went to the adjacent OR 4 to see how my other resident was doing with his case. As I walked out, the surgeons were just starting to position the patient for surgery.
It wasn’t even three minutes before the door burst open. An RN yelled that they needed me stat in OR 3. Upon arrival I saw my resident mask ventilating our Ludwig’s Angina patient, the ETT on the ground. The surgeon had tripped over the anesthesia breathing circuit while turning the table and pulled the tube out. We had an unplanned extubation.
Normally we would have awakened him. We would then have redone the awake intubation. However, my resident had just paralyzed him with a long acting agent. Rapid reversal with Suggamedex was decades from being invented.
Instead, I inserted a lubricated nasal airway into the left nostril. Then, we connected an endotracheal tube adaptor to the airway. Next, we attached our breathing circuit to the adaptor. My resident ventilated, closing the patient’s mouth with his left hand while squeezing the bag with his right.
In the meantime I inserted a new endotracheal tube into the right nostril and repeated the fiberoptic visualization. With the mouth tightly closed, there was a fortuitous fold in the swollen tongue. It formed an open channel in the midline, leading straight to the larynx. I followed it down and reintubated the patient. We retaped the tube and this time we turned the table for the surgeon, while holding the tube securely. The rest of the case was uneventful.
Find a more detailed description of this intubation technique here.
Case #2:
The 66 year-old male patient was prone, with his head secured in tongs, undergoing posterior cervical laminectomy. About halfway through the procedure a large leak was noted around the endotracheal tube. Checking showed that the tape holding the endotracheal tube in position was saturated with saliva draining from the patient’s mouth. It had released and the cuff was visible inside the mouth. My partner’s patient had an unplanned extubation!
My partner alerted the surgical team. They called for help. The circulating nurse brought the gurney into the OR in case we needed to turn the patient. However, turning the patient would require releasing the tongs and exposing the patient’s neck to movement at a critical juncture.
My partner slipped a Laryngeal Mask airway into the patient’s mouth. Fortunately ventilation was easy. The anesthesia team that responded to his call for help brought the difficult airway cart and the fiberoptic bronchoscope. Using the LM airway as a guide, he successfully reintubated the patient using the fiberoptic bronchoscope. He chose to leave the LM airway in place after intubation. Removing the airway with the patient prone could prove to be a greater risk than leaving it. He deflated the cuff on the LM airway to reduce pressure on the tongue and posterior pharynx. Prolonged LM airway cuff or tube pressure can cause pressure injury. The surgeons completed the surgery and the patient was extubated supine at the conclusion of the case.
Case #3:
The patient was a 30 year-old woman undergoing maxillofacial surgery with oral intubation. I was urgently called to the room after an accidental extubation by the surgeon. My resident had already reintubated the patient but now cannot ventilate. Oxygen saturation was 80% and dropping. My first thought was that the reintubation had been esophageal.
The Head and Neck surgeon grabbed his laryngoscope to verify placement and said, “It looks like it’s in.” He was an expert in airway management so I trusted him.
I then started down a different diagnostic tree. I considered severe bronchospasm or a mucous plug. This was because breath sounds were barely audible and squeaky. There was an end-tidal CO2 wave on the monitor, but it was blunted and dropping in value.
Oxygen saturation hit 50% and the pulse rate dropped to 20. ETCO2 vanished. Cardiac arrest was imminent.
I grabbed the laryngoscope and did my own direct laryngoscopy. The endotracheal tube was esophageal. I immediately extubated and reintubated the patient. Ventilation was easy. Oxygen saturation and pulse rate quickly rose together. All the providers in the room took a collective sign of relief.
How Did We Miss the Unplanned Extubation?
As the dust settled, I discovered something troubling. During reintubation, my resident had not had a good view of the larynx. This was due to the blood and distortion in the airway from the surgery. It turned out that our surgeon had performed the laryngoscopy to check placement. However, he had not actually seen the ETT passing between the cords. He saw it turning the corner around the tongue. It seemed to be heading in the right direction. In the crisis atmosphere of the moment, he had called it good.
The initial ETCO2 on the monitor was deceptive. Most likely CO2 entered the stomach during the initial efforts to ventilate after the first unplanned extubation. Over the next few minutes, this ETCO2 got washed out.
Fortunately, the patient tolerated the episode well and surgery was completed without any further complication.
Discussion
Unfortunately, unplanned extubation is a common and costly risk to your patient. Most of these extubations occur in the ICU or NICU. By one calculation using a median unplanned extubation rate of 7.3% for ICU and 18.2% for NICU patients, an estimated 120,000 ICU patient and 80,000 NICU patients suffer unplanned extubations each year [1]. Unplanned extubations in the OR are more rare. They are potentially more difficult to manage if occurring intraoperatively. Factors such as prone positioning or lack of access to the airway complicate care.
Risks To Unplanned Extubations in the OR include:
- inadequately securing the endotracheal tube
- repositioning the patient
- rotating the bed
- lack of access to the airway during surgery.
- operating close to or around the ETT
- patient restlessness or agitation during emergence
- head extension, which moves the tip of the ETT upwards in the trachea
- infants and toddlers, whose tracheas are quite short, are especially at risk.
Complications Linked to Unplanned Extubation
Complications to unplanned extubation can be catastrophic.
Clinical Complications
- Aspiration pneumonia
- Brain damage
- Cardiac arrest
- Death
- Hemodynamic instability
- Hypoxemia/hypoxia
- Respiratory failure
- Vocal cord injury
Other Complications
- Increased hospital costs
- Increased hospital length of stay
- Prolonged ICU length of stay
Preventing Unplanned Extubation in The OR
Watch your feet. Every room is different. Take note of the arrangement of equipment before you begin. Ensure all your cables are either disconnected or protected. Do the same for the ventilation hoses when moving the patient or the OR table. Always reverify tracheal placement after any move.
Always tape your endotracheal tubes as though your patient’s life depends on it, because it does. One of my instructors used to joke about proper tube taping. “If you couldn’t lift the patient’s head up by the endotracheal tube”, he said, “it wasn’t taped well enough”. The ETT must be taped securely, and protected from saliva.
The patient’s face must be prepped with care. I find that OR RNs love to vigorously scrub ETT tape. They do this to make sure it’s sterile. This loosens the tape and frees the ETT to move. In these situations, I routinely cuse a moisture-proof barrier such as Tegaderm or a 10/10 drape to protect my tape. Check after the prep and before the drape. Once the face is in the operative field, ability to check the tube is often lost.
When moving the patient, hold onto the tube where it exits the mouth. That way, if the head moves one way, your hand will move with it — even if you’re not looking. Hold the tube near the adapter carefully. If the head moves when you’re not looking, you may accidentally pull it out.
Always be ready for accidental extubation with the equipment and supplies you would need to reintubate that particular patient. If the patient is prone, make sure that the gurney is kept outside your OR. It should be ready in case there is an emergency requiring immediate supine flipping of the patient.
If you are not sure an endotracheal tube is in the correct place, look yourself. Trust but don’t be afraid, or hesitate, to verify.
To be a good anesthesia provider means becoming a catastrophist. You must examine the things you do. Consider the objects you work with. Imagine all of the possible things that can go wrong. Always be prepared.
May The Force be With You
Christine E. Whitten MD, author:
Anyone Can Intubate: A Step-by-Step Guide, 5th Edition
Pediatric Airway Management: A Step-by-Step Guide
Basic Airway Management: A Step-by-Step Guide
References
- Berkow L. Unplanned or accidental extubation in the perioperative environment. Anesthesiology News Airway Management. 2019;12:71-77.
Anesthesia residency trainer’s (Jeffrey Levitt, M.D.) rule for securing ETT’s for a prone position operation was, “never depend on the tape to keep it (ETT) secure”. All residents were taught to add a elastic band to keep gravity from pulling it toward floor AND in case saliva saturated the tape.