Decreasing Unplanned Extubation in the Neonatal ICU With a Focus on Endotracheal Tube Tip Position

BACKGROUND: Unplanned extubation (UE) is an important quality metric in the neonatal ICU that is associated with hypoxia, bradycardia, and risk for airway trauma with emergent re-intubation. Initial efforts to reduce UE in our level 4 neonatal ICU included standardized securement of the endotracheal tube (ETT) and requiring multiple providers to be present for ETT adjustments and patient positioning as phase 1 interventions. After an initial decline, the UE rate plateaued; an internal retrospective review revealed that the odds of UE were 2.9 times higher in the setting of an ETT tip at or above T1 (high ETT) on chest radiograph just prior to UE. The team hypothesized that advancing ETT tips to below T1 would reduce UE risk in infants of all gestational ages.

METHODS: Over a period of 32 months, we compared pre-intervention and post-intervention UE rates in our neonatal ICU after a 2-step initiative that focused initially on ETT securement and assessment, with a subsequent addition of a single intervention to advance ETT tips below T1. To determine if the decrease in UE rate could be secondary to our intervention, data were analyzed from 3 cohorts: a control group of 40 infants with 185 chest radiographs and no UEs, 46 infants with chest radiographs prior to 58 UE events before the intervention, and 37 infants with chest radiographs prior to 48 UE events following the intervention.

RESULTS: Advancing ETT tips below T1, in addition to the use of a standard UE-prevention bundle, led to a significant decrease in the UE rate from 1.23 to 0.91 UEs per 100 ventilator days, with 14% of postintervention UEs attributed to ETT advancement.

CONCLUSIONS: High ETTs are significantly associated with UEs in the neonatal ICU. Optimizing ETT position may be an underrecognized driver in the provider’s toolbox to reduce UEs. Because ETT repositioning carries risk of UE, extra caution should be taken during advancement.