Self-extubation occurs when a patient removes their own endotracheal tube (ETT), the tube connecting them to a mechanical ventilator. This is classified as an unplanned extubation, distinct from accidental extubation caused by staff error or equipment failure. The incidence of unplanned extubation in intensive care units typically ranges from 3% to 16% of all mechanically ventilated patients, with self-extubation being the most common cause in adults.
Unplanned removal of the ETT immediately compromises the patient’s ability to breathe, oxygenate their blood, and protect their airway. This event can lead to severe consequences, including aspiration, respiratory failure, and cardiac arrest. Because swift deterioration can follow, recognizing the event immediately and executing an organized, rapid response is essential for patient safety.
Immediate Recognition of Self-Extubation
Recognizing self-extubation begins with a sudden change in the patient’s status. The patient may exhibit signs of severe distress, such as agitation, restlessness, or a sudden, forceful bout of coughing, which often causes the tube to be pulled out.
Physiological indicators rapidly follow, including a precipitous drop in peripheral oxygen saturation (SpO2). The heart rate will likely increase (tachycardia) as the body attempts to compensate for the lack of oxygen. The patient’s respiratory rate will also increase (tachypnea), demonstrating a heightened effort to breathe.
Technical alarms from the ventilator provide confirmation of the event. A loud, persistent alarm will sound, typically indicating high-pressure limits have been exceeded or the circuit is disconnected. Monitoring will also show an abrupt loss of the end-tidal carbon dioxide (EtCO2) waveform, confirming the breathing tube is no longer correctly positioned.
Visually, the most obvious sign is finding the patient sitting up and holding the ETT or seeing the tube near the bed. The tube’s security device may be pulled free. The patient may also be trying to speak or whisper, which is impossible when an ETT is correctly positioned.
Emergency Response and Stabilization
The immediate response must prioritize the patient’s oxygenation and ventilation. Call for assistance from a respiratory therapist, physician, and nursing staff to assemble a rapid response team. Simultaneously, place the patient on a high-flow oxygen source, such as a 100% non-rebreather mask, to maximize oxygen delivery.
The team must establish manual ventilation using a bag-valve mask (BVM) connected to 100% oxygen. Before applying the BVM, remove any remaining tube fragments. Position the patient’s head using a head-tilt chin-lift, or a jaw thrust if a cervical spine injury is suspected. Insert an oropharyngeal or nasopharyngeal airway adjunct to maintain airway patency.
One provider should maintain a tight seal over the patient’s nose and mouth, often using a two-handed technique. The second provider gently squeezes the bag, delivering a breath every five to six seconds for an adult, watching for visible chest rise. Provide just enough volume to see the chest rise, avoiding excessive pressure.
While manual ventilation is ongoing, stop all sedative and analgesic infusions that may have contributed to the patient’s agitation. Continuous monitoring of SpO2, heart rate, and respiratory effort is maintained while the need for re-intubation is assessed. The focus remains on stabilizing the patient until a full clinical assessment can be performed.
Comprehensive Post-Event Assessment
Once the patient is stabilized, a structured assessment determines the next steps and identifies complications. The fundamental decision is whether the patient requires re-intubation, which is necessary for only about 50% of patients who self-extubate. The assessment evaluates the patient’s mental status, respiratory mechanics, and gas exchange.
A patient who is awake, cooperative, has a strong cough, and can protect their airway may be monitored closely without immediate re-intubation. Blood gas analysis is performed to check for adequate ventilation and oxygenation, aiming for a pH above 7.25. Re-intubation becomes necessary if the patient exhibits signs of respiratory distress, such as excessive work of breathing or a drop in consciousness.
The clinician must evaluate the patient for potential injuries resulting from forceful tube removal. Laryngeal trauma and vocal cord edema are concerns, especially if the tube was removed with the cuff still inflated. Stridor, a harsh sound during breathing, signals upper airway obstruction due to swelling and often indicates the need for re-intubation or treatment with nebulized medications.
Complications like aspiration of gastric contents or pneumothorax (a collapsed lung) must also be evaluated. While re-intubation prevents immediate respiratory failure, it carries risks like ventilator-associated pneumonia and prolonged hospital stays, emphasizing the need for a cautious decision process.
Strategies to Prevent Recurrence
Preventing self-extubation requires addressing underlying patient factors, primarily agitation, which accounts for up to 74% of unplanned extubations. Optimizing the patient’s comfort and mental state is the most effective proactive measure. This involves careful titration of sedation and analgesia, using tools like the Richmond Agitation Sedation Scale (RASS) to ensure the patient is calm but not excessively sedated.
Sedation strategies should favor continuous review and adjustment rather than an “as-needed” approach, as inadequate sedation increases agitation and the risk of tube removal. Delirium, characterized by fluctuating mental states, must be actively assessed and managed as a major risk factor. Providing a calm environment, frequent reorientation, and optimizing sleep hygiene helps manage delirium.
The use of physical restraints is controversial, as they may increase patient agitation and the likelihood of self-extubation. Restraints should only be used as a last resort when other measures to protect the airway have failed, and must be paired with increased surveillance. Regular checks of the ETT position and the security of its fixation device reduce the risk of removal.
Patients should be continuously assessed for readiness for planned extubation through spontaneous breathing trials. Identifying these patients early removes the risk of self-extubation. Increased staff-to-patient ratios, especially during high-risk times like shift changes or patient transport, provide closer observation and prevent opportunities for tube removal.