A study of critical care patients at a large children’s hospital finds unplanned extubations are common and linked to adverse events in nearly half of patients. Researchers identify the top risk factors, informing potential patient safety improvement practices.

By Alyx Arnett

Unplanned extubation—the unintentional dislodgement of an endotracheal tube—is one of the most common causes of preventable adverse events in mechanically ventilated patients.1

Unplanned extubation poses serious risks, including hypoxemia, respiratory distress, cardiopulmonary arrest, emergent reintubation, and morbidity.

The Solution for Patient Safety has proposed a national benchmark to reduce unplanned extubation rates to less than one per 100 ventilator days. However, when data from a large academic children’s hospital showed its rates were as high as 3.08 per 100 ventilator days, it prompted a study to identify common risk factors and patient situations associated with these unplanned extubations.

Researchers aimed to use the findings to develop quality improvement interventions to minimize unplanned extubations. “Prioritizing prevention helps safeguard the well-being of these vulnerable patients,” said Cheryl Dominick, RRT, lead author of the study and respiratory clinical specialist in the Department of Respiratory Care at Children’s Hospital of Philadelphia.

Outcomes of Unplanned Extubations

Researchers reviewed data from patients in the hospital’s pediatric intensive care unit (PICU), cardiac intensive care unit (CICU), and neonatal intensive care unit (NICU) who experienced an unplanned extubation between Jan 1, 2016, and Dec 31, 2021. The PICU, CICU, and NICU had 82, 31, and 102 beds, respectively.

According to their study1 published in Respiratory Care, they found that 339 patients experienced 408 unplanned extubations, with the largest number occurring in the NICU (80%), followed by the PICU (13%) and the CICU (7%).

Most unplanned extubations (54%) were unwitnessed—with the highest occurrences in the CICU (77%)—so circumstances surrounding those events could not be determined. However, of the witnessed unplanned extubations, most occurred during routine nursing care (18%) or retaping of the endotracheal tube (16%), followed by endotracheal suctioning and being held, both accounting for 3.9%.1

Oral endotracheal tubes were present in 94% of unplanned extubation cases. Many unplanned extubations in the CICU occurred shortly after patients returned from the operating room.1

Adverse events were common, occurring in 44% of the unplanned extubations (NICU 46%, PICU 38.5%, and CICU 32%). The most common adverse events were desaturation (33.3%) and bradycardia (22.8%).1 Chest compressions were required in 12% of unplanned extubations. Mortality occurred in 18% of patients, with the PICU experiencing the highest mortality rate at 23%.1

Most patients (67%) required reintubation, though it varied significantly across the units: NICU 71%, PICU 62%, and CICU 35%.1 Dominick pointed out that reintubation presents its own set of risks, including airway trauma, infection, and prolonged mechanical ventilation.1 “By preventing unplanned extubations, healthcare providers can reduce the likelihood of these complications and associated morbidities,” she said.

Improving Patient Safety

The findings highlighted areas where targeted interventions could reduce the incidence of unplanned extubations.

Among these, the CICU’s high rate of unwitnessed unplanned extubations, at 77%, stands out as a critical area. Dominick said this rate suggests a potential link to nursing workload, a factor that researchers believe merits further investigation.

According to Dominick, a surprising finding was that one-third of unplanned extubations did not require reintubation. This group often involved patients receiving minimal ventilatory support or those who had completed an extubation readiness trial. The finding suggests a possibility that some physicians, erring on the side of caution, delay extubation despite evidence that such prolongation can unnecessarily extend hospital stays and increase costs.2 “[This] indicates that our current practice in weaning mechanical ventilation and assessing extubation readiness has room for improvement,” Dominick says.

Improving best practices in routine nursing care and endotracheal tube retaping, identified as significant contributors to unplanned extubations, can help mitigate risk. During routine nursing care, activities such as repositioning patients, suctioning airways, and conducting patient assessments can contribute to unplanned extubations, while frequency and technique can contribute during endotracheal tube retaping, according to Dominick.

She explained that repositioning a patient may inadvertently cause the endotracheal tube to shift, while improper technique or excessive suctioning can also dislodge it. The physical manipulations involved in patient assessments also can inadvertently disturb the endotracheal tube. Additionally, some patients—especially those who are moving or agitated—may require retaping, but the frequency of retaping increases the risk of accidental extubation. Improper retaping techniques, such as inadequate securing or excessive tension on the tape, can lead to insufficient stability and an increased risk of unplanned extubation.

Dominick offered recommendations in these areas to improve patient safety. For patient repositioning, she suggested implementing standardized protocols for maintaining endotracheal tube stability, which may require coordinating movements with other staff members to ensure safer airway handling. For suctioning, she recommended thorough training on proper techniques, including appropriate suction pressure and frequency. For patient assessments, she suggested training staff to conduct evaluations with minimal disruption to the endotracheal tube.

To reduce the risk associated with the frequency of retaping, Dominick recommended developing guidelines that balance the need for securement with the risk of manipulation. “Consider alternative methods of securement, such as using specialized devices or securing the [endotracheal tube] with a securement device that reduces the need for frequent retaping,” she said. Dominick noted that training on proper retaping techniques and standardizing the retaping process to ensure consistency may also contribute to improved patient safety.

“By implementing specific measures to minimize the risk of unplanned extubations associated with these activities, healthcare providers can improve patient safety and quality of care in the hospital,” said Dominick.

Lessons Learned

From the study, key lessons have emerged, according to Dominick. Regularly monitoring data is vital for spotting improvement areas and gauging intervention success. Standardizing practices, particularly in endotracheal tube management and nursing routines, alongside comprehensive staff education, can reduce risks.

Collaborative efforts from multidisciplinary teams can ensure a unified approach to unplanned extubation reduction, while implementing and continuously refining quality improvement measures, coupled with thorough documentation and communication, are fundamental to fostering a culture of safety.

Lastly, she said addressing broader systemic factors, such as workload and specific unit practices, is critical for achieving sustained progress in lowering unplanned extubation rates.

“By sharing these key lessons learned, institutions can benefit from the experiences and insights gained through the study and collaborate to enhance patient safety and quality of care in pediatric settings by reducing unplanned extubations,” said Dominick.

Following the study, the hospital’s PICU initiated a daily assessment using an Unplanned Extubation Risk Assessment Score to minimize unplanned extubations. The score provides clinicians with insight into patients at elevated risk, offering a chance to intervene before an unplanned extubation occurs. The pilot program is expected to expand to other ICUs.


Alyx Arnett is associate editor of RT. For more information, contact [email protected].


  1. Dominick CL, Blanke BN, Simmons EM, et al. Outcomes of unplanned extubations in a large children’s hospital. Respir Care. 2024 Jan 24;69(2):184-90.
  2. Sadowski R, Dechert RE, Bandy KP, et al. Continuous quality improvement: reducing unplanned extubations in a pediatric intensive care unit. Pediatrics. 2004;114(3):628-32.