Prevention of Accidental

Extubation in Newborns
Mark S. Brown, MD

\s=b\ Maintaining endotracheal intuba- ported, although most have not been angle improved the tube's stability. Benzoin
tion is critical to treating respiratory used on asystematic basis.41017 was not routinely applied to the tube in
failure in newborns. To reduce acciden- To decrease accidental extuba¬ either method.
tal extubations in our neonatal intensive The other patient-care practice studied
care unit, a prospective comparison of
tions,18 we devised a prospective study was head restraint. This consisted of a
to compare rates of accidental extu¬
rates of extubation was made between rolled diaper fastened snugly across the
two taping methods and whether or not
bation when two different taping head diagonally from one side of the bed to
a head restraint was used. One tape
methods were used and whether or the other, overlying the side of the face
method was significantly better at pre- not a head restraint was used. In (Fig 2). This was left in place at all times
venting accidental extubations. Head re- addition, the occurrence of certain unless patient care required access to the
straint was not a benefit when used infant activities and nursing and res¬ head or endotracheal tube.
prospectively. Factors that preceded or piratory care procedures before acci¬ Thus, there were four groups of care
were associated with accidental extu- dental extubations were recorded to practices: tape method 1 with or without
bation included the time intubated, in- determine which factors preceded or head restraint and tape method 2 with or
fant agitation, endotracheal tube suc- were associated with accidental extu¬ without head restraint. In addition, infants
tioning, the infant turning its head, chest were stratified by birth weight (<1500 g
bations.
physiotherapy, loose tape, too short a or >1500 g). Care practices were assigned
tube between lip and adapter, weighing, METHODS randomly on admission for each of the two
and endotracheal tube taping. This in- weight groups and continued until inten¬
formation and the study design are All intubated newborns admitted to the tional extubation, death, or 28 days of
valuable in developing strategies to min- newborn center at The Children's Hospital, postnatal age. Oral intubation has been the
imize accidental endotracheal extuba- Denver, from June 1, 1983, through Nov standard of practice since 1978.18 Nasal
tion and the subsequent risks of airway 30, 1983, were entered into the study. The tubes were not changed as part of the
injury and subglottic stenosis in sick study design involved prospective compar¬ study; they were changed only at the at¬
newborns. ison of rates of accidental extubation be¬ tending physician's discretion. Daily
(AJDC 1988;142:1240-1243) tween two different endotracheal tube tap¬ rounds were made by one of six nurses to
ing methods and head restraint, all of which review each infant's bedside chart for medi¬
were currently in use. cations and extubations and to inspect the
Successful management of respira-
tory failure in newborns is the Taping method 1 used two strips of 1-in infant for compliance with the assigned
cornerstone of newborn intensive cloth tape attached to the cheek over care practices.
dried benzoin, each split in a Y up to the A six-month study period was projected
care. Endotracheal intubation is an
corner of the month (Fig 1). The inner leg based on the number of infants who were
integral part of this respiratory ther¬ of each Y was wrapped in a spiral fashion intubated and admitted, the current esti¬
apy, and accidental extubation in a around the tube for at least two wraps, and mated rate of extubation, and an ideal 50%
sick newborn with respiratory failure the remaining leg was attached to the drop in accidental extubations by success¬
can cause rapid deterioration and, of¬ upper or lower lip. Taping method 2 used ful care practice. The rate of extubation
ten, a difficult recovery. Frequent elastic tape cut in an H; one side of the H was expressed as the number of accidental
reintubations may result in airway was applied as a mustache over dried ben¬ extubations per 100 patient-days of intu¬
trauma and subglottic stenosis.1-4 To zoin, and the other side was wrapped in a bation. At two-month intervals the data
reduce accidental extubation, recom¬ spiral fashion around the tube for at least were analyzed. This study was reviewed by
two complete wraps, first one leg, then the the institutional review board.
mendations have been made to mini¬
other (Fig 1). A small tab was folded back Patients were excluded from data analy¬
mize traction on the tube and to se¬ at the end of these halves to facilitate sis if they met any of the following condi¬
curely anchor the endotracheal tube.5-9 removal. A second type of tape, pink tape tions over half the time they were intu¬
A variety of methods of taping or or Hy-Tape (Hy-Tape Surgical Products bated: (1) if the incorrect study protocol
anchoring the tube have been re- Corp, New York), was placed diagonally was being used for either tape method or
from the skin of the zygoma over the elastic head restraint, (2) if they were nasally
Accepted for publication July 10, 1988. tape on the tube, wrapped around once, intubated, (3) if they were paralyzed, or (4)
From the Department of Pediatrics, University and then taken back up to the skin of the if they were sedated.
of Colorado Health Sciences Center, and the
other zygoma. In addition to being water Statistical analysis was by 2 to compare
Department of Perinatology, The Children's Hos-
pital, Denver. resistant, the pink tape does not stretch, rates of extubation, Student's t test to
Reprints not available. and the approach to the tube from a second compare means, and Poisson regression to

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 28 days of age still intubated. There of the time of intubation is supported
was a total of 2158 patient-days of by the fact that the infants who had
intubation (5.9 years); 805 days in accidental extubations in both weight
infants with a birth weight greater groups had been intubated signifi¬
than 1500 g (6.6 days per patient) and cantly longer compared with those
1353 days in infants with a birth who did not have extubations (Ta¬
weight lower than 1500 g (16.7 days ble 1).
per patient) (Table 1). Although nasal intubation was not
A total of 71 patients (35%) were part of this study, only one accidental
excluded from analysis; 35 were ex¬ extubation occurred in these 18 in¬
cluded because of lack of head re¬ fants during a total of 93 days of
straint, ten because of the wrong tape intubation, for an extubation rate of
method, 18 because of nasal intuba¬ 1.1 per 100 days. This extubation rate
tion, five because of paralysis, and was consistent with other reports in
three because of sedation. There were the literature of better endotracheal
no differences between excluded and tube stability with nasal tubes.18·19
included patients in birth weight or Activities around the time of acci¬
gestational age. dental extubation were tabulated from
Fig 1.—Top, Taping method 1 utilized two After four months, data analysis the extubation logs. These logs were
strips of one-Inch cloth tape partially split revealed that taping method 2 was completed for 64 (68%) of the 94 re¬
in Y and taped to side of face, with one leg
of each piece taped to tube and other leg significantly better. For the remaining corded extubations, with a total of 93
taped to upper or lower lip. Bottom, Taping two months, only taping method 2 was responses (Table 3). Agitation and suc¬
method 2 used elastic tape split into H, with used, and infants were randomized to tioning of the endotracheal tube were
one side taped to middle-upper lip and other receive head restraint or not. After the most frequent preextubation ac¬
side taped to tube. Next, Vá-in strip of pink the six-month study period, there was tivities reported. These were followed
tape was taped from skin over one zygoma no difference in the extubation rate
down to tube, around, then back up to other by nothing being noticed, the infant
side of face. between infants with head restraint turning its head, and the infant receiv¬
and those without (Table 2). ing chest physiotherapy. Despite the
Accidental extubations occurred a improved skin adherence of the elas-
total of 94 times, for an overall extu¬ toplast and pink tape, skin abrasion
bation rate of 4.4 per 100 days of was not more of a problem in the
intubation. Of these, 30 (32%) were infants on whom these tapes were
picked up from the bedside chart used.
alone, 49 (52%) from both the bedside COMMENT
chart and the extubation logs, and 15
(16%) from the extubation logs only. The use of an uncuffed endotracheal
Accidental extubations were itemized tube in newborns makes meticulous
by the hour of the day and occurred attention to securely anchoring the
evenly thoughout 24 hours. After the endotracheal tube to the face or head
excluded patients were dropped there imperative to prevent accidental ex¬
Fig 2.—Head restraint method. Rolled dia¬ was a total of 64 extubations, for a rate tubation. Accidental extubations in
per was placed diagonally across infant's of 4.2 per 100 days. newborns can be reduced by evalua¬
head and fastened snugly under or to mat¬ There was no difference between the tion of the taping method and by
tress.
two weight groups in the extubation increased awareness of the risk factors
rate expressed per 100 days of intu¬ associated with accidental extubation.
bation (Table 1). By Poisson regression These factors include the time intu¬
analyze factors predicting the rate of ex¬ analysis the most significant factor bated, agitation, endotracheal tube
tubation. predicting extubation, regardless of suctioning, head turning, chest physi¬
birth weight, was the time intubated otherapy, loose tape, too short a tube
RESULTS between lip and adapter, weighing,
(P<.0001); next was the taping
During the six-month study period method (P<.02). Therefore, because and endotracheal tube retaping.
a total of 269 newborns were admitted the smaller infants were intubated The important elements of any suc¬
to the newborn center, and 206 (77%) longer as a group, they had accidental cessful tube-anchoring method in¬
were intubated. Three infants were extubations more often. Only 28 (23%) clude resistance to oral secretions
not enrolled; one died and two were of the 122 infants with a birth weight while maximizing the stability of the
extubated before randomization. One greater than 1500 g had extubations, tube against inadvertent traction from
hundred forty-one infants underwent while 34 (42%) of the 81 infants with a head movement, suctioning, or respi¬
successful extubation at younger than birth weight less than 1500 g had rator tubing.57·9 Adhesive tape, which
28 days of age, 23 died, and 39 reached extubations (P<.04). The importance is readily available and easy to apply,

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 is most often used; however, tape is
Table 1.—Patient Characteristics*
likely to lose adhesiveness from con¬
Birth Weight, g stant exposure to oral secretions.
Characteristic <1500 >1500 Pf
Thus, with any movement of the head,
endotracheal tube, or respirator tub¬
No. of patients 81 122
Birth weight, g 1024(285) 2420(610)
ing, loss of adhesiveness can result in
accidental extubation. To circumvent
Gestational age, wk 28.1 (3.5) 35.7 (3.2) this problem, a variety of approaches
No. [%] of patients with extubations 34/81 [42] 28/122 [23] <.04 have been reported or recommended,
Time Intubated, d
Total 16.7 (6.5) 6.6 (5.9) <.0001 including the following: waterproof
Extubations 24.0 (7.2) 13.8 (9.2)$ <.0001 tape8·20; sutures or pins through the
No extubations 12.6 (6.1)}: 4.4 (4.9)t <.0001
tube57·15·21; tape from the tube around
the neck610; rigid devices, such as an
Rate of extubation, ./100 patient-days 4.3 4.5 NS
umbilical clamp,11·12 nasal airway,13 Lo¬
Postnatal age at extubation, d 14.9(2.1) 9.5(3.2) <,0001
gan bow,4 cable or suture ties,15·16 or
No. of extubations, No. [%] of patients Rottenrow holder17; and a lever arm
1 20 [59] 24 [86]
2 9 [26] 1 [3.5] support of the respirator tubing.14 Na¬
sal tubes also provide the advantages
3 3 [9] 2 [7]
of avoidance of oral secretions and
4 1 [3] 0
increased stability, and they are asso¬
5 0 1 [3.5] ciated with decreased accidental ex¬
6 1 [3] 0
tubations and subglottic stenosis.18·19
'Values are mean (SD) where parentheses are used. However, nasal intubation is not com¬
fNS indicates not significant.
JP<.0001 for extubations vs no extubations within birth-weight group. monly used because of the greater skill
required, trauma to the nose and nasal
septum, and concern for trauma to
the eustachian tubes and infec¬
tion.7·10·2123 The success of any of
Table 2.—Extubation Rates According to Care Practices
these approaches lies in improving
Rate of tape adhesiveness or avoiding tape or
No. of Time No. of Extubation, oral secretions altogether and in de¬
Study Group Patients Intubated, d Extubations N0./IOO Patient-Days
Taping method 1,
creasing traction on the endotracheal
no head restraint 36 356 24 6.7* tube or minimizing head movement
Taping method 1, away from the endotracheal tube. The
head restraint 22 281 18 6.4t current study documents the impor¬
Taping method 2, tance of tape adhesiveness in reducing
no head restraint 53 589 15 2.5* accidental extubation and emphasizes
Taping method 2,
head restraint 31 266 7 2.6f
specific factors in infant activity and
care that may increase traction on the
Total 142 1492 64 4.2
tube, resulting in accidental extuba¬
*P<.001 for taping method 1 vs 2 with no head restraint. tion.
fP<.03 for taping method 1 vs 2 with head restraint. Evaluation of the impact of head
restraint in this study was difficult
because of the large number of pa¬
tients dropped from the head restraint
Table 3.—Infant Care Activities Before Extubation ( =
93) groups. The restraint was often inad¬
Activity No. (%) of Patients vertently left off after care was admin¬
Infant was agitated 14 (15.5)
istered to the infant, and better com¬
Endotracheal tube suctioning 12 (13) pliance would have been necessary to
Nothing specific noted 11 (12) have adequately evaluated the benefit
Infant was turning its head 10 (11)
Infant was receiving chest physiotherapy 10 (11)
of routine head restraint. When the
Tape was too loose 8 (8.5) extubation logs were reviewed, one
Endotracheal tube from lip to adapter was too short 6 (6.5) third of the accidental extubations
Head restraint was off 5 (5.5) recorded were associated with move¬
Infant was being weighed 5 (5.5)
Endotracheal tube taping 4 (4) ment of the infant's head away from
Endotracheal tube was too high 3 (3) the endotracheal tube; for example,
Infant was being fed 2 (2)
Infant was being turned over 1 (l) when the infant turned its head or was
Blood samples were being taken
Hand ventilation
1
1
(1)
(1)
agitated. Head restraint may benefit
infants who are stronger or more eas-

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 ily agitated, such as large infants or portion of the smaller infants had ex¬ cially those intubated for a long time,
infants who have been intubated a long tubations. It is important to pay atten¬ minimizing agitation and head move¬
time. tion to endotracheal stability when ment away from the tube may be
The extubation logs were a valuable designing care strategies for infants important.5 This information is impor¬
source of information and served to who are likely to remain intubated for tant in increasing awareness of risk
punctuate the importance of any acci¬ a long time. factors for accidental extubation and,
dental extubation. Factors associated Several important patient-care is¬ thus, preventing recurrent extuba¬
with accidental extubation that were sues can be addressed to minimize tions and complications of frequent
found from these logs can be divided accidental extubations in sick new¬ reintubations.1·4 The approach used in
into inadequate tube stability and borns, similar to those reported in this study is an important tool in
events that put additional traction on older infants24: (1) We can reduce the critically evaluating not only other
the tube. These two categories could impact oral secretions have on loos¬ methods of preventing accidental ex¬
be additive; loose tape might result in ening the tape on both the endotra¬ tubation but also other patient-care
accidental extubation when additional cheal tube and face. This may include activities.
traction is put on the tube. Awareness a different tape, suture or pin through
I appreciate the cooperation and support of the
of these factors in caring for an intu¬ the tube, a rigid device, or moving the medical, nursing, and respiratory therapy staff
bated newborn, using a second or third tape as far as possible from the mouth of the newborn center at The Children's Hospital,
person to assist during the proce¬ while still providing maximum stabil¬ especially the diligent efforts of the six intensive
care nursery nurses who made this study possible
dures, and replacing loose tape would ity. (2) Care of the endotracheal tube by making daily bedside chart rounds and who
minimize accidental extubations dur¬ and tubing during suctioning, weigh¬ continued to display enthusiasm throughout the
study: Kathy Mennick, BSN, Sheryl Miller, BSN,
ing necessary care. ing, feeding, or turning the infant may Mary Jo Glugla, MSN, Maryann Ruiz, BSN, Julie
As might be expected, the time of require an assistant to hold the tube Gosen, MSN, and Evelyn Swanton, BSN. I thank
intubation was the most significant to ensure its stability and decrease Dennis Luckey, PhD, for statistical analysis
tube traction. (3) For infants who are assistance, Jhonna Mc Henry for manuscript
risk factor identified for accidental paration, and David Chavez for figure prepara¬
extubation. As a result, a larger pro- easily agitated while intubated, espe- tion.

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