Unplanned extubations are one of the most common adverse events that can occur with mechanical ventilation in the NICU.1 Approximately 415,000 neonates require invasive mechanical ventilation for more than 24 hours.2 Nearly 75,000 of these neonates subsequently experience at least one unplanned extubation – that’s one in five neonates.2 That means more time on the ventilator, more days in the hospital, and potentially negative long-term clinical outcomes.1
Implementing appropriate preventive measures — including incorporating technology designed to alert clinicians of endotracheal tube (ETT) migration — could enhance neonate patient outcomes and promote NICU excellence. These practices may also help reduce the frequency of unplanned extubations and improve assessment and intervention when an unplanned extubation occurs. This could potentially lead to a lower morbidity risk for these sensitive patients and possibly reduce healthcare costs.1
Critically-ill neonates requiring 24-hour ETT placement have a heightened risk of enduring accidental tube shifts that can happen instantly. Unplanned extubations can lead to a number of serious complications — some of which may result in long-term complications for infant neonates if not properly addressed within seconds.1
Why are NICU patients at an increased risk of unplanned extubations?
Premature neonates — both extreme premature and preterm — could be more at risk of unplanned extubations because of their physiology. With smaller airways, they require very small, uncuffed ETTs. This requires various methods of securing ETTs, including tape, which could become easily displaced during movement.
Simple motions, including an infant’s facial movements or coughing, may cause ETT tape insecurities. Clinicians providing hands-on care, conducting assessments that occur every one to four hours, could also pose a risk for ETT displacement. Manipulation of the patient in any way may cause an increased risk for dislodgement or full extubation if the tube is moved accidentally.
Some clinicians may perform daily chest X-rays to evaluate ETT placement and assess progression of lung conditions. Because a chest X-ray shows a snapshot in time of the positioning of the ETT at the moment it’s taken, once movement occurs, it is no longer valid confirmation of ETT positioning. This further denotes the sensitivity of these patients as well as the risks of ETT shifts and migration, supporting the need for a continuous monitoring modality.
What is the impact of neonatal unplanned extubations?
When a neonate is born, they can experience poor perfusion and have minimal oxygenation reserves, resulting in the decreased ability to self-correct unplanned extubation episodes. These events require immediate intervention to prevent critical outcomes. Unplanned extubations may lead to short and long-term complications including:
- Hypoxic events1
- Bradycardia events1
- Poor respiratory rate1
- Airway trauma1
- Ventilator-associated pneumonia1
- Intracranial pressure1
- Increased length of stay3
- Increased risk of morbidity1
How long does a clinician have to correct unplanned extubations and short-term complications?
In the NICU, timely intervention is critical to potentially diminish adverse outcomes associated with unplanned extubations. The appropriate intervention response may be as important as a quick response. For example, when a patient begins to desaturate, clinicians could immediately address the issue with suctioning, but without having visibility inside the trachea to assess the ETT, this may be an inappropriate treatment. If a clinician uses suctioning on what’s thought to be lung fluid obstructing proper breathing — but is actually ETT migration — the outcome could traumatize the patient’s lungs.4 This underscores the importance of delivering the proper care at the proper moment to help improve positive outcomes of neonates in the NICU.
How does decreasing unplanned extubations help improve patient outcomes?
Light, sound, and caregiving interventions are the main environmental stressors that cause harm to preterm infants in NICUs.5 Daily chest X-rays, which may be intensely stressful for some neonates, is the primary method for insights to ensure optimal ETT placement. Some NICU best practices include:
- Vital sign monitoring for cardiorespiratory events
- Visual assessments of ETT placement focusing on depth markers
- Daily reapplication of ETT tape to ensure proper adhesive properties are maintained
- Auscultation for bilateral and equal breath sounds
- Remote patient monitoring technologies, including the SonarMed™ airway monitoring system
Remote monitoring systems could reduce the need to disturb patients during routine checks, allowing for more uninterrupted sleep. It may also improve staff access to vital information and reduce unnecessary clinical interventions.6 The SonarMed™ airway monitoring system is the first U.S. Food and Drug Administration (FDA) cleared airway monitoring system to offer this. The ability to assist in verifying ETT position and patency — in real time.*
What are the clinical advantages of implementing SonarMed™ airway monitoring into the NICU?
The SonarMed™ airway monitoring system may help improve a clinician’s ability to manage a patient’s airway by providing precise continuous, real-time monitoring of the ETT position and patency.7-9 This provides clinicians the ability to troubleshoot at the bedside, which may result in better peace of mind.
The SonarMed™ system is designed to monitor ETT movement and provide notification of tube location changes, for early alerts of potential unplanned extubations.7 It does this by using acoustic monitoring technology to emit sound waves through the ETT, then measuring sound waves as they return to the sensor. The system analyzes the timing and amplitude of the echoes to estimate the position and patency of the tube. This provides immediate audible alerts when movement or obstructions are detected, and allows for clinicians to intervene quickly to administer support. Alarms may be configured on an individualized per patient level to maximize care support. This reinforces the NICU sequence response to airway, breathing, and circulation supporting immediate and appropriate interventions.
What is required to integrate the SonarMed™ airway monitoring system in my NICU?
Integrating the SonarMed™ airway monitoring system into the NICU is as simple as attaching the SonarMed™ sensor to the end of the ETT and connecting that to the existing ventilation circuit. The SonarMed™ system is designed for easy setup by either a NICU or respiratory clinician.
Additionally, the SonarMed™ airway monitoring system is noninvasive. It’s a less disruptive solution providing actionable airway management information to support clinician care. The system connects to the ETT by replacing the 15 mm connector that attaches to the ventilator circuit and the sensor fits any brand of standard ETT. That means no expensive system overhauls. The monitor was designed for clinicians to quickly review screen displays for any status changes of the ETT and monitors the correction of the tube to the optimal baseline position.7 Providing real-time notifications and specific measurements, it can promote a coordinated response to address potentially critical events supports clinicians with making more informed decisions for their patients.
*The SonarMed Airway Monitoring System should not be used as the sole basis for diagnosis or therapy and is intended only as an adjunct in patient assessment.
1. Hatch LD 3rd, Scott TA, Slaughter JC, et al. Outcomes, Resource Use, and Financial Costs of Unplanned Extubations in Preterm Infants. Pediatrics. 2020;145(6):e20192819. doi:10.1542/peds.2019–2819.
2. Internal analysis of Premier Data, GMA data, 3rd party consulting and primary research.
3. Roddy DJ, Spaeder MC, Pastor W, Stockwell DC, Klugman D. Unplanned Extubations in Children: Impact on Hospital Cost and Length of Stay. Pediatr Crit Care Med. 2015;16(6):572–575. doi:10.1097/PCC.0000000000000406.
4. Gonçalves RL, Tsuzuki LM, Carvalho MG. Endotracheal suctioning in intubated newborns: an integrative literature review. Rev Bras Ter Intensiva. 2015;27(3):284–292. doi:10.5935/0103-507X.20150048.
5. Peng NH, Bachman J, Jenkins R, et al. Relationships between environmental stressors and stress biobehavioral responses of preterm infants in NICU. J Perinat Neonatal Nurs. 2009;23(4):363–371. doi:10.1097/JPN.0b013e3181bdd3fd.
6. Schiavenato M, Antos SA, Bell FA, et al. Development of a scale for estimating procedural distress in the newborn intensive care unit: the Procedural Load Index. Early Hum Dev. 2013;89(9):615–619. doi:10.1016/j.earlhumdev.2013.04.007.
7. Nacheli GC, Sharma M, Wang X, Gupta A, Guzman JA, Tonelli AR. Novel device (AirWave) to assess endotracheal tube migration: a pilot study. J Crit Care. 2013;28(4):535.e1-535.e5358. doi:10.1016/j.jcrc.2012.10.015
8.Don C, Faulkner G. Bench study of the SonarMed airwave to detect fixed airway obstructions at varying locations within an endotracheal tube. Respiratory Care - AARC 2012. 2012;57(10):1714.
9. Withers, L, Finch, C, Jackson, J, Measuring ETT carina distance using the airwave device in patients identified as a difficult airway, 862, Crit Care Med: December 2014, vol 42, Issue12 - p A1568 doi: 10.1097/01.ccm.0000458359.97855.92.
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About the AuthorMore Content by Kimberly Kerns