Incidence, risk factors, and outcomes of unplanned extubation in adult patients in a resource-limited teaching hospital in the Philippines: a cohort study

Uy, Angelique Bea C; Ramos, Everly Faith P; Rivera, Adovich S; Maghuyop, Norman L; Suratos, Cezar Thomas R; Miguel, Red Thaddeus D; Gaddi, Mairre James S; Zaldivar, Joan Kristi D

doi:10.5935/0103-507X.20190012

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Revista Brasileira de Terapia Intensiva

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ORIGINAL ARTICLES • Rev. bras. ter. intensiva 31 (1) • 18 Mar 2019 • https://doi.org/10.5935/0103-507X.20190012 copy

Incidence, risk factors, and outcomes of unplanned extubation in adult patients in a resource-limited teaching hospital in the Philippines: a cohort study

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

We aimed to determine the incidence, risk factors, and outcomes of unplanned extubation among adult patients.

Methods:

We conducted a prospective cohort study of adult intubated patients admitted to the charity wards of a government tertiary teaching hospital in the Philippines. Patients managed in both intensive care and nonintensive care settings were included. Patients were followed-up until discharge or until seven days postextubation.

Results:

The outcomes of the 191 included patients were planned extubation (35%), unplanned extubation (19%), death (39%), and discharge against advice (7%). Competing risk regression showed that male sex (Crude OR: 2.25, 95%CI: 1.10 - 4.63) and age (Crude OR 0.976, 95%CI: 0.957 - 0.996) were significant baseline factors. The night shift (Crude OR: 24.6, 95%CI: 2.87 - 211) was also consistently associated with more unplanned extubations. Among postextubation outcomes, reintubation (unplanned extubation: 61.1% versus planned extubation: 25.4%), acute respiratory failure (unplanned extubation: 38.9% versus planned extubation: 17.5%), and cardiovascular events (unplanned extubation: 8.33% versus planned extubation: 1.49%) occurred significantly more often among the unplanned extubation patients. Admission in an intensive care unit was not associated with a lower risk of unplanned extubation (Crude OR 1.15, 95%CI: 0.594 - 2.21).

Conclusion:

Many intubated patients had unplanned extubation. Patients admitted in nonintensive care unit settings did not have significantly higher odds of unplanned extubation.

Keywords:
Intubation; Airway extubation; Critical care; Developing country; Prospective studies

Patient characteristics	Whole cohort n = 191	Unplanned extubation n = 36	Planned extubation n = 67	Death or DAA n = 88	p value
Age	54.8 (15.5)	49.7 (15.8)	56.4 (14.6)	55.5 (16.0)	0.091^* * One-way ANOVA;
Female	44.5	27.8	53.7	47.3	0.044^† † Chi-square test;
Mean SAPS II^‡ ‡ n are as follows: whole - 143; unplanned extubation - 30; planned extubation - 53; death/discharge against advice - 60;	49.0 (0.26)	50.4 (13.9)	46.1 (14.5)	52.2 (13.5)	0.151^* * One-way ANOVA;
Admission to the ICU	55.0	58.3	35.1	38.7	0.032
Admission to nonsurgical area	73.3	58.3	67.2	45.9	0.063^† † Chi-square test;
Reasons for intubation
Cardiovascular	24.1	19.4	29.9	23.0	0.548^† † Chi-square test;
Pulmonary	43.5	33.3	35.6	54.1	0.081^† † Chi-square test;
Sepsis	12.0	11.1	7.5	14.9	0.331^† † Chi-square test;
Neurologic	37.2	47.2	40.3	33.8	0.146^† † Chi-square test;
Surgical and others	7.9	2.8	9.0	8.1	0.752^† † Chi-square test;
CPAP mode (versus other MV modes)	14.1	19.4	7.5	16.2	0.180^† † Chi-square test;
Median length of stay (days)	17 [22]	21.5 [23.5]	26 [28]	10 [16]	< 0.001^§ § Kruskal-Wallis rank test.
Median length of intubation (days)	8 [10]	4.5 [7.5]	8 [9]	10 [16]	< 0.001^§ § Kruskal-Wallis rank test.

Patient characteristics	Crude SHR	Adjusted SHR (full model)	Adjusted SHR (stepwise)
Age	0.976^* * p value < 0.05. Results expressed by standardized hazards ratio point estimate and 95% confidence interval (in parentheses). (0.957 - 0.996)	0.969^* * p value < 0.05. Results expressed by standardized hazards ratio point estimate and 95% confidence interval (in parentheses). (0.941 - 0.999)	0.975 (0.950 - 1.00)
Male sex (reference: female)	2.25^* * p value < 0.05. Results expressed by standardized hazards ratio point estimate and 95% confidence interval (in parentheses). (1.10 - 4.63)	2.54^* * p value < 0.05. Results expressed by standardized hazards ratio point estimate and 95% confidence interval (in parentheses). (1.09 - 5.94)	2.39^* * p value < 0.05. Results expressed by standardized hazards ratio point estimate and 95% confidence interval (in parentheses). (1.09 - 5.27)
Admission to the ICU	1.15 (0.594 - 2.21)	1.04 (0.481 - 2.23)	Not included
Admission to nonsurgical area	0.711 (0.360 - 1.41)	0.473 (0.168 - 1.33)	Not included
Primary diagnosis for intubation
Cardiovascular	0.762 (0.332 - 1.75)	1.13 (0.389 - 3.29)	Not included
Pulmonary	0.616 (0.311 - 1.22)	0.512 (0.190 - 1.38)	0.441 (0.184 - 1.06)
Sepsis	0.959 (0.327 - 2.812)	1.29 (0.313 - 5.317)	Not included
Neurologic	1.53 (0.802 - 2.92)	0.988 (0.404 - 2.42)	Not included
Surgical and others	0.669 (0.162 - 2.77)	0.162 (0.010 - 2.51)	0.221 (0.265 - 1.84)
CPAP mode (versus other MV modes) (%)	1.50 (0.672 - 3.35)	1.79 (0.503 - 6.37)	Not included
SAPS II	1.01 (0.981 - 1.03)	1.00 (0.974 - 1.03)	Not included

Circumstantial factors	Unplanned extubation (%)	Planned extubation (%)	Odds ratio (95% confidence interval)
Circumstantial factors	Unplanned extubation (%)	Planned extubation (%)	Crude	Adjusted (full model)^* * Models included baseline risk factors	Adjusted (stepwise)^† † Final model included age, sex, surgical and other reasons for intubation, mechanical ventilation mode, admission in nonsurgical wards.
Timing
AM	41.7	63.1	-	-	-
PM	33.3	35.4	1.42 (0.571 - 3.56)	2.76 (0.449 - 17.0)	2.31 (0.73 - 7.32)
Night	25.0	1.5	24.6^‡ ‡ p-value <0.05. (2.87 - 211)	86.3^‡ ‡ p-value <0.05. (2.44 - 3,050)	37.0^‡ ‡ p-value <0.05. (3.10 - 442)
Use of restraints	41.7	29.9	0.518 (0.722 - 3.90)	8.439^‡ ‡ p-value <0.05. (1.40 - 51.0)	2.88 (0.939 - 8.84)
Use of sedation	5.6	26.9	0.160 (0.035 - 0.736)	0.053^‡ ‡ p-value <0.05. (0.004 - 0.777)	0.284 (0.052 - 1.56)
Tape for fixation	11.1	3.0	1.40 (0.706 - 23.4)	Omitted (predicts success perfectly)	Not included
X-ray confirmation	91.7	85.1	0.657 (0.496 - 7.52)	1.00 (0.050 - 20.0)	Not included

Postextubation outcome	Unplanned extubation (n = 36)	Planned extubation (n = 67)	Wilcoxon-Breslow test^* * Comparison of Kaplan-Meier failure curves. Results expressed by count and percent (in parentheses). p value
Reintubation	22 (61.1)	16 (23.9)	< 0.001
Acute respiratory failure	14 (38.9)	11 (16.42)	0.002
Cardiovascular event	3 (8.33)	1 (1.49)	0.045
Infection	10 (27.8)	15 (22.4)	0.273
Death	8 (22.2)	8 (11.9)	0.112

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[1] Corresponding author: Adovich S Rivera, Northwestern University, 633 N St Clair 20^th Floor, Chicago, IL, USA, 60611, E-mail: adovichrivera2021@u.northwestern.edu