Unplanned Extubation in a Patient with Acute Hypercapnic Respiratory Failure: A Case Report
Format
Presentation
Start Date
6-11-2020 2:30 PM
End Date
6-11-2020 2:45 PM
Abstract
Introduction: Acute Respiratory Failure occurs from either pulmonary dysfunction or muscle pump failure resulting in hypercapnia, and/or hypoxemia. Approximate incidence in the U.S. is 360,000 cases per year and accounts for 36% of deaths in hospitalized patients. Endotracheal Intubation is crucial in advanced airway management and serves as a conduit between the patient and a ventilator. Clinical Vignette: A 71-year old obese, female nursing home resident with history of atrial fibrillation, congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease presented to the hospital with cough and breathing difficulty. Physical examination was significant for marginal bradycardia, tachypnea, oxygen saturation of 97% on 2 liters by nasal cannula, and lower extremity bilateral pitting edema. Arterial blood gas analysis suggested a respiratory acidosis. BNP was elevated. Chest X-ray revealed likely perihilar infiltrates, pulmonary edema, small right pleural effusion, and cardiomegaly. She was initially managed for acute hypercapnic respiratory failure secondary to acute CHF excercebation with COPD, and placed on BiPAP. A trial of diuresis was unsuccessful with progressive hypoxemia and hypercapnia necessitating endotracheal intubation with mechanical ventilation. On day 3, she self-extubated; however, with monitoring, showed improvement on BIPAP with resulting clinical stabilization. Discussion: An unplanned extubation is the unintentional removal or dislodgement of a patient’s breathing tube either by the patient or by an external force. This occurs in about 7% of patients undergoing mechanical ventilation in an intensive care setting. It results in over 12,000 deaths annually, increases incidence of ventilator acquired pneumonia from 14% to 28% and the average ventilated patients ICU stay from 9 to 22 days. It is a fairly common occurrence in the ED, ICU, CVICU, and long term acute care facilities. Increased awareness, and education of personnel in these different clinical settings is critical. Healthcare organizations must accurately track data related to unplanned extubations, tailored to these diverse clinical settings, in order to effectively enact changes that optimally impact patient morbidity and mortality.
Unplanned Extubation in a Patient with Acute Hypercapnic Respiratory Failure: A Case Report
Introduction: Acute Respiratory Failure occurs from either pulmonary dysfunction or muscle pump failure resulting in hypercapnia, and/or hypoxemia. Approximate incidence in the U.S. is 360,000 cases per year and accounts for 36% of deaths in hospitalized patients. Endotracheal Intubation is crucial in advanced airway management and serves as a conduit between the patient and a ventilator. Clinical Vignette: A 71-year old obese, female nursing home resident with history of atrial fibrillation, congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease presented to the hospital with cough and breathing difficulty. Physical examination was significant for marginal bradycardia, tachypnea, oxygen saturation of 97% on 2 liters by nasal cannula, and lower extremity bilateral pitting edema. Arterial blood gas analysis suggested a respiratory acidosis. BNP was elevated. Chest X-ray revealed likely perihilar infiltrates, pulmonary edema, small right pleural effusion, and cardiomegaly. She was initially managed for acute hypercapnic respiratory failure secondary to acute CHF excercebation with COPD, and placed on BiPAP. A trial of diuresis was unsuccessful with progressive hypoxemia and hypercapnia necessitating endotracheal intubation with mechanical ventilation. On day 3, she self-extubated; however, with monitoring, showed improvement on BIPAP with resulting clinical stabilization. Discussion: An unplanned extubation is the unintentional removal or dislodgement of a patient’s breathing tube either by the patient or by an external force. This occurs in about 7% of patients undergoing mechanical ventilation in an intensive care setting. It results in over 12,000 deaths annually, increases incidence of ventilator acquired pneumonia from 14% to 28% and the average ventilated patients ICU stay from 9 to 22 days. It is a fairly common occurrence in the ED, ICU, CVICU, and long term acute care facilities. Increased awareness, and education of personnel in these different clinical settings is critical. Healthcare organizations must accurately track data related to unplanned extubations, tailored to these diverse clinical settings, in order to effectively enact changes that optimally impact patient morbidity and mortality.