What do you do if your patient partially self extubates?

[stripec30]

What would be your course of action if a patient partially self extubates (enough to where you can see the balloon)? Pull the tube, grab the ambu-bag and have anesthesia reintubate? or assess the patientcy of the tube, if patient then reinsert the tube?

[EricJRN, MSN, RN]

I haven't worked with intubated adults in some time, but I don't think that my employer or my insurance carrier would be too stoked about a staff nurse reintroducing an displaced ET tube. I'd go with option A - bag and call for help.

[OptimusPrime]

Assess your patient. o2 sats, WOB, lung sounds, HR, RR/min, and eye color... Maybe they're fine without being intubated and all they need is some oxygen. Maybe they need an ambu, maybe not. Why were they intubated initially? Where and how much of the balloon could you see? Lots of variables.

I personally feel comfortable enough with ET tubes, that given the right situation, I would try to advance the tube and see what happens. Then call for CXR, if Im able to re-insert it.

Since you're asking this question on here, you're probably better off, for now, having someone call RT and have them come assess the situation.

BUT... If you're patient condition is deteriorating before the RT can get there, or they have a paralytic on board, don't be afraid to pull the tube, hook up to o2 and bag.

[sunnycalifRN]

Well, as a former RRT, I can tell you the "by the book" answer.

First off, if you can see the balloon, he hasn't "partially extubated", he's extubated himself . . . the ETT is just sitting at the back of his throat.

I would never try to "re-insert" the ETT without direct laryngoscopy because you could just as easily end up in the esophagus as the trachea.

Has it been done? Sure, but the RRT doing it knows to watch the EtCO2 waveform to be sure that the tube is back in the trachea. Personally, I'd call anesthesia and just use the ambu bag until they arrive.

[chare]

If you are able to see the endotracheal tube cuff on the patient's mouth this makes your decision easy. In this case, your patient has not "partially self extubated" they are completely extubated and you need to remove the tube from the mouth and provide whatever ventilatory support that is appropriate.

However, if the tube has been properly secured to the patient's face, and whatever was used to do this is still intact, you will rarely if ever see the cuff in the patient's mouth. What typically happens is that the tip of the tube is displaced from within the trachea and ends up in the esophagus.

At this time you must assess your patient to determine whether the tube is still patent or not.

The first thing you need to do is listen to your patient while providing assisted ventilations. If you have lung sounds with spontaneous ventilations the patient could be breathing around the displaced tube.

Listen over the epigastrium first. If you hear gurgling the tube is in the esophagus and needs to be removed. If you don't hear gurgling over the epigastrium then listen over both lungs. You should hear air movement equally well over both lungs.

If you are still uncertain whether the tube is still patent, you need to look at your patient.

• Do they appear to be in any distress?
  
• If spontaneous breathing is present, what is the rate and quality?
  
• Does the chest rise and fall?
  
• If the ventilator circuit or resuscitator bag is still attached, do you hear audible breath sounds?
  
• What is their skin color? Is there any cyanosis, pallor, or mottling?
  
• What is the heart rate?
  
• What is the oxygen saturation?
  
• If you are using capnometry/capnography are the results appropriate?
  

Remember, at any time, if there is ever any doubt as to whether the endotracheal tube is patent or not, you need to remove it.

I hope this information is helpful.

[stripec30]

Thanks for all the responses.

[meandragonbrett]

Determine if your patient actually still requires invasive PPV. Often times those who pull their tube tend to be awake and alert enough to fly on their own with an aerosol facemask...providing there is no sedation/paralytic on board.

We often leave ours on their own to see if they will fly (particularly if they're already being weaned).

I wouldn't push the ETT back down. How do you know that the cuff isn't defective?

[DhornRN]

I'd remove the ETT and ambu. Then, start the assessment process to see if reintubation is needed. Some of the pts who self-extubate are really needing to be extubated. For example, during the weaning process when sedation is off and they are pulling against the restraints.

[dtrmnd2sccd]

This just happened on our unit today (I'm a student nurse/tech graduating in May). I heard the vent alarm and went in to check--the pt had pulled the tube out as far as the tape would allow, and was gagging/gasping with TONS of secretions... I unhooked his grasp on the tubes, saw how far it had come up, and immediately stuck my head out into the hall and called for help. Several RNs came running in. No attempt was made to push it back in--they deflated the cuff, cut the tape, and had an ambu bag ready, but he was able to breathe on is own with a face mask and O2 (they'd planned to extubate later in the afternoon). It definitely got my adrenaline pumping, but they were cool, calm and collected... very impressive.