EXtubation-related complications—an international observational study To Understand the impact and BEst practices in the operating room and intensive care unit—the EXTUBE study

Matteo Parotto, MD, PhD

Matteo Parotto, MD, PhD

Matteo Parotto, MD, PhD
Associate Professor, Anesthesia & Pain Management, University Health Network, Toronto General Hospital

Dr. Parotto’s project is entitled: “EXtubation-related complications—an international observational study To Understand the impact and BEst practices in the operating room and intensive care unit—the EXTUBE study.”

Background: Globally, over 200 million people each year require extubation. While routinely performed, extubation is a skilled and potentially high-risk procedure that should be performed only when physiologic, pharmacologic, and contextual conditions are optimal.1 Complications at this stage of patient care can result in decreased oxygen delivery to the brain and body, sometimes leading to serious adverse events such as cardiac arrest, brain damage, or death. Indeed, one quarter of airway complications that result in death or brain death occur at the time of extubation.2 Despite the frequency of extubation and the potential for life-threatening complications, we lack systematic data on the rate and circumstances under which these severe complications occur. The limited data indicate 10–30% of extubations may lead to severe complications, depending on the population and outcome definition.2-4 However, the certainty of these estimates is severely limited because they are based on studies that are small, mostly single-center, based on clinician recall, only capture a small portion of extubation complications (e.g., malpractice claims), or do not reflect current clinical practice. In addition, most lack a denominator and exclude successful extubations, making estimates of actual complication rates and risk factors impossible. Promisingly, a recent focus on intubation complications, risk factors, and best-practices has decreased intubation complications by up to 26%,5 suggesting that a similar program of research focusing on extubation could have a comparable impact on patient safety and outcomes. As a result, there have been calls for a large, systematic study to identify risks of extubation complications and effective extubation techniques, fitting with the APSF priority in Airway Management difficulties. In particular, high-quality baseline data on complication rates are needed to evaluate future interventions and clinical practice guidelines. There has been no large study of extubation techniques or adherence to guidelines; so procedural factors associated with complications must be elucidated. While adherence to clinical practice guidelines has not been formally evaluated, surveys show nonadherence to some best practices and considerable variation in practice, and data from audits and medicolegal claims show that lack of adherence to best practices is frequently at the root cause of severe adverse extubation outcomes with half of the complications deemed preventable.2-4 Therefore, data on the frequency and nature of extubation complications, patient and procedural risk factors for complications, and guideline adherence rates are needed before these preventable events can be addressed.

Aims: Our primary question is “What is the incidence of severe extubation complications within 60 minutes after extubation in adults who have undergone mechanical ventilation for general anesthesia or critical illness?” Severe complications will be measured by i) Severe hypoxemia (SpO2 < 80% for >5 minutes); ii) Unplanned noninvasive ventilation; iii) Cardiac arrest; iv) Need for airway management (reintubation, insertion of a supraglottic airway, bag-mask ventilation). Our secondary questions are: 1) “What is the incidence of mild extubation complications?”; 2) “What are patient- and procedure-related risk factors for extubation complications?”; 3) “Is there an association between extubation complications and outcomes until hospital discharge?”; 4) “What is the rate of adherence to extubation clinical practice guidelines?”

Implications: EXTUBE will establish the burden of extubation complications and the extent to which they are preventable, which could guide future interventions and guideline updates. This information will directly contribute to the advancement of the APSF priority in Airway Management difficulties, skills, and equipment, moving the field forward in improving patient safety in this fundamental area of care.

REFERENCES

  1. Parotto M, Ellard L. Extubation following anesthesia. UpToDate; 2022. https://www.uptodate.com/contents/extubation-following-anesthesia Accessed November 30, 2023.
  2. Joffe AM, Aziz MF, Posner KL, et al. Management of difficult tracheal intubation: a closed claims analysis. Anesthesiology. 2019;13:818–829. PMID: 31584884.
  3. Cook TM, Woodall N, Frerk C. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society: major complications of airway management in the United Kingdom Report and Findings. 2011. PMID: 21447488.
  4. Crosby ET, Duggan LV, Finestone PJ, et al. Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association. Can J Anaesth. 2021;68:183–195. PMID: 33200320.
  5. Pedersen TH, Ueltschi F, Hornshaw T, et al. Optimisation of airway management strategies: a prospective before-and-after study on events related to airway management. Br J Aneasth. 2021;127:798–806. PMID: 34535275.

Funding: $149,999 (January 1, 2024–December 31, 2025). This grant was designated as the APSF/American Society of Anesthesiologists (ASA) President’s Research Award and Ellison C. Pierce, Jr., MD, Merit Award with $5,000 unrestricted research support.