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Updated: Aug 13, 2026
A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation
Published on: January 18, 2011
A low-cost educational intervention to reduce unplanned extubation in low-resourced pediatric intensive care units
Asitha D L Jayawardena1, Zelda J Ghersin2, Luis Jose Guzman3
1Children's Minnesota, Department of Otolaryngology, Minneapolis, MN, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, Boston, MA, USA.
Insights
A low-cost intervention significantly reduced unplanned extubations (UE) in a pediatric intensive care unit (PICU). This educational bundle, including cuffed endotracheal tubes, also decreased pediatric mortality, demonstrating a cost-effective approach to improving patient safety.
Area of Science:
- Pediatric Critical Care Medicine
- Patient Safety
- Health Equity
Background:
- Unplanned extubation (UE) rates are disproportionately high in low-income Pediatric Intensive Care Units (PICUs).
- Approximately 20% of UEs lead to critical events, increasing morbidity and mortality.
- Safe airway management principles are universal, necessitating accessible solutions for resource-limited settings.
Purpose of the Study:
- To evaluate a multi-disciplinary educational intervention bundle aimed at reducing UE in a low-resourced PICU.
- To assess the impact of providing low-cost cuffed endotracheal tubes (ETT) and ETT tape on UE rates.
- To explore the effect of the intervention on overall PICU mortality.
Main Methods:
- A pre-post interventional study was conducted in an El Salvadorian PICU.
- A multidisciplinary team delivered an educational curriculum including hands-on training and online modules.
- Low-cost disposable materials, including cuffed ETTs, were provided at an intervention cost of $1.32 per child.
Main Results:
- UE rates decreased significantly from 29.4% to 17.3% post-intervention (p=0.01).
- Cuffed ETT use increased from 12% to 36% and was associated with reduced UE (OR: 0.40).
- A 4.3% decrease in pediatric mortality was observed, with a low incremental cost-effectiveness ratio (ICER) per mortality prevented ($30.7).
Conclusions:
- A multi-faceted intervention bundle is an accessible and scalable strategy to reduce UE in low-resource PICUs.
- This intervention demonstrates cost-effectiveness in reducing pediatric mortality.
- The findings have significant implications for improving global pediatric patient safety and outcomes.
Introduction:
Unplanned extubation (UE) is orders of magnitude worse in low-income Pediatric Intensive Care Units (PICUs) than their high-income counterparts. Furthermore, a significant percent (20 %) of UEs result in a destabilizing event or cardiac collapse that negatively contributes to morbidity and mortality. As the principles of safe airway management are universal, we hypothesize that a multi-disciplinary educational intervention bundle which included provision of low-cost cuffed endotracheal tubes (ETT) and ETT tape will decrease the rate of unplanned extubation (UE) in a low-resourced PICU.
Methods:
This is a pre-post interventional study powered to evaluate UE of intubated pediatric patients in an El Salvadorian PICU after a multi-disciplinary educational effort and provision of low-cost disposable materials. A multidisciplinary (otolaryngologists, intensivists, anesthesiologists, respiratory therapists, and nurses) educational curriculum involving hands on training, online video modules readily available via bedside QR codes, and pre- and post-testing was administered. The cost of the intervention materials was $1.32 per child. PICU mortality was evaluated as an exploratory outcome.
Results:
Nine-hundred and fifty-seven (859 pre-intervention and 98 post-intervention) patients met inclusion criteria. Patients with one or more UEs decreased significantly from 29.4 % to 17.3 % post-intervention (p = 0.01; CI: 0.28-0.88) with an odds ratio of 0.51. The use of a cuffed ETT increased from 12 % to 36 % (p < 0.001; CI: 0.17-0.44; OR:3.74) and cuffed ETT use was associated with a reduction in UE with an odds ratio of 0.40 (p < 0.001; CI: 0.24-0.66). Finally, there was a 4.3 % decrease in pediatric mortality from 26.7 % to 22.4 % that equates to a number needed to treat to prevent a single child mortality of 23. Therefore, the ICER per mortality prevented is $30.7 and the ICER per Disability Adjusted Life Year (DALY) is $0.44.
Conclusion:
This multi-faceted intervention bundle is an accessible, scalable, cost-effective means to reduce UE and has implications in reducing global pediatric mortality.
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