Unplanned Extubation in Extremely Preterm Neonates: Incidence, Risk Factors, and Impact on Clinical Outcomes

Background Unplanned extubation (UE) poses a significant safety risk to mechanically ventilated, preterm, and critically ill neonates in the neonatal intensive care unit (NICU).  Objective The aim of this study was to evaluate the incidence of UE from January 2018 to December 2021, identify contributing risk factors, and compare the outcomes with a cohort of extremely preterm (EP) infants. Methods A retrospective study was conducted in the NICU at the Women's Wellness and Research Center, Hamad Medical Corporation in Qatar. The study included 25 EP neonates who experienced UE events. The characteristics and outcomes of these infants were compared with a matched cohort of 75 EP infants without UE, selected using propensity score matching at a ratio of 1:3 to balance key baseline characteristics. This study was initiated in early 2018 following the introduction of a care improvement bundle that integrated various care practices and involved multiple healthcare staff. Results We recorded 25 UE events in our cohort of 507 EP neonates, totaling 5,668 invasive ventilation days. The incidence of UE events was 0.44 per 100 ventilation days over the four-year period, ranging from 0.60 in 2018 to 0.27 in 2020. UE occurred mainly during routine care activities (24%), due to agitation (20%), or during endotracheal tube manipulation (20%). Following a UE event, 64% of the neonates required positive pressure ventilation, and 88% were reintubated. Comparisons between the UE and non-UE groups revealed that UE was associated with significantly higher rates of bronchopulmonary dysplasia (BPD) (91.3% vs. 59.6%, p = 0.006), severe BPD (34.8% vs. 8.8%, p = 0.008), and increased postnatal steroid use (72.0% vs. 18.7%, p < 0.001). Neonates in the UE group had significantly longer hospital stays (127.0 days (IQR: 112.0-183.2) vs. 101.0 days (IQR: 90.0-139.5), p = 0.010), a higher median discharge postmenstrual age (42.8 weeks (IQR: 41.1-50.4) vs. 40.1 weeks (IQR: 37.3-46.6), p = 0.006), and a higher rate of receptive neurodevelopmental delays (50.0% vs. 19.5%, p = 0.009). Conclusion Neonates who experienced UE faced an increased risk of adverse respiratory and neurodevelopmental outcomes, including higher rates of BPD, increased postnatal steroid use, and longer NICU stays. This highlights the critical role of nursing care and continuous quality improvement efforts in the NICU to prevent UE.