Intubations are among the most common invasive interventions performed in the intensive care unit (ICU), and most ICU patients who require mechanical ventilation are intubated. Unplanned extubation (UE), an intubation-associated complication, is defined as the removal of an endotracheal tube by a patient or its accidental removal. The reported frequency of UE ranges between 3 and 16 % among patients on mechanical ventilatory support [1–3]. A previous study in our center showed a similar rate of extubation (11 %) [4]. Among its main causes are inadequate sedation and insufficient nursing care during positioning. Nevertheless, UE may occur even under optimal conditions where sedation is adequate and all necessary precautions are taken. Successful management of UE may result in shortened duration of intubation and reduced rate of complications associated with mechanical ventilation. On the other hand, failure to do so may lead to the need for reintubation, leading to an increased risk of complications.

In a case-control study by Epstein et al. [5], a total of 75 patients with UE were compared with 150 controls. In their center, the incidence of UE was 11 %. Patients with UE had a longer duration of stay in the ICU as well as prolonged hospitalization. However, patients with UE who did not require reintubation had similar mortality, ICU and hospital stay, and mechanical ventilation duration as controls. In that study, controls and patients with UE did not significantly differ in terms of in-hospital mortality. Furthermore, patients who did or did not require reintubation after UE had similar rates of in-hospital mortality. Thus, UE emerged as a risk factor associated with prolonged duration of intensive care and hospitalization.

In another study, by Atkin et al. [6], the clinical outcomes in 50 patients with UE and 100 controls were compared, whereby the frequency of nosocomial infections before the occurrence of UE was higher among patients with UE than among controls. However, these authors did not report on the infection incidence following the occurrence of UE. Similar to the previously mentioned study, patients with UE had longer hospital and ICU stay, despite the absence of a significant difference in in-hospital mortality rates from controls (38 % vs 25 %; p = 0.14).

Krinsley and Barone [7] compared 100 patients with UE and 200 control subjects and observed an increased duration of hospital and ICU stay, in addition to a prolonged requirement for mechanical ventilation in UE cases. However, there was a significantly higher mortality rate in controls. As compared with patients with UE who did not require reintubation, those who required reintubation had an increase in hospital and ICU stay, requirement for mechanical ventilation, frequency of infections acquired during intensive care, costs associated with intensive care, laboratory work-up, and diagnostic imaging studies, and, most importantly, they had increased mortality. In the same study, a multiple logistic regression analysis showed that age was the single most important determinant of the need for reintubation, while reintubation was the most important determinant of mortality after UE. In that study, reintubation was not only associated with an increased occurrence of intensive care-acquired infections but also with increased mortality.

Between 22 and 74 % of patients require reintubation after UE and most studies reported increased mortality in patients requiring reintubation after UE. The reported rate of reintubation was 56 % in the study by Epstein et al. [5]. Risk factors for UE and factors associated with the need for reintubation were explored by Chevron et al. [8], who found that a Glasgow Coma Scale score below 11 and a PaO₂/FiO₂ ratio below 200 correlated with a higher frequency of the need for reintubation in patients in whom UE occurred during weaning.

Despite the clear association between UE and life-threatening complications, most institutions still lack standard procedures to be implemented in the case of UE. While the need for reintubation is immediately evident in a certain proportion of patients (e.g., inability to maintain an airway, significant oxygen requirement, unconsciousness) who require prompt reintubation after UE, others may not be in the need of reintubation despite the continued need for mechanical ventilation at the time of the occurrence of UE. The need for intubation is not synonymous with the need for mechanical ventilation, and in a certain group of patients noninvasive mechanical ventilation may be considered as an alternative to re-intubation.

Invasive mechanical ventilation is a safe method in ICU patients when noninvasive positive-pressure ventilation (NPPV) is contraindicated or not applicable. However, complications like nosocomial pneumonia and intubation-related complications may occur.

Prevalence of nosocomial pneumonia rises significantly with recurrent intubations [9]. In a study examining the role of reintubation in the development of nosocomial pneumonia, 40 patients who underwent reintubation were compared with controls. A significant proportion (47 %) of patients who underwent reintubation had pneumonia compared with only 10 % of controls, a statistically significant difference. A logistic regression analysis in the same study showed that reintubation was the most important factor for the development of pneumonia. Reintubated patients had a significantly longer total duration of stay in the ICU as well as increased mortality. Therefore, early administration of NPPV before the development of respiratory failure may decrease the frequency of reintubations, which was demonstrated in previous studies, along with a decrease in ICU mortality.