Trends, Risk Factors, and Outcomes of Unplanned Extubation in a Neonatal Intensive Care Unit: A Seven-Year Retrospective Study

Kamal Ali^1,2,3*Mohammed Almahdi¹Saleh S Algarni^1,2,3Saif Alsaif^1,2,3Reem O Alharbi¹Maisa A Alqahtani¹Rashed Aldubaian¹Malak Alsharif¹Mark Castro¹Abigail Esclanda¹Manal Althubaiti¹Mohanned Alrahili¹Musab Alshareef¹Abdulaziz Homedi¹Ibrahim Ali¹

• ¹King Abdulaziz Medical City, Riyadh, Saudi Arabia
• ²King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
• ³King Abdullah International Medical Research Center (KAIMRC), Riyadh, Saudi Arabia

Background: Unplanned extubation (UE) is a critical adverse event in neonatal intensive care units (NICUs), contributing to increased morbidity, and potential complications such as airway trauma, ventilator-associated pneumonia. This study aimed to evaluate the incidence and trends of UE over a seven-year period, and assess clinical outcomes following these events.Methods This retrospective observational study was conducted at the NICU of King Abdulaziz Medical City, Riyadh, from January 2018 to December 2024. Data were extracted from electronic medical records and included demographic details, ventilation parameters, and clinical outcomes of neonates experiencing UE. UE events were defined as the unintentional removal of an endotracheal tube during mechanical ventilation. The primary outcome was the incidence of UE per 100 ventilator days. Logistic regression analysis was performed to identify predictors of reintubation following UE. Results
A total of 175 UE episodes were recorded over the study period. The annual UE rate ranged from 1.31 per 100 ventilator days to the lowest recorded rate of 0.42. Notably, the lowest UE rate was observed in 2024, despite an increase in unit capacity, coinciding with improved respiratory therapist (RT) staffing levels. Lower gestational age (GA) was associated with increased odds of reintubation (OR = 0.79, 95% CI: 0.66–0.93, p = 0.006), as was lower birth weight (OR = 1.002, 95% CI: 1.001–1.003, p = 0.002). HFOV use at the time of UE was linked to a higher reintubation rate (p < 0.001). Duration of ventilation and length of hospital stay were significantly longer in infants who required reintubation after UE (p<0.001, 0.004 respectively). Mortality prior to discharge was notably higher among neonates who required reintubation (23%) compared to those who did not (3%, p<0.001). Conclusions
The study demonstrated an overall decline in UE rates over the seven-year period, with the lowest rate observed in 2024. This decline occurred despite increased NICU capacity, suggesting that improvements in workforce staffing, particularly an increase in RT coverage, contributed to enhanced patient safety. Reintubation following UE was influenced by gestational age, birth weight, and pre-extubation FiO₂ levels, emphasizing the need for improved preventive strategies.