Accidental Extubation

Published 03/08/2022

Accidental Extubation




RIJ CVC & left radial arterial line  


Sedatives, noradrenaline, 1L crystalloid at 100ml/hr 


ETT sitting supraglottically (tip must be sitting in laryngeal inlet, balloon above cords 


P-SIMV 15/10 FiO2 0.3 Rate 16 breaths/min (needs hole in test lung to simulate leak) 


Airway trolley 

2L reservoir bag with hole in. Occluded with a clamp that can be removed to progress leak 

Clinical Setting

I:          You are the ICU registrar called by the nurse of the patient in bed 3 

S:        Nurse reports patient in what looks like atrial fibrillation 

B:        76M morbidly obese patient, recently admitted with septic shock secondary to                 necrotising fasciitis 

A:        Low tidal volumes on ventilator and atrial fibrillation 

R:        Called for help 


Potential Clinical Course

  • Initially A ETT, B SpO2 95% on FiO2 0.3 PSIMV at 16bpm, low VTs, ETCO2 3.5kPa, quiet breath sounds bilaterally, C HR92bpm AF, BP 118/62, D Sedated 
  • Falling VTs, falling saturations, loss of ETCO2 trace 
  • Examination reveals ETT sitting supraglotically 
  • Saturations continue to fall 
  • Remove ETT 
  • Proceed with attempted re-intubation – impossible intubation – proceeds down DAS algorithm 
  • Difficult but possible FM ventilation – only with 2 handed technique, repositioning and adjuncts 
  • Calls for help and hands over patient 

Information for Faculty

  • Initial settings:   
    • SpO2 95% on FiO2 0.3 
    • ETCO2 3.5kPa 
    • RR 16/min 
    • Quiet breath sounds through both lung fields 
    • HR82bpm AF 
    • BP 118/62 


  • Progress to:  
    • SpO2 92% on FiO2 0.3 
    • ETCO2 2.5kPa 
    • Quiet breath sounds throughout both lung fields 
    • HR 90bpm AF 
    • BP 111/57 


  • Progress to: 
    • SpO2 92%  
    • Loss of ETCO2 trace 
    • Absent breath sounds 
    • Increase HR to 115bpm AF 
    • BP 102/48 


  • On induction of anaesthesia/NMBD: 
    • SpO2 90% 
    • RR zero 
    • Absent breath sounds 
    • Reduce BP to 82/45 
    • Increase HR to 128bpm
    • Further observations depend upon actions 

Faculty Roles

Bedside Nurse 1: 

  • You are a CNS 
  • You are looking after a 76M with septic shock 
  • You have noticed the patient is in AF and want to know, from the registrar, if this is old or new? 
  • You have no other concerns except that the patient’s tidal volumes are a little low, but you’d expect that with a morbidly obese patient, and have increased the respiratory rate accordingly 
  • You take direction well, and can perform tasks asked if you in a timely fashion, you just lack impetus 
  • If the candidate asks the patient has been a little restless requiring the odd bolus of propofol 
  • During the failed intubation process you repeatedly suggest trying to intubate the patient again.  


Bedside Nurse 2: 

  • You are a new starter – you have never seen an airway emergency before 
  • You are quite startled when asked questions/given directions, requiring instructions to be repeated to you 
  • If the candidate names equipment using technical terms then you inform them that you don’t know what that is eg bougie 
  • You are keen to help, but are unwilling to do anything beyond your skill set .


HiLLO: 10