RESEARCH

Extubation in intensive care units

in the UK: an online survey
Jack Hodd, Alex Doyle, Joseph Carter, John Albarran and Peter Young
ABSTRACT
Aim: To determine the current practice among critical care nurses in the UK with regard to airway management during cuff deflation and
extubation.
Background: There are a number of techniques used by clinicians to prevent aspiration during cuff deflation and extubation of patients.
There are no published clinical studies comparing the different manoeuvres available to clinicians at the time of extubation nor any data to
suggest which technique is most commonly used.
Methods: All members of the British Association of Critical Care Nurses with an email address were invited to participate in an online survey.
Results: A total of 533 (29%) nurses from 184 (84%) intensive care unit (ICUs) in the UK completed the survey. Just under half of the
sample (n = 258, 484%) had more than 10 years of critical care experience and the vast majority (n = 427, 801%) worked in general ICUs.
The majority of respondents (n = 461, 865%) suction the trachea during cuff deflation and extubation. A further 304 (57%) respondents ask
patients to cough as part of extubation. Respondents increase the positive end expiratory pressure setting on the ventilator infrequently as part
of routine procedure for extubation (n = 7, 13%).
Conclusion: The majority of UK critical care nurses either suction the trachea during cuff deflation and extubation of patients and/or simply
ask the patient to cough. Further clinical trials are required to identify the most appropriate and safe technique for critically ill patients.
Key words: Advancing practice Clinical audit Intensive care nursing Mechanical ventilation Respiratory care

AIM OF THE STUDY

To determine the current practice among critical care
nurses in the UK with regard to airway management
during cuff deflation and extubation.

BACKGROUND
An audit of 176 intensive care units (ICUs) in England
and Wales recently reported that 35% of patient
extubations were undertaken by nurses and a further
30% were carried out jointly by nurses and doctors
(Suresh and Cheesman, 2006). The decision to extubate
Authors: J Hodd, MB BChir, Critical Care Trainee, Department of
Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical
Care, Kings Lynn, UK; A Doyle, MB BS, Critical Care Trainee, Department
of Anaesthesia and Critical Care, Queen Elizabeth Hospital NHS Trust,
Critical Care, Kings Lynn, UK; J Carter, MB ChB, Consultant in Anaesthesia
and Critical Care, Department of Anaesthesia and Critical Care, Queen
Elizabeth Hospital NHS Trust, Critical Care, Kings Lynn, UK; J Albarran,
DPhil, Reader in Cardiovascular Critical Care Nursing, Centre for Clinical
and Health Services Research, University of the West of England, Bristol,
UK; P Young, MD, MBChB, Consultant in Anaesthesia and Critical Care,
Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital
NHS Trust, Critical Care, Kings Lynn, UK
Address for correspondence: P Young, Department of Anaesthesia
and Critical Care, Queen Elizabeth Hospital NHS Trust, Critical Care, Kings
Lynn, UK
E-mail: peter.young@qehkl.nhs.uk

is often guided by specific objective criteria in the

form of clinical parameters. These include an ability to
initiate respiratory effort, assessment of cough strength
and ability to clear secretions as well as obey commands
(McIntyre, 2001; Epstein, 2002; Pilsworth, 2007).
During intubation, subglottic secretions accumulate
in the space above the endotracheal tube cuff.
There is a risk that these secretions are aspirated
during cuff deflation and extubation. This may
precipitate pneumonitis or pneumonia (Estes and
Meduri, 1995). Ensuring that endotracheal airway
removal is performed safely and without precipitating
adverse events is critical to patient outcomes (Epstein,
2004). Re-intubation following the extubation of
critically ill patients is a serious adverse event that is
required in approximately 1520% of patients (Epstein,
2004; Siner and Manthous, 2007).
Various techniques are used during cuff deflation
and extubation to prevent secretions from entering the
lungs. These include suctioning the trachea during cuff
deflation and extubation, adjusting the positive end
expiratory pressure (PEEP) setting on the ventilator
or compressing the reservoir bag just prior to cuff
deflation and extubation (Rassam et al., 2005). We
recently published an article comparing the ability
of simulated intratracheal suction and a PEEP level of
35 cm H2 O to minimize aspiration during cuff deflation

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Extubation in intensive care units

and extubation in a bench-top model (Hodd et al., 2010).

This found that applying PEEP during extubation
results in significantly less aspiration compared with
the use of a tracheal suction catheter. However,
there are no published clinical studies comparing the
different manoeuvres available to clinicians at the time
of extubation nor any data to suggest which technique
is most commonly used.

METHOD
After review by the Local Research and Ethics Committee, this study was conducted over a 12-week
period. Eligible participants were identified from the
British Association of Critical Care Nurses (BACCN)
membership database. The BACCN contacted all members who had registered an email address (n = 1830).
Each member was sent an email, which contained
an outline of the study and a hyperlink to the website http://www.surveymonkey.com, which hosted
the online survey. Respondents opted to participate
in the survey by clicking on the hyperlink. Each question was developed and tested in a pilot study. We
asked five senior critical care nurses from our ICU to
complete the survey and comment on any areas, which
were not straightforward for them to complete. The
questionnaire was deliberately short (four questions)
to ensure as high a response rate as possible.
1.

Which hospital is your main place of work?

2.

How long have you worked in the intensive

care/high dependency unit?

3.

What type of intensive care/high dependency

unit do you work in?

4.

Less than 1 year

15 years
610 years
More than 10 years

RESULTS
All 1830 email addresses were contacted. A total of 533
(29%) nurses from 184 (84%) ICUs in the UK completed
the survey (CMA Medical Data, Loughborough, UK).
The number of respondents who had experience
of less than 1 year, between 1 and 5 years, 6 and
10 years and more than 10 years was 9 (17%), 133
(25%), 130 (244%) and 258 (484%), respectively, and
3 (06%) respondents did not answer the question.
The number of respondents who worked in general,
cardiothoracic, neurological and paediatric ICUs was
427 (801%), 50 (94%), 29 (54%) and 7 (13%),
respectively, and 20 (38%) respondents did not answer
the question. During cuff deflation and extubation,
31 (58%) respondents compress the reservoir bag,
7 (13%) adjust the PEEP setting on the ventilator, 461
(865%) suction the trachea, 4 (08%) extubate with the
cuff inflated and 304 (57%) ask the patient to cough
(Figure 1). The combinations of techniques used by
respondents during cuff deflation and extubation are
shown in Table 1.

DISCUSSION
Our study suggests that the majority of UK critical
care nurses either suction the trachea during cuff deflation and extubation of patients and/or simply ask the
patient to cough. This is the first study to determine the
current practice among critical care nurses in the UK
with regard to airway management during cuff deflation and extubation. There are a number of techniques
that are used during cuff deflation and extubation. So
far, there are no published clinical studies comparing
the effectiveness of the different manoeuvres.

Cardiothoracic intensive care

Neuro-critical care
Paediatric intensive care
Other (please specify)

When you extubate a patient on the intensive care

unit, do you (please select all that apply)?

Compress the reservoir bag

Adjust the PEEP setting on the ventilator
Suction the trachea
Extubate with the cuff inflated
Ask the patient to cough

A reminder email was sent out 2 weeks after the

survey was initiated. No incentives were used to
282

increase the response rate. The sampling approach

did not discriminate between those nurses in practice,
education, management or research. Data were entered
into a spreadsheet and analysed using Microsoft Excel.

Figure 1 Techniques used by respondents during cuff deflation and

extubation.

2010 The Authors. Nursing in Critical Care 2010 British Association of Critical Care Nurses

Extubation in intensive care units

Table 1 The combinations of techniques used by respondents during cuff

deflation and extubation
Technique
1. Suction trachea and ask patient to cough
2. Suction trachea alone
3. Ask patient to cough alone
4. Compress reservoir bag alone
5. Compress reservoir bag, suction trachea and ask patient to
cough
6. Compress reservoir bag and ask patient to cough
7. Compress reservoir bag and suction trachea
8. Adjust PEEP setting and ask patient to cough
9. Adjust PEEP setting, suction trachea and ask patient to
cough
10. Suction trachea, extubate with cuff inflated and ask
patient to cough
11. Compress reservoir bag, adjust PEEP setting and suction
trachea
12. Adjust PEEP setting and suction trachea
13. Adjust PEEP setting and extubate with cuff inflated
14. Suction trachea and extubate with cuff inflated
15. None of the above
Total

Number
244 (478%)
197 (37%)
39 (73%)
10 (19%)
8 (15%)
7 (13%)
5 (<1%)
2 (<1%)
2 (<1%)
2 (<1%)
1 (<1%)
1 (<1%)
1 (<1%)
1 (<1%)
13 (24%)
533

PEEP, positive end expiratory pressure.

There is limited evidence to support suctioning of

the trachea during cuff deflation and extubation. Previously, we have shown in a simulated model of the
trachea that applying PEEP during cuff deflation and
extubation results in significantly less aspiration compared with the use of a tracheal suction catheter (Hodd
et al., 2010). Our survey indicates that only a very
small proportion of critical care nurses apply PEEP as
part of their routine procedure for extubation. These
respondents worked at six UK hospitals.
Data from this survey provides a useful baseline, which will allow comparison in the future once
further research has determined the optimum extubation technique. The questionnaire was deliberately

short to encourage as high a response rate as possible.

Although the response rate from individual nurses was
low (28%), this does represent a reasonable response
rate for an online survey (Sheehan, 2001). A possible
explanation for the low response rate in our survey
is that the sampling approach did not discriminate
between those nurses in practice, education, management or research. In addition, the number of inactive
email accounts was unknown. However, our sample
was representative of nurses responding from 84% of
the UK ICUs. We believe that nurses from the same ICU
are likely to have similar practices and consequently
our results represent a broad spectrum of practice
across the UK. The questionnaire was also deliberately
simple to avoid ambiguity. This is reflected by the
vast majority of questionnaires that were successfully
completed. However, 95 (178%) respondents failed to
answer the first question. The reason for this is not clear;
a possible explanation is that this question required free
text input and so was not so straightforward to answer.
We conclude that the majority of UK critical care
nurses either suction the trachea during cuff deflation and extubation of patients and/or simply ask the
patient to cough. Further clinical studies are needed
to determine the effectiveness of different manoeuvres
available to clinicians at the time of extubation. Until
a definitive scientific answer is made available, we
believe that more critical care nurses and ICUs should
consider the application of PEEP during cuff deflation
and extubation.

ACKNOWLEDGEMENTS
We wish to acknowledge the support of the BACCN
for allowing us access to its membership to collect this
data.

CONFLICTS OF INTEREST
None declared.

WHAT IS KNOWN ABOUT THIS TOPIC

Around a third of all endotracheal tube extubations are performed by nurses.
Various extubation techniques are used, but there are no published clinical studies comparing the different manoeuvres available to
clinicians at the time of extubation.
The most common extubation technique used by intensive care nurses in the UK remains unknown.
WHAT THIS PAPER ADDS
Suctioning the trachea during cuff deflation and extubation is the most common extubation technique in the UK.
Patients are asked to cough as the tube is being withdrawn from their airway in over half of the extubations.
Increasing the PEEP setting on the ventilator is used infrequently during cuff deflation and extubation.

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Extubation in intensive care units

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2010 The Authors. Nursing in Critical Care 2010 British Association of Critical Care Nurses