Reasons why a patient may may need to be reintubated after extubation
(1) accidental extubation
(2) problem with endotracheal tube
(2a) endotracheal tube malposition
(2b) cuff or pilot tube problem
(2c) problem with airway (kinked, blocked)
(3) physiologic deterioration after inappropriate extubation (error in judgment and/or preparation)
(4) physiologic deterioration after appropriate extubation
Patients who present a problem:
(1) difficult body habitus (morbid obesity, etc)
(2) uncooperative
(3) inadequate analgesia
(4) agitated
Reasons why staff may make an error:
(1) high unit activity and/or staff busy
(2) lack of skilled assistance
(3) inadequate training
(4) failure in problem recognition
(5) inadequate patient assessment
(6) error in decision making or judgment
