Extubation: Plan The End At The Beginning

Anesthesia providers frequently have the equipment and help available for intubation. However, they tend to take extubation for granted. The anesthesia provider should treat extubation with the same degree of caution as intubation. Like an airline pilot must treat take-off and landing with equal respect, the anesthesia provider must treat intubation and extubation with equal respect.

Increased use of video-laryngoscopy, bougies, and the use of supra-glottic airways have revolutionized airway safety. Death or brain damage in closed claims associated with induction of anesthesia has decreased significantly. In contrast, death/brain damage associated with maintenance, extubation, or recovery has not significantly improved. About 12% of death/brain damage claims were associated with extubation. The majority of these patients had difficult intubation on induction, obesity, and/or sleep apnea. In other words: difficult airways.

Approach extubation of the patient with a difficult airway with caution. This is especially true if you are considering deep extubation to avoid coughing and bucking. Laryngospasm, if it occurs, could worsen any preexisting obstruction. The Difficult Airway Society and the American Society of Anesthesiologist’s Task Force on Management of the Difficult Airway have published clinical practice guidelines for managing the difficult airway, including an extubation algorithm.

Difficult  Airway Society Extubation Guidelines: Basic Algorithm

Any Patient Can Fail Extubation!

Never assume an extubation will be easy. Any patient can develop laryngospasm, aspiration, or hypoventilation.

Anticipate Problems

Before extubation, assess carefully when there is:

  • a history of difficult intubation
  • potentially difficult intubation/ventilation (obesity, edema, obstruction)
  • any fixed instrumentation impeding reintubation, such as halo traction or a jaw wired shut
  • administration of large volumes of IV fluids or colloid
  • airway edema from trauma or infection

Does This Patient Meet Extubation Criteria?

Your patient should meet awake extubation criteria. Routine extubation criteria include:

  • inspiratory capacity of at least 15 ml/kg;
  • no hypoxia, hypercarbia, or major acid/base imbalance;
  • no cardiopulmonary instability;
  • intact muscle power (including reversal of muscle relaxants if indicated);
  • absence of retraction during spontaneous respiration;
  • absence of a distended stomach.

In other words, you want your patient to be stable, able to breathe without help, at minimal risk of vomiting and aspirating, and able to protect the airway. There are rare instances when extubation without meeting these criteria may be appropriate. An example of a case requiring a decision of whether to extubate or not extubate can be found here:

To Extubate or Not to Extubate: That Is the Question

Optimize Your Patient For Extubation

Hemodynamics should be stable.  Preoxygenate well — if the patient goes into laryngospasm this increases time to treat before oxygen desaturation occurs. Suction the airway clear of secretions. Make sure to reverse any muscle relaxation. Raise the back of the bed, if possible, to optimize ventilation and open the airway.

If you’re concerned about airway edema, consider direct examination of the airway with laryngoscope or fiberoptic. Alternatively, perform a leak test. After suctioning, deflate the endotracheal tube cuff and listen for a leak around the tube as the patient exhales. If there isn’t a leak, there may be too much edema to ensure an open airway after extubation.

Extubation Technique

After you have suctioned and oxygenated the patient, untape the tube, but continue to hold it securely at the corner of the mouth so it doesn’t come out until you’re ready. Have the patient take a deep breath or manually assist the patient to take a deep breath. Deflate the cuff, and then pull the tube out quickly. 

The order of steps is important. When the patient inhales after the cuff is down, they can aspirate any secretions that are pooled above the cuff. On the other hand, if the lungs are already inflated, then the initial gas flow is outward. Frequently the initial outward flow of air will blow any secretions sticking to the cuff into the mouth where you can suction them. Squeezing the ventilation bag at the moment of extubation also helps blow secretions out. Deflating the cuff should immediately precede extubation for the same reason — to prevent aspiration around the tube. Have suction, oxygen, and the means to reintubate the patient immediately available.

Observe the patient carefully

Always Prepare For Reintubation

Providers often breathe a sigh of relief after intubation. But don’t relax until after extubation.

Have the equipment needed to reintubate at the bedside whenever you extubate. I work in a few surgicenters with limited numbers of laryngoscopes. Staff frequently try to take laryngoscope to clean it immediately after intubation. Make sure you have a backup in the room.

Have an assistant available to help. Don’t extubate while your nurse is out of the room getting the transport gurney!

Remember that reintubation is often more difficult than initial intubation. Edema from IV fluid administration, intubation trauma or surgical insult can obscure the view.

Your crew will want to transfer the patient to the gurney immediately following extubation. Ensure good air exchange first. Laryngospasm can be silent.

Monitor pulse, blood pressure and O2 saturation following extubation. Hypoventilation, hypoxemia and airway obstruction can develop if the patient goes back to sleep after stimulus decreases.

Deep Extubation

Deep extubation avoids coughing or bucking against the endotracheal tube to avoid increasing blood pressure or intracranial pressure. However, if such a patient also has a difficult airway, deep extubation carries greater risk. For further discussion of the technique of deep extubation see:

Deep Extubation Technique

Prioritize Safety

Eventually that endotracheal tube must come out. Make extubation safety as much a priority as intubation safety. Plan for the end from the beginning.

Ultimately we are responsible for keeping our patient safe. This means minimizing risk. However, if we don’t recognize the areas of risk, we can’t mitigate that risk.  For 3 review articles on minimizing risk and avoiding common complications in adults and children see:

May The Force Be With You!

Christine E Whitten MD, author:
Anyone Can Intubate: A Step By Step Guide
Pediatric Airway Management: A Step By Step Guide

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon
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Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten
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1 thought on “Extubation: Plan The End At The Beginning”

  1. The article in Anesthesiology News is terrific. However, as a former EIC of Anesthesiology, I do object to certain jargon you use repeatedly. These include “intubating and/ or ventilating patients. In other words, it would be more accurate to state “ventilating the patient’s lungs”, and “intubating the patient’s trachea”.
    Great article and algorithms and and other suggestions

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