Difficult Airway Society: Extubation



·         Plan

·         Prepare

·         Perform



Risk factors for failure

·           Previous airway difficulty

·           Airway trauma/bleeding/swelling)

·           Restricted access

·           Obesity/OSA

·           Full stomach



Physiological prerequisites

·           CVS ok (minimal supports)

·           Resp ok (minimal support, FiO2 <0.4, RR and VT adequate)

·           Neuro ok (anticipate obeying command)

·           Neuromuscular ok (TOF >0.9)

·           Acid-base ok

·           Temperature ok

Logistical pre-requisites

·           Monitoring there

·           Equipment there

·           Personnel there



If low risk

·           Awake extubation

o  Pre-oxygenate

o  Suction

o  Bite block

o  Sitting up

o  Wait until obeying command

o  Apply positive pressure

o  Deflate cuff

o  Remove ETT

o  Apply face mask with 100% oxygen and CPAP

o  Observe

·           Deep extubation

o  Experience essential

o  Observe until emergence

If high risk

·           Remifentanil infusion:

o  Awake

o  Breathing upon command

·           LMA exchange:

o  Railroad over ETT

o  Test ventilate LMA

o  Remove ETT

·           Airway exchange catheter:

o  Pass through ETT

o  Remove ETT

If very high risk

·           Postpone extubation

o  i.e. send to ICU

·           Tracheostomy


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