What are the steps to take before and after extubation?

Management of Tracheal Extubation

Extubation must follow a systematic four-step approach: plan, prepare, perform, and provide post-extubation care, with meticulous attention to risk stratification and optimization of airway, general, and logistical factors before removing the tube. 1

BEFORE EXTUBATION

Step 1: Plan Extubation and Risk Stratify

Risk stratification should occur before induction of anesthesia and be reviewed immediately before extubation. 1

Identify Airway Risk Factors:

• Pre-existing airway difficulties: Difficult intubation at induction, obesity, obstructive sleep apnea, or aspiration risk 1
• Peri-operative airway deterioration: Distorted anatomy, hemorrhage, hematoma, or edema from surgery or trauma 1
• Restricted airway access: Halo fixation, mandibular wiring, surgical implants, or cervical spine fixation 1

Identify General Risk Factors:

• Impaired respiratory function, cardiovascular instability, neurological/neuromuscular impairment 1
• Hypothermia/hyperthermia, coagulation abnormalities, acid-base or electrolyte disturbances 1
• Prolonged mechanical ventilation (>14 days), chronic lung disease, myocardial dysfunction 2

If any risk factors are present, classify as "at-risk extubation" requiring enhanced preparation and monitoring. 1

Step 2: Prepare for Extubation

Airway Assessment:

• Perform direct or indirect laryngoscopy to assess for oedema, bleeding, blood clots, trauma, foreign bodies, and airway distortion 1
• Conduct cuff-leak test: Deflate the tracheal tube cuff and listen for audible leak; absence of leak around an appropriately sized tube generally precludes safe extubation 1, 2
• For high-risk patients: An absolute leak volume <110 mL or relative leak volume <10% indicates high risk for post-extubation stridor 2
• Confirm bag-mask ventilation would be achievable if reintubation becomes necessary 1

Optimize General Factors:

• Fully reverse neuromuscular blockade: Use peripheral nerve stimulator to ensure train-of-four ratio ≥0.9 1, 2
• Sugammadex provides more reliable antagonism of rocuronium and vecuronium than neostigmine 1
• Correct cardiovascular instability and ensure adequate fluid balance 1
• Optimize body temperature, acid-base balance, electrolytes, and coagulation status 1
• Provide adequate analgesia to minimize coughing and straining 1
• Ensure adequate oxygenation: FiO2 <0.6 with SpO2 >90%, respiratory rate <30 breaths/minute 2
• Confirm adequate mental status to protect the airway 2

Logistical Preparation:

• Ensure same standards of monitoring, equipment, and skilled assistance as at induction 1
• Have vasopressors drawn up and immediately available (epinephrine, norepinephrine) 3
• Prepare backup equipment: supraglottic airways, cricothyrotomy kit 3
• Conduct team briefing with clear role assignments and shared strategy for rescue plans 3
• For at-risk patients: Consider having physiotherapist present during extubation 2, 4

Step 3: Perform Extubation

Pre-oxygenation:

• Administer 100% oxygen via tight-fitting facemask to maximize pulmonary oxygen stores and raise FEO2 above 0.9 1
• Use two-handed technique to minimize leak 3
• Confirm adequate pre-oxygenation with end-tidal oxygen concentration >85% 3

Patient Positioning:

• Head-up (reverse Trendelenburg) or semi-recumbent position is increasingly preferred, especially for obese patients 1
• Left-lateral, head-down position for non-fasted patients at aspiration risk 1

Airway Clearance:

• Perform pharyngeal suction under direct vision using laryngoscope to avoid soft tissue trauma 1
• Be vigilant for blood in the airway ("coroner's clot") which can cause fatal obstruction 1
• Suction lower airway using endobronchial catheters if needed 1
• Aspirate gastric tubes 1

Extubation Technique:

• Remove tube at peak of inspiration during simultaneous cuff deflation to maximize alveolar recruitment 1
• For at-risk patients with difficult airway: Consider airway exchange catheter (AEC) placement before extubation to facilitate reintubation if needed 1, 2

AFTER EXTUBATION

Immediate Post-Extubation Care:

Respiratory Support:

• For high-risk patients with hypercapnia: Apply prophylactic noninvasive ventilation (NIV) immediately after extubation 2, 5, 6
• For hypoxemic patients at low risk of reintubation: Use high-flow nasal cannula oxygen therapy 2, 4
• For patients at high risk of pulmonary collapse: Consider direct extubation from CPAP levels ≥10 cmH2O 2

Monitoring:

• Monitor for inspiratory stridor which occurs in 1-30% of extubations, typically within minutes 2
• Observe bilateral chest wall expansion during ventilation 4
• Assess for signs of respiratory distress: increased work of breathing, hypoxemia, tachypnea 2, 6

Interventions for Complications:

• If upper airway obstruction develops: High-flow oxygen via facemask, standard airway maneuvers, mask-delivered CPAP, nebulized adrenaline 1
• Consider helium-oxygen (Heliox) as temporizing measure to reduce impact of airway swelling 1

Recovery and Follow-up:

Success Criteria:

• Extubation is successful if patient does not require reintubation or NIV within 48-72 hours 2
• Target extubation failure rate: 5-10% 2

Reintubation Considerations:

• Extubation failure occurs in 10-20% of patients and is associated with mortality rates of 25-50% 6
• Mortality increases with delays in reintubation for patients failing extubation 7, 6
• Timely identification and rapid re-establishment of ventilatory support improves outcomes 7

High-Risk Patient Management:

• Physiotherapy before and after extubation for patients ventilated >48 hours reduces weaning duration and extubation failure 2, 4
• Nurse in high dependency or critical care unit if airway exchange catheter remains in place 1
• Remain nil by mouth until airway is no longer at risk 1

Common Pitfalls to Avoid:

• Do not extubate without confirming adequate neuromuscular function (TOF ≥0.9), as this increases postoperative airway complications 1
• Do not rely solely on visual assessment of train-of-four; use accelerometer for accuracy 1
• Do not proceed with extubation if no cuff leak is present around appropriately sized tube 1
• Do not underestimate the risk of rapid oedema progression after extubation 1
• Do not delay reintubation in patients with clear extubation failure, as mortality increases with delays 7, 6