End of surgery · Adult · Decision aid

Extubation Planner

DAS 2012 tracheal extubation guidelines — stratify low-risk vs at-risk, then pick the technique.

Draft — not yet clinically verified. From the DAS extubation guidelines (Popat et al, Anaesthesia 2012). Extubation is elective — plan it like an induction. Advanced techniques need training before you rely on them.

01Airway risk factors — select any that apply

02General risk factors — select any that apply

Every extubation — the basics

Preoxygenate with FiO₂ 1.0 before removing the tube; extubate head-up (especially the obese).
Reverse fully — train-of-four ratio ≥ 0.9 on a nerve stimulator.
Suction under direct vision — beware the "coroner's clot" behind the tube after blood in the airway.
Bite block — biting an occluded tube can cause negative-pressure pulmonary oedema; if biting occurs, deflate the cuff.
Remove the tube with positive pressure at near vital capacity — expels secretions, may reduce laryngospasm.
Gastric decompression if high-pressure mask/SAD ventilation was needed; consider whether the neck is accessible if the rescue plan is subglottic.

Popat M, et al. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia 2012;67:318–40 (Figs 1–3, Tables 2–6).

04After extubation — recovery & follow-up

Oxygen for transfer; one trained recovery nurse per patient, an anaesthetist immediately available.
Life-threatening complications are not confined to the immediate period — never ignore the patient who is agitated or reports difficulty breathing, even without objective signs.
Airway perforation → mediastinitis: severe sore throat, deep cervical or chest pain, painful swallowing, fever, crepitus. Warn the patient to seek help.
Document the airway and communicate concerns to recovery and the ward.