1. 1
STEP I Screen
Passed SBT
SAT Done
Tracheal suction <q2h
Minimal oral secretions
Spontaneous cough
Cuff leak
SBT=Spontaneous Breathing Trial; SAT=Spontaneous Awakening Trial
!
If yes to any of the screening items,
patient automatically classified as
High Risk - Delayed Failure.
If all criteria met, STOP - proceed
to routine extubation.
Screen failure in any of the criteria
place patient in categories above
Low Risk.

2. 2
STEP II Assess
Any Of The Following:
C-Spine Surgery
(>3 levels + operative time > 5 hrs or blood loss >300 mL)
Restricted Airway Access
Cervical Immobility/Instability
History of Difficult Airway
BMI >40kg/m2

3. 3
STEP II Assess
>2 Of The Following:
Age >60 years
End Stage Kidney Disease
Male Gender
Tracheal Suctioning >q2h
Coma (GCS <10)
Frequent oral suctioning
Chronic Lung Disease
Failed >3 previous SBTs
Positive Cardiac History
!
!
!

4. 4
STEP III Prepare
HIGH RISK: Immediate Failure
Immediate post-extubation respiratory distress requiring reintubation w/in 2hrs of extubation.
Difficult Airway Cart: at bedside
Notify Anesthesia Airway Pager
Allow Continuous Airway Access
Hold Feeds: 2h pre- & 6h post-extubation
Insulin Treated Patients: initiate dextrose
Recommend: methylprednisolone 20mg IV q4h;
3 doses prior to extubation

5. 5
STEP III Prepare
HIGH RISK: Delayed Failure
Post-extubation respiratory distress requiring reintubation up to 24-48 hrs after extubation
Backup Plan
Notify ICU Team
Consider ABG/VBG q12 h
Respiratory Therapist
Assess 4h post-extubation
Bronchial Hygiene Protocol (if indicated)

6. 6
STEP III Prepare
LOW RISK
Routine extubation

7. 7
STEP III:Extubate
IV Prepare
Clear communication among teams,
observation & monitoring
Resume feeds after succesful
intubation
If reintubation, prepare smaller size
endotracheal tube