This document discusses guidelines for extubation and managing risks associated with extubation. It begins by outlining criteria that must be met for safe extubation, such as adequate breathing and hemodynamics. It then describes methods for standard, awake, deep and difficult/high risk extubations. Risks of immediate extubation are outlined. The document provides detailed protocols for managing complications like laryngospasm and laryngeal edema to prevent reintubation. Prophylactic medications, strategies for difficult airways, and criteria for determining pre-extubation airway edema are discussed to ensure extubations are performed safely.

1. EXTUBATION AND REINTUBATION
- Dr. PAYAL PATEL
GUIDE: Dr. K.L.AGRAWAL

2. EXTUBATION
Extubation means removal of endotracheal
tube from trachea after achieving
spontaneous adequate breathing,stable
hemodynamics and satisfactory recovery.

3. Before extubating trachea one should
ensure following:
• 1.Patient should able to maintaining patent airway and is
able to generate adequate spontaneous ventilation.
• 2.There should not any problem with central inspiratory
drive by drugs or CNS dysfunction.
• 3.Patient should have adequate respiratory muscle
strength.
• 4.Can clear secretions by coughing
• 5.Has no laryngeal dysfunction
• 6.Adequate clearance of sedatives and neuromuscular
blockers.
• 7.Normothermia
• 8.Adequate analgesia

4. GENERAL CRITERIA FOR EXTUBATION
• 1.Rapid shallow breathing index(f/vT):
• It is calculated by dividing spontaneous breathing
frequency per minute by average tidal volume in
litres.value less than 100/min/L predictive of successful
extubation outcome.The patient should be allowed to
breathe spontaneously for at least 3 minutes before
taking measurements.Otherwise the f/vT index may
not reflex patient’s actual condition.
• 2.Blood gases:
• Acceptable blood gases on Fio2 less than 40% and
spontaneous minute ventilation less than 10L/min.

5. 3.Ventilatory reserve:
Maximal inspiratory
pressure>20cm H2O
Vital capacity:>15ml/kg
4.Cardiopulmonary assessment:Absence of
cardiopulmonary problems e.g. CHF,pulmonary
edema,pneumonia,tachycardia,arrhythmia,chest
retraction,distended stomach.

6. AWAKE TRACHEAL EXTUBATION
• Awake extubation is safer and preferable because of
better control of airway by patient,reduced risk of
aspiration and seldom need of reintubation.
• Criteria for awake extubation:
• 1.Difficult mask ventilation
• 2.Difficult tracheal intubation
• 3.Iadequate reversal of residual neuromuscular block
• 4.High chances for regurgitation eg pregnancy,hiatus
hernia,recent ingestion of food,obesity,gastric
neurpathy of diabetics
• 5.Pediatric patients

7. DEEP EXTUBATION
• Deep extubation avoids coughing,increased
ICT,IOP,increased intra abdominal pressure and adverse
hemodynamics. So,it avoids bleeding at wound site,wound
dehiscence & useful in neuro surgery and eye surgeries.
• The presence of TT in awake asthmatic patient may leads to
bronchspasm.so,deep extubation can be done.
• Criteria for deep extubation:
• 1.Easy mask ventilation
• 2.Easy tracheal intubation
• 3.Adequate reversal of neuromuscular blockade
• 4.No risk of regurgitation and aspiration
• 5.Normothermic patient

8. LIGHT PLANE EXTUBATION
• Extubation in light plane of anesthesia should always be
avoided due to risk of laryngospasm and other airway
complications.Extubation during exictement stage tend to
stimulate the vocal cord and lead to reflex protective
spasm.
• Stridor is heard when laryngospasm or edema developed
post operatively.
• The distinction between deep & light anesthesia is usually
apparent during pharyngeal suctioning:any reaction to
suctioning eg breath holding,coughing signals light plane of
anesthesia, whereas no reaction is characteristic in deep
plane.simillarly, eye opening or purposeful movements
imply that patient is totally awake.

9. Contraindication of immediate
tracheal extubation
• 1.SpO2 < 90% while breathing 40% oxygen
• 2.EtCo2->45 mmHg
• 3.Temp< 34 C
• 4.Surgery resulted in impaired cough/gag reflex
e.g. brainstem surgeries
• 5.Paralysis of vocal cords
• 6.Unstable hemodynamics

10. Routine low risk tracheal extubation
• 1.Regular breathing should be ensured and suctioning of oropharynx
should be done to avoid aspiration of secretions.
• 2.Immediately prior to extubation 100% O2 should be given for 3-5
minutes
• 3.Sniffing position is standard position for extubation
• 4.If patient has adequate vital capacity and cough reflex the cuff is
deflated and ET tube is removed.
• 5.To reduce post extubation laryngeal spasm extubation should be
performed at the end inspiratory phase.
• 6.A positive pressure should be applied as cuff is being deflated.This
reduces risk of pulmonary edema and provokes cough reflex that clears
secretions present in airway.Extubation with inflated cuff can causes
vocal cord injury & arytenoid dislocation.

11. • 7.In case of patient bites on TT or supraglottic device chances of
negative pressure pulmonary edema raised.Leave device in situ and
deflate cuff at this moment,as leak around cuff would prevent
development of significant negative pressure.Oropharyngeal airway
can not be inserted as bite block because it may causes dental
damage.Rolled gauze securely inserted between molars before
lightening of patient will secure airway.
• 8.Gastric insufflation with air can increase risk of pulmonary
aspiration.patient in whom mask ventilation with high pressure is
necessary should have NG tube placed & suctioned before
extubation.
• 9.Vitals,blood gases and signs of tissue damage should be assessed
carefully after extubation.
• 10.O2 delivery by face mask is maintained during the period of
transportation to recovery room.

13. DAS GUIDELINES FOR EXTUBATION

14. Difficult “At Risk” extubation
• 1.Decreased mouth opening
• 2.Short thyromental distance
• 3.Class III & IV Mallampatti grade
• 4.Other airway abnormality
• 5.Patient who has faced difficult mask ventilation
• 6.Difficult intubation
• 7.Airway edema following difficult intubation
• 8.Upper airway facio maxillary surgery
• 9.Malignancy o trauma of oropharynx and neck region
• 10.Thyroidcectomy leading to recurrent nerve paralysis and
hematoma
• 11.surgeries of neck and oro mandibular region which
alters upper airway antomy

15. • 12.Exaggerated laryngeal reflexes:coughing,bucking or
breathholding in response to mechanical removal of ET.
• 13.Reduced airway reflexes:Patient with obesity or
obstructive sleep apnea.They are more sensitive to effects
of opioids and residual anesthesia.
• 14.Dysfunctional airway reflexes:Vocal cord abduction
occurs during inspiration but rarely vocal cord adduction
occurs during this phase of respiration.This is called
paradoxical vocal cord motion and can only be diagnosed
by direct observation of vocal cords and responds to
treatment with anxiolytic;sedative or opioid agent.
• 15.General risk factors:CVS disease,Respiratory disease,
Neuromuscular disease,Metabolic derengement

16. MECHANICAL FACTORS
- Difficult tracheal extubation may occasionally be
a case of difficult extraction of tracheal tube also
called difficult de-cannulation of the airway.
Causes:
Tracheal stenosis
Inadvertent stitching of TT to patiet’s airway
Incomplete deflation of cuff
Severe airway edema causing obstruction

17. STRATEGY FOR DIFFICULT AT RISK
TRACHEAL EXTUBATION:
• - Ensure that expert help should be available
• -Obstructive sleep apnea and obese patient should be extubated in head
up position
• -Patient having risk of aspiration should be extubated in left lateral
position
• -If one is predicting that patient may develop laryngespasm deep
extubation can be done.But there is risk of hypoventilation and upper
airway obstruction.so,one can exchange TT with LMA.Remove TT
when patient is deep then oxygenate patient with LMA in semi sitting
position for undisturbed awakening from anesthesia.
• -Airway Exchange Catheter can be used to perform staged tracheal
extubation.An appropriate size ,well lubricated AEC should be
introduced via TT lumen and left situ after tracheal extubation till
chances of reintubation is significantly reduced.The AECs are hollow
tubes with blunt ends having side ports for uninterrupted gas flows.

18. • -After tracheal extubation over AEC, it should be ensured that the
AEC is appropriately fixed to patient’s face with adhesive
tape.generally it is fixed at 20-22 cm orally & 27-30 cm nasally.
• -Supplemental oxygen should be continuously administered and
monitoring of vitals should be done.
• -in case of AEC is not available,a gum elastic bougie can be
used.But it will not permit oxygenation but very useful if rapid
reintubation is needed.
• In majority of cases AEC is removed within 30-60 minutes,by which
time chances of reintubation is dismissed.
• A duration of 72 hours has been reported as maximum time before
removing AEC.
• The first attempt success rate of reintubation over AEC is 87%
• If need arise preplaced AEC should be used for railroading a new
TT to re-achieve a definite airway

19. BAILEY’S MANOEUVRE FOR HIGH RISK
EXTUBATION
During Baily manoeuvre an LMA is substituted for ETT
during deep anesthesia,with subsequent removal of
LMA when patient resumes spontaneous ventilation
and obeys commands.
With this technique, patient emergence has been
observed to be superior to either awake or deep
extubation.
This technique is useful in patients where there is risk of
disruption of surgical repair due to CVS stimulation
resulting from presence of TT.
-It may also benefit smokers,asthmatics and other
patients with irritable airway.

20. -This has also been found to appropriate for
patients who have undergone neuro or
intraoccular surgeries which may be affected
by bouts of coughing and bucking on tracheal
tube.
-Disadvantage:This method is inappropriate in
whom re-intubation would be difficult or if
there is risk for regurgitation.

21. DAS GUIDELINES FOR AT RISK EXTUBATION

22. PROPHYLACTIC MEDICATIONS FOR AT
RISK EXTUBATION
1.Lidocaine 1.5-2.0 mg/kg 1-2 minutes before
extubation may reduces hemodynamic
disturbance,coughing & laryngeal spasm.
2.Lidocaine instilled into ETT cuff reduces the
incidence of cough.
3. 2 ml 2% lidocaine in 1.4% or 8.4% sodium
bicarbonate is used to inflate ETT cuff which may
improve diffusion of lidocaine across cuff
membrane.so it reduces post op sore throat &
cough.

23. 4.In high risk exubation one may use 1-2 doses of steroids
dexamethasone 4-8 mg 12 hrs apart,last dose being
given at least 12 hours prior to
extubation.Administration of steroids as a single dose
prior to extubation has no value.
5.Low dose remifentanil 0.014 microgm/kg/min infusion
or alfentanil 15 microgm/kg prior to extubation
reduces coughing and hemodynamic response to
extubation.
6.Esmolol or Labetalol are equally effective in controlling
the rise in heart rate and systolic BP at extubation.

24. POST EXTUBATION MEDICAL THERAPY
- Aerosolized epinephrine 1:1000 0.5ml/kg up to 5
ml is often used to manage post extubation
laryngeal edema and stridor.
- Aerosolized levo-epinephrine is as effective as
aerosolized epinephrine in management of post
extubation laryngeal edema specially in children.
- Heliox(60:40 or 80:20) have also been
successfully used to alleviate the symptoms of
partial airway obstruction and accompanying
stridor,improve patient’s comfort,decrease work
of breathing and prevent re-intubation.

25. COMPLICATIONS OF EXTUBATION
IMMEDIATE COMPLICATIONS:
-Upper Airway obstruction
-Hypoventilation
-Hemodynamic complication(Hypertension,Tachycardia)
-Coughing and straining leading to surgical wound dehiscence
-Aspiration
-Laryngospasm & Bronchospasm
-Horseness
-Laryngeal and Subglottic edema
-Pulmonary edema
-Paradoxical vocal cord motion
-Arytenoid dislocation
FOLLOWING COMPLICATIONS:
-Mucosal injuries
-Laryngeal stenosis
-Tracheal inflammation
-Tracheal dilatation
-Tracheal stenosis
-Vocal cord paralysis

26. LARYNGOSPASM
- Commonly occurs in patient with upper
respiratory infection over 4-6 weeks.
- causes:
Mechanical stimulus by TT extraction
Oropharyngeal suctioning
Presence of blood or secretions
Surgical stimulation

27. COMPLICATIONS FOLLOWING
UNTREATED LARYNGEAL SPASM
1.Negative pressure pulmonary edema
2.Subsequent hypoxic cardiac arrest

28. Steps to resolve postextubation
laryngospasm
-once laryngospasm is diagnosed, any ongoing
stimulus should be stopped and 100% O2 should
be administered.
-If laryngospasm persist ,chin lift/jaw thurst or
Larson’s maneuver should be applied.
-Larson’s maneuver: Apply firm steady pressure in
space between ascending ramus of mandible and
mastoid process.
-If above steps fails to relieve spasm ,administer
0.5-0.8mg/kg propofol.

29. -Unresponsive spasm may need administration of 0.1-0.3
mg/kg succinylcholine.It never abolishes respiration
but breaks laryngeal spasm.
-While all this is being done,continuous positive pressure
and bag & mask ventilation should be attempted.
-Rarely,tracheal intubation and ventilation needed.
-Laryngospasm is caused by acute glottic closure of the
vocal cords and is mediated by superior laeyngeal
nerve.Blockade can be achieved by injecting 2ml of
local anaesthetic 1cm medial to superior cornu of
hyoid through the thyrohyoid membrane prior to
awake fiberoptic intubation.

30. LARYNGEAL EDEMA
IDENTIFICATION OF PRE EXTUBATION AIRWAY EDEMA
There are several ways of asessing airway edema that might lead to
post extubation stridor and need of emergent reintubation.
1.GENTLE LARYNGOSCOPY:
It will evaluate presence of any edema of oropharynx.But this is not
best method because TT obscures visualization of larynx as well as
it distorts anatomy.
2.FLEXIBLE FIBREOPTIC EXAMINATION:
Factors ruling out airway edema-
- clearly visible vocal cord around TT
- absence of significant preglottic edema
- adequate space to introduce the fibrescope between TT and
trachea
- absence of excessive secretions

31. 3.IMAGING TECHNIQUE
CT,MRI & ultrasound can be used
Ultrasound is more feasible in all above.
It identify configuration of vocal cords, morphology of larynx and ease of
airway via vocal cord before preceeding to tracheal extubation.
4.CUFF LEAK TEST
It involves putting the patient on assist control mode of ventilation so as to
assure a guaranteed delivery of tidal volume.
The expiratory tidal volume from 6 respiratory cycles is measured and cuff of
TT is deflated.
If there is a loss of 10-25% or more of tidal volume or 110-130 ml in
adults,significant airway edema safely ruled out.
If this mode of ventilation is not available in ventilator other method is used.
In other method ,the spontaneously breathing patient is disconnected from
ventilatory circuit,the cuff of TT is deflated,and proximal end of TT is
occluded.If patient is able to breathe from around the tube,no significant
laryngeal edema has developed.however,one should be vigilat against
possibilit of negative pressure pulmonary edema.

32. PREVENTION OF LARYNGEAL EDEMA
Dexamethasone and methyl prednisolone is used to alleviate
development of edema secondary to airway
instrumentation and/or surgery of oropharynx.
Steroids should be administered as soon as it is reallized that
patient having risk of developing inflammatory edema.
Single dose steroid immediately prior to extubation has
unproven value.
100 mg hydrocortisone 6 hourly should be continued
postoperatively for at least 12-24 hours.
If despite this measures, airway edema develpos and leads to
postextubation airway obstruction, nebuized racemic
adrenaline can be administered.

33. REINTUBATION
Incidence of reintubation-0.1%-0.45%
Reasons for reintubation:
Respiratory insufficiency due to disease,inadequate
reversal of residual neuro muscula block,obstructed
airway.
Respiratory depression due to
opioids.bronchospasm and pulmonary edema.
3 most common causes for reintubation:
1.Persistent sedation
2.Residual effects of neuromuscular blocking drugs
3.Inappropriate fuid management

34. Reintubation may not always be as easy as initial
tracheal intubation because surgical
procedure and prior intubation had disturbed
airway antomy.
A simple check list may help to identify difficult
reintubation.

35. COMPONENETS OF HELP-ET TO
IDENTIFY DIFFICULT REINTUBATION
Human factor-Fatigue,stress of operator toward
end of surgery.
Experience-takeover a case by inexperienced
person
Location-Expert help not available
Patient factor-morbid obesity,previous difficult
intubation,airway edema,altered airway
anatomy,cervical collar,heavy bandaging of head and
neck restricting movement
Equipment-technical problems with airway equipment
Time factor-Rapid desaturation,unstable vitals

36. The only reliable strategy to avoid difficult
reintubation is to identify the patient in
advance and perform controlled tracheal
extubation over an AEC.
In case AEC has not been placed, one should
immediately seek expert help and arrange for
difficult airway cart if reintubation is urgently
needed.

37. CLINICAL PREDICTORS OF
REINTUBATION1.SIMV or AC rate >6/min:
Patient is dependent on the ventilator
2.Most recent pH>=7.45
Oxyhemoglobin saturation curve shifts to left
(increase O2 affinity and decrease O2 release to tissues)
3.Most recent PaO2/FiO2<250mmHg-
Poor oxygenation status
4.Highest heart rate in the past 24 C>120/min
Cardiac compansation for poor perfusion or oxygenation
5.Presence of >3 medical disorders
Potential of medical complications.
6.Not alert
Poor mental status;blunted drive for breathing
7.Reason for intubation other than preoperative
Presence of medical problems and potential complications
Presence of four or more predictors favour reintubation.
Presence of 3 or less predictors indicates no need of reintubation.

38. Delayed reintubation
Adverse outcome:
Hypoventilation
Hypoxemia
Hypoxia