In critical care medicine the invasive life saving techniques are often employed and when all goes well such interventions will be withdrawn to all for normal physiology to resume. Identifying this point for safe withdrawal for the resumption of normal respiratory function is of utmost importance.

1. Formulate an Extubation Protocol
for the Operating Room and the
ICU.
Discuss the Pros and Cons of Awake
and Deep Extubation
Dr Okoye Ral
Department of Anaesthesia, UCTH
April 2018

2. Outline
• Introduction
• Management of Tracheal Extubation
• Extubation Protocol
• Awake Vs Deep Extubation
• Conclusion

3. Introduction
• Airway management is a fundamental aspect of
anaesthesiology and comprises of mask
ventilation, laryngoscopy, endotracheal
intubation and extubation.
• Considerable research and development have
been devoted to the first 3 with relatively little
consideration to the final step.

4. Introduction
• Tracheal extubation is a high risk procedure in
anaesthesia and critical care.
• Complications associated with extubation are
preventable and usually result from improper
technique.
• Extubation following general anesthesia
requires skill and judgment learned through
experience.

5. Introduction
• Extubation failure can lead to:
– cyanosis, hypertension
– hypoxia, negative‐pressure pulmonary edema
– tachycardia, acute bronchospasm,
– agitation, and, cardiopulmonary arrest.
• Reintubated patients have a significantly
increased risk of
– prolonged hospitalization or intensive care unit
(ICU) stay,
– ventilator‐acquired pneumonia,
– and morbidity and mortality.

6. Management of Tracheal Extubation
• Step 1: plan extubation
• Step 2: prepare for extubation.
• Step 3: perform extubation.
• Step 4: post‐extubation care: recovery and
follow‐up.

7. Plan extubation
• Airway Risk factors
– Anticipated difficult
airway
– Restricted airway
access
– Obesity
– OSA
– Aspiration risk
– Airway deterioration
• Other Risk factors
– Respiratory
– Neurological(ICP)
– Co morbid conditions
– Special surgical
requirements

8. Plan extubation
• Potential Difficult Extubation
– History of difficult intubation
– OSA
– Maxillofacial trauma
– Generalized edema
– Paradoxical vocal cord motion (preexisting)
– Post‐procedural complications: –
• Thyroid surgery (~4% risk of RLN injury, late hypocalcaemia)
• Diagnostic laryngoscopy +/‐ biopsy (laryngospasm, edema)
• Uvulopalatoplasty (edema)
• Carotid endarterectomy (hematoma, nerve palsies)
• ENT surgeries (hematoma, jaw wires)
• Cervical decompression (edema)

9. Plan Extubation
• Low‐risk extubation is a routine or
uncomplicated extubation. The airway was
normal/uncomplicated at induction and remains
unchanged at the end of surgery, and no general
risk factors are present.
• ‘At‐risk’ extubations are associated with
potential complications. Airway risk factors are
present.

10. Prepare for extubation
• It is an elective process and should be carried out
in a controlled manner with the same standards
of monitoring, equipment and assistance that are
available at induction.
• Tracheal extubation can take as long to perform
safely as tracheal intubation, and this should be
considered when organizing list schedules, or
sending for the next patient.

11. Prepare for extubation
Optimize Patient Factors
• Cardiovascular
• Respiratory
• Temperature
• Neuromuscular
Optimize Other Factors
• Monitoring
equipment
• Location
• Skilled
help/assistance

12. Prepare for extubation
• Extubation checklist
• Inhalational anaesthetics

13. Patient Extubation Checklist
Criteria Yes No/NA
Awake
Follows Command
Agitated
Cooperative
Train of four recorded
Muscle relaxant reversed?
Temperature within normal?
ETT leak test (if airway edema is suspected)
Comments
Provider’s Name/Title Provider’s Signature

14. Extubation Criteria ‐ OR
•• Adequate Adequate OxygenationOxygenation
– SpO2 > 92%, PaO2 > 60 mm Hg
•• Adequate VentilationAdequate Ventilation
– VT > 5 ml/kg, spontaneous RR > 7 bpm, ETCO2 < 50
mm Hg, PaCO2 < 60 mm Hg
•• Hemodynamically Hemodynamically Stable Stable
•• Full Full Reversal of Muscle Relaxation Reversal of Muscle Relaxation
– Sustained tetany, TOF ratio >0.9
– Sustained 5‐second head lift or hand grasp
•• Neurologically Neurologically Intact Intact
– Follows verbal commands
– Intact cough/gag reflex

15. Extubation Criteria ‐ OR
•• Appropriate Acid‐Base Appropriate Acid‐Base StatusStatus
– pH > 7.25 7.
•• Normal Normal Metabolic Metabolic StatusStatus
– Normal electrolytes
– Normovolemic
•• NormothermicNormothermic
– Temp > 35.5˚ 9.
•• Other Considerations Other Considerations
– Aspiration risk
– Airway edema
– Awake vs. Deep

16. Extubation Criteria ‐ ICU
•• Subjective Subjective CriteriaCriteria
– Underlying disease process improving/resolving
•• Objective CriteriaObjective Criteria
– GCS > 13, minimal sedation
– Hemodynamically stable, on minimal pressors
– SaO2 > 90%, PaO2 > 60 mm Hg
– PaO2/FiO2 > 150 on PEEP < 5‐8 cm H2O
– FiO2 < 0.4‐0.5
– PaCO2 < 60 mm Hg,
– pH > 7.25

17. Extubation Criteria ‐ ICU
•• Ventilator Criteria Ventilator Criteria (during SBT)
– RSBI (RR/VT) < 100
– NIF > 20 cm H2O
– VT > 5 ml/kg
– VC > 10 ml/kg
– RR < 30 bpm

18. Perform extubation
• Awake or Deep
• Give 100% oxygen
• Suction as appropriate under direct vision
• Insert bite block
• Position patient
• Assess neuromuscular blockade and reverse as
appropriate
• Ensure regular breathing and adequate
spontaneous ventilation

19. Perform extubation
• Minimize neck movement
• Wait until awake
• During positive pressure, deflate cuff and
remove the tube in one smooth motion
• Continue oxygen supplementation while
checking for airway patency and adequacy of
breathing

20. Perform extubation
• Advanced extubation techniques:
–Laryngeal mask exchange
–Remifentanil exchange
–Airway exchange catheter

21. Post‐extubation care
• Recovery and follow up in PACU/HDU/ICU
–Safe transfer
–Analgesia
–Handover communication
–Observation and monitoring
–Oxygen and airway management
–Staffing and equipment

22. EXTUBATION PROTOCOL‐ low risk awake
• Deliver 100% oxygen through the breathing system
• Remove oropharyngeal secretions using a suction
device, ideally under direct vision
• Insert a bite block to prevent occlusion of the tube
• Position the patient appropriately
• Antagonize residual neuromuscular blockade
• Establish regular breathing and an adequate
spontaneous minute ventilation

23. EXTUBATION PROTOCOL‐ low risk awake
• Allow emergence to an awake state of
eye‐opening and obeying commands
• Minimize head and neck movements
• Apply positive pressure, deflate the cuff and
remove the tube while the lung is near vital
capacity
• Provide 100% oxygen with an anaesthetic
breathing system and confirm airway patency
and adequacy of breathing
• Continue delivering oxygen by mask until
recovery is complete

24. EXTUBATION PROTOCOL‐ low risk deep
• Ensure that there is no further surgical stimulation
• Balance adequate analgesia against inhibition of
respiratory drive
• Deliver 100% oxygen through the breathing system
• Ensure adequate depth of anaesthesia with volatile
agent or TIVA as appropriate
• Position the patient appropriately
• Remove oropharyngeal secretions using a suction
device, ideally under direct vision

25. EXTUBATION PROTOCOL‐ low risk deep
• Deflate the tracheal tube cuff. Airway responses such as
cough, gag or a change in breathing pattern indicate an
inadequate depth and the need to deepen anaesthesia
• Apply positive pressure via the breathing circuit and
remove the tracheal tube
• Reconfirm airway patency and adequacy of breathing
• Maintain airway patency with simple airway maneuvers
or oro‐/nasopharyngeal airway until the patient is fully
awake
• Continue delivering oxygen by mask until recovery is
complete
• Anaesthetic supervision is needed until the patient is
awake and maintaining their own airway

29. Awake Vs Awake Vs DeepDeep

30. • Two schools of thought on how to extubate patients at
the conclusion of general anesthesia:
• Allow the patient to wake up with the endotracheal
tube in place, gagging on the tube and flailing like a
chicken, while someone behind the patient’s head
shouts, “Open your eyes! Surgery is over!”
Or:
• Remove the endotracheal tube while the patient is still
sleeping peacefully, which results in the smooth
emergence from anesthesia like waking from a nap.

31. Awake Extubation
• Defined by Miller as “tracheal extubation after
the return of appropriate response to verbal
stimuli with recovery of protective respiratory
reflexes”.
• According to the DAS Guidelines (2012), this was
most ideal for patients with difficult airways.
• Furthermore, with return of airway tone, the risks
of respiratory complications in the PACU are less
dependent on the skill level of the nurses in
charge of recovery (Daley, Norman and Coveler,
1999).

32. Awake Extubation ‐ cons
• Tracheal irritation ; Coughing/ bucking was the most
common problem (6‐96%).
• Multiple techniques to minimize cough reflex have
been studied (no touch technique)
• Cough though physiologic can cause
– oxygen desaturation, laryngeal edema (Koka et al., 1977)
– increased abdominal pressure (Irwin, 2006)
– potential bronchospasm (Westhorpe et al 2005)
– hypertension, tachycardia, arrhythmias, increased
intracranial pressure (Blaise et al., 1990)

33. Awake Extubation ‐ cons
• Laryngospasm; due to time pressure/ training
some anaesthetists may rely on clinical sign of
the swallowing reflex/ bucking as the
surrogate end point for wakefulness.

34. Awake Extubation ‐ cons
• Jaw clenching during emergence, can;
–lead to avulsion of teeth thus
–increasing the risk of aspiration and
–development of negative pulmonary
pressure edema following extubation (Liu
and Yih, 1999)

35. Deep Extubation
• Miller (2010) defined deep extubation as
“tracheal extubation in spontaneously
breathing patients under the absence of any
protective respiratory reflexes”.

36. Deep Extubation ‐ pros
• It was demonstrated to result in a smoother emergence
with decreased likelihood of breath‐holding, and bucking
and coughing on ETT (Valley et al., 1999; Valley et al.,
2003).
• Thus, this technique can potentially minimize:
– oxygen desaturation,
– airway trauma,
– CVS complications
– increased ICP and abdominal pressure
– respiratory complications in pediatric patients with
reactive airway disease

37. Deep Extubation ‐ pros
• No association between deep extubation and
aspiration has been established in any studies
presently
• The DAS Guidelines (2012) indicated that this
technique should be used in healthy, fasted
patients with a low risk of difficult airway, who
can be monitored until fully awake.

38. Comparisons
• There were no statistically significant differences in
the incidence of laryngospasm and excessive
coughing between awake and deep extubation. Koga
et al. (1998) studied the two techniques in healthy
adults receiving elective non‐oral surgery.
• Von Ungern‐Sternberg et al. (2013) compared awake
and deep extubation in children with increased
airway reactivity undergoing adenotonsillectomy.
The awake group had higher incidence of coughing
and hoarseness of voice postoperatively.

39. Conclusion
• Tracheal extubation is a critical milestone in the patient’s
recovery process and it carries potential risk of
developing complications especially in the presence of a
difficult airway.
• Clinical judgment regarding the timing and method of
extubation is dependent on patient and surgical factors
as well as the anaesthetist’s preference.
• The clinician’s decision to extubate is dependent upon
the return of patient’s airway protective reflexes such as
coughing and gagging and the ability to breathe
spontaneously without ventilatory support.

40. Conclusion
• Deep extubation has known benefits and may offer
advantages over awake extubation especially in
patients with reactive airway diseases or
cardiovascular pathology.
• However the lack of standardized criteria and
insufficiently documented protocols that can
promote favourable outcomes may be reasons why
deep extubation is regarded by some anaesthetists
as less advantageous compared to awake
extubation, and therefore is not as commonly
practiced.

41. References
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42. • Thank you