BJA Education, 21(12): 446e454 (2021)

doi: 10.1016/j.bjae.2021.07.003
Advance Access Publication Date: 25
August 2021

Matrix codes: 1A02,

1C01, 1C02, 1I03,
2A01, 2A03, 2A06,
3A01, 3I00

Safe tracheal extubation after general

anaesthesia
J. Benham-Hermetz and V. Mitchell*

University College London Hospitals NHS Foundation Trust, London, UK

*Corresponding author: [email protected]

Keywords: airway management; general anaesthesia; tracheal extubation

Learning objectives 50% of these cases and obesity was a common
By reading this article, you should be comorbid condition.1 A prospective survey by
able to: Asai and colleagues found that respiratory
complications after extubation and in the post-
List the complications occurring
anaesthesia care
during emergence, extubation and

in recovery.
Julia Benham-Hermetz MA MRCP FRCA is a
Detail the factors that increase the specialty registrar in anaesthesia and airway
fellow at University College London
risks of adverse events.
Hospitals.
Explain how to
Viki Mitchell FRCA is a consultant at University
optimise conditions before College London Hospitals. Her interests are in
maxillofacial anaesthesia and teaching airway
tracheal extubation. management.
Discuss techniques to reduce Key points

complications at extubation. Complications during emergence,

extubation and in the PACU are
common and can be

Tracheal extubation generates less interest

lifethreatening.
than tracheal intubation. Research, guidelines An extubation plan should be
and clinical anecdotes tend to focus on airway formulated before anaesthesia and
management at the beginning of anaesthesia,
consider patient-related,
and it is rare for the challenges of extubation to
receive as much attention. Despite the focus on anaesthetic, surgical and human
intubation, extubation and emergence from factors.
general anaesthesia are not without risk. The The patient’s clinical condition
Royal College of Anaesthetists and Difficult should be optimised for
Airway Society (DAS) 4th National Audit
extubation.
Project (NAP4) found that almost a third of
major airway complications occurred during Awake extubation is the standard
emergence and in the recovery period. Two technique.
cases resulted in death and one in severe brain
Extubation is an elective procedure,
injury, and there were 10 emergency surgical
airways attempted.1 Patients undergoing oral and removal of the tracheal tube
or head and neck surgery accounted for almost immediately after general
 Safe tracheal extubation after general anaesthesia

anaesthesia may not always be the Airway obstruction

safest approach. The NAP4 report found that airway
obstruction was the primary cause of all
airway complications at the end of anaesthesia
unit (PACU) were much more common than
and in the PACU.1 A patent airway is a
complications occurring with tracheal
prerequisite for successful extubation but there
intubation.2 Data from the American Society of
is a high risk of airway obstruction during
Anesthesiologists’ (ASA) closed claims
emergence. Although a difficult airway at
database found that 18% of insurance claims
induction of anaesthesia is likely to remain
for death or brain damage arising from
difficult, easy airway management at the start
management of the difficult airway occurred
of anaesthesia can be falsely reassuring and the
during or after extubation.3 Although
anaesthetist may find that the airway they are
complications at emergence and in the PACU
managing at the end of the procedure is very
may appear minor and transient, the NAP4
different.
project shows that they can result in long-term
injury and death.1
Risk factors for airway obstruction
This article describes the physiological
The causes of airway obstruction during
changes and complications that occur during
emergence and extubation are summarised in
tracheal extubation and emergence from
Table 2. Factors specific to the patient may be
general anaesthesia. The DAS guidelines on
present at induction or exacerbated by surgery
safe extubation after surgery are introduced
and anaesthesia.
and approaches to extubation explained.4 We
describe specific techniques used to manage the
Residual neuromuscular block
’
‘at-risk airway. Weaning and extubation in the Residual neuromuscular block as a result of
ICU are beyond the scope of this article. incomplete antagonism of neuromuscular
blocking drugs (NMBDs) is common and is
associated with postoperative airway
Problems encountered during complications.
emergence, extubation and in
recovery
Physiological effects and potential
morbidity
Most of the adverse effects that can occur
during emergence and extubation result from
airway obstruction or exaggerated

Accepted: 12 July 2021

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: [email protected]

446
airway reflexes. The cranial nerves innervating
the pharynx and larynx mediate reflexes that
protect and maintain a patent airway.
Anaesthesia impairs these reflexes, allowing
airway manipulation and insertion of airway
’
devices. During the transition from ‘asleep to
’
‘awake , the sensitivity of these reflexes is
exaggerated.5,6 The problems encountered are
summarised in Table 1. Airway and
respiratory complications are the most
common.5,7,8

447 BJA Education - Volume 21, Number 12, 2021

 Safe tracheal extubation after general anaesthesia

Residual neuromuscular block most Neuromuscular block can be antagonised

commonly presents as airway obstruction. with neostigmine or sugammadex, but
Respiratory dynamics may appear normal sugammadex is only effective if rocuronium or
despite a significant degree of residual vecuronium have been given. Reversal of
paralysis because the muscles of the upper neuromuscular block is faster with
airway and pharynx are more sensitive and sugammadex than neostigmine and is
take longer to recover. Inadequate ventilation associated with fewer adverse effects including
and suppression of the hypoxic chemoreflex is a lower incidence of residual postoperative
common, and together, these factors combine paralysis.15 A peripheral nerve stimulator
to make the extubation period hazardous should be used with sugammadex as an
unless reversal of neuromuscular block is insufficient dose may result in a recurrence of
complete.14 neuromuscular block after reversal or
The most commonly used measure of ’
‘recurarisation , caused by the redistribution of
neuromuscular block is the train-of-four (TOF)
free rocuronium from the plasma back to the
ratio, which assesses the strength of muscle
effect site at the neuromuscular junction.17
twitch response of the fourth stimuli compared
After giving sugammadex, it is important to
with the first. For many years, a TOF ratio of
consider how
0.7 was considered adequate, with such patients
able to generate good tidal volumes and cough,
however studies have shown that pharyngeal
dysfunction and increased aspiration risk are
still present with a TOF ratio <0.9.15 A recent
meta-analysis demonstrated that many patients
arrive in the PACU with residual
neuromuscular block, 12% have a TOF ratio of
<0.7 and 41% <0.9.9 Use of a neuromuscular
monitoring device is mandatory whenever
NMBDs are used.16 A simple nerve simulator
relies on qualitative assessment of muscle
twitch by the anaesthetist, which is unreliable;
therefore current guidelines recommend a
quantitative neuromuscular monitoring device
is used.14,16 A TOF ratio of 0.9 is recommended
before extubation.9,15

2 , 4 e 13
Table 1Effects of extubation and emergence from general anaesthesia with incidence as percentage where
*General
available.
anaesthesia for noncardiac surgery.

Cause Effect Incidence

Airway irritation Coughing and bucking 18e66%

Laryngospasm 17e25%
DesaturationSp(O2 <90%) 24%
Inadequate reversal 5e10%
Post-obstructive pulmonary oedema 0.1%
Bronchospasm 1%
Reduced level of Breath holding 13e20%
consciousness/obtunded reflexes Airway obstruction 5e19%
Apnoea/hypoventilation 2e9%
Vomiting/aspiration 2/0.5%
Laryngeal incompetence
Cardiovascular changes Hypertension/tachycardia 10% (haemodynamic instability
)
Arrhythmias 7%*
Raised intracranial pressure
Raised intraocular pressure
Myocardial ischaemia
Flap disruption/bleeding at surgical site
Trauma Dental damage 0.02%
Airway oedema
Drug effect Residual neuromuscular block 5e10%
Masseter spasm

BJA Education
448
 Safe tracheal extubation after general anaesthesia

neuromuscular benzylisoquinolinium NMBD if neuromuscular

block will be re- block is required within 24 h of sugammadex.
established if There is evidence to suggest that rocuronium
Table 2 Patient-related, surgical and anaesthetic factors that contribute
to airway obstruction during emergence and extubation. required for can be used within this period provided a rapid
reintubation. The sequence induction is not required. If
manufacturer neuromuscular block is needed within 3 h of
Patient-related Obesity recommends using sugammadex, the dose of rocuronium should
a be increased to 1.2 mg kg1.17
Obstructive sleep apnoea
Smoker
C-spine immobility Laryngospasm
History of head and neck radiotherapy Laryngeal spasm is a common complication of
Pharyngeal obstruction (tonsillar/adenoidal
general anaesthesia and results from direct
hypertrophy)
Craniofacial abnormalities (micrognathia, maxillary irritation of the vocal cords by blood, saliva or
hypoplasia) instrumentation, or indirectly from surgical
Neuromuscular disorders (bulbar weakness) stimulation. Contraction of the muscles of the
Connective tissue disorders larynx causes adduction of the vocal cords and
Storage diseases airway obstruction.5,6
Chronic renal failure
Laryngomalacia Partial airway obstruction presents with
Surgical Airway soiling (blood, secretions) inspiratory stridor and increased airway
Swelling pressure but complete obstruction is silent. If
Vocal cord damage untreated, laryngospasm can progress to
Neck haematoma hypoventilation, hypoxaemia and ultimately
Trendelenburg position (facial and airway oedema)
hypoxic cardiac
Fixation of cervical spine or facial bones
(causes reduced head and neck mobility) arrest.4,7
Laryngospasm during emergence and
Anaesthetic Anaesthetic agents (reduce consciousness, impair extubation is avoided by ensuring sufficient
reflexes, reduce muscle tone) depth of anaesthesia before manipulation of the
Laryngospasm
airway, removal of airway blood and
Residual neuromuscular block
Glottic oedema secretions, and
1
anaesthesia-related airway complications in the NAP4 study. minimising head and
Airway device occlusion (from biting, secretions or
blood) neck movements during
transfer.4 Specific drugs
may also be beneficial
DAS Extubation Guidelines: Basic algorithm (see below).

Airway risk factors General risk factors

Known difficult airway Cardiovascular Post-obstructive
Plan
Airway deterioration (trauma,
Respiratory pulmonary oedema
oedema or bleeding) Neurological
sess airway and general risk factors Post-obstructive
Restricted airway access Metabolic
Obesity / OSA Special surgical requirements pulmonary oedema
Aspiration risk Special medical conditions (POPO) can develop
after an episode of
Prepare Optimise patient factors Optimise other factors airway obstruction.6 It
Optimise patient and other factors Cardiovascular Location
was noted in 10% of all
Respiratory Skilled help / assistance
Metabolic / temperature Monitoring
Risk Stratify
Neuromuscular Equipment
w risk ‘At risk’
asted Ability to oxygenate
licated airway uncertain
ral risk factors Reintubation potentially
difficult and/or general
risk factors present

sk algorithm ‘At risk’ algorithm

Safe transfer Analgesia

Handover / communicationStaffing
Recovery or HDU / ICU O2 and airway managementEquipment
Observation and monitoringDocumentation
General medical and surgical management

4
AS) extubation guidelines: basic algorithm. Reproduced from Popat and
with
colleagues,
permission from the Association of
shing Ltd. HDU, high dependency unit; OSA, obstructive sleep apnoea.

449 BJA Education - Volume 21, Number 12, 2021

 General medical and surgical management

4
Fig 2 Difficult Airway Society (DAS) extubation guidelines: ‘at-risk
’ algorithm. Reproduced from Popat and colleagues,
with permission from the Association of
Anaesthetists and Blackwell Publishing Ltd. HDU, high dependency unit.

This complication is caused by a forced that there is no one single technique suitable
inspiratory effort against a closed glottis or an for all patients.4 There is general agreement
occluded airway. This generates a negative that the extubation strategy should be
intrathoracic pressure that alters the Starling considered before anaesthesia, to assess the
forces across the pulmonary capillaries and individual risk for each patient and allow
alters cardiac filling pressures and afterload. sufficient time for planning and preparation. 4
The result is movement of fluid into the alveoli Preoperative plans can then be modified
and pulmonary interstitium with pulmonary depending on intraoperative events. 1 During
oedema despite normal cardiac function. Direct extubation, as with intubation, the aim is to
mechanical stress, acidosis and hypoxia may ensure adequate delivery of oxygen to the
also contribute by disrupting the alveolar lungs. In 2012 DAS published guidelines on the
epithelium and pulmonary capillaries.10 management of tracheal extubation in adults.
Postobstructive pulmonary oedema typically This was the first guideline to focus specifically
occurs in young, muscular adults and can on tracheal extubation and is applicable to all
follow airway obstruction of any cause, adults undergoing general anaesthesia, not just
although laryngospasm is the most common.6 those with a difficult airway. The guidelines
Patients present with a cough, pink frothy present a systematic approach to stratify
sputum and hypoxia. Chest radiographs show ’ ’
patients into ‘low or ‘at-risk groups and
features of pulmonary oedema. Management is
outline some extubation techniques (Figs. 1 and
supportive with admission to the high
2).4
dependency unit (HDU) for oxygen
supplementation and application of continuous
positive airway pressure; in some cases,
diuretics have been used.10 Planning and preparation for extubation
Preparation creates conditions that favour safe
and successful extubation (Table 3). A safe
Inadequate ventilation
extubation depends on good communication
Opioids and anaesthetic agents obtund the between the anaesthetist, surgeon and
central respiratory response to increased PaCO2 operating theatre team, particularly for the ‘at-
and hypoxia, reducing ventilatory drive.14 ’
Poorly controlled pain and residual risk airway.4
neuromuscular block may prevent a patient
from generating adequate tidal volumes. Table 3 An ABC approach to extubation: essential considerations when
Pulmonary atelectasis results in preparing for extubation at the end of surgery.
ventilation/perfusion mismatch and increases
the work of breathing.5,7 Although ventilation
Airway Ensure the airway is patent Patient is
may be compromised, patients will have an
able to protect airway adequately
increased oxygen demand at the end of Consider inserting a bite block
surgery, particularly those with a systemic Remove any throat packs
inflammatory response or sepsis.
Breathing Adequate ventilation e oxygenation and removal
of CO2
Environmental and human factors Assess SpO2 and PE0CO2
during emergence from anaesthesia Regular ventilatory pattern, breathing with steady
Human factors also increase the risk of rate and tidal volumes
complications during emergence and
If using a supported ventilation mode, pressure
extubation. The task load for the anaesthetist
support and PEEP should be minimal
at the end of surgery is high and the
Give 100% oxygen
environment is less controlled than at
Circulation Stable blood pressure, heart rate and rhythm
induction. The patient’s airway may be less Normotension without need for high levels of
accessible at the end anaesthesia because of
inotrope or vasopressor support
positioning for surgery, and there are
Adequate fluid balance, normal or improving
additional stressors such as extraneous noise
and fatigue.4,18 lactate

No significant acidosis
Arrhythmias treated and controlled
Management of emergence, Drugs Confirm reversal of neuromuscular block
Ensure adequate analgesia
extubation and recovery
There is little evidence from RCTs and meta-
analyses for managing extubation but it is clear
Safe tracheal extubation after general anaesthesia

Environment Temperature Maintain ’

reduce ‘secondary swelling resulting from
normothermia
positioning and poor venous return.4
Equipment
Dexmedetomidine
Airway management equipment readily available can reduce coughing and
the haemodynamic effects of extubation while
Positioning
Head up or left lateral
avoiding the respiratory depression associated
with opioids. It is currently only licensed for
Location
ICU sedation in the UK, but studies have
Suitablelocationwithadequatemonitoring and
assistance shown it may be useful perioperatively as
Human factors Timing infusion or a bolus dose before extubation.19
Consider time of day, staff availability,
Doxapramlevels of
is a respiratory stimulant that
fatigue has been used to reduce postoperative
pulmonary
Appropriateassistance/expertiseavailable complications, primarily
hypoventilation, although it may cause
Formulate a plan for extubation failure 4
particularly in high-risk caseshypertension and tachycardia.

Planning for failure

Both the patient’s clinical condition and
The NAP4 report found that routine airway
situational factors are important. The
equipment was not readily available when
necessary equipment, monitoring and staff
airway problems occurred.1 Airway equipment
should available.1,4,18
must be easily accessible and a back-up plan
for extubation failure considered. A rational
Depth of anaesthesia approach for problems after extubation is to
Extubation should be carried out with the follow published guidelines on the management
patient either fully awake or deeply of the airway at induction. 4 Those at high risk
anaesthetised as attempting extubation in an of complications should have a specific
intermediate plane of anaesthesia is more likely extubation and reintubation plan, which
to result in complications.4 In the fully awake should be shared with the theatre team.
patient who is breathing spontaneously, airway
protective reflexes have returned and the Postponing extubation
patient is able to protect and maintain a patent Extubation is an elective procedure. In
airway. The presence of the tracheal tube may circumstances where the airway is severely
trigger coughing, straining and sympathetic compromised, it may be safer to delay removal
activation resulting in tachycardia and of the tracheal tube and transfer the patient to
hypertension.5e7 Tracheal stimulation can be the intensive care unit to allow for a period of
avoided by reducing movement of both the weaning. Alternatively, if the weaning period is
patient and tracheal tube and minimising likely to be prolonged or there is a risk of
oropharyngeal suctioning. If the airway deterioration (e.g. from oedema), a
haemodynamic or respiratory effects surgical tracheostomy may be performed
secondary to coughing and bucking are electively. This decision should be made jointly
undesirable, a modified technique such as deep by the anaesthetist and surgeon.4
extubation may be considered (see below).

Process of extubation
Pharmacological interventions during
emergence and extubation The majority of patients will have an awake
Various drugs have been used to reduce extubation (Fig. 3).4 Safe extubation can take
coughing and cardiovascular changes at time; it should not be rushed, and this should
extubation. Lidocaine i.v. or topically, sprayed be considered when operating lists are planned.
onto the vocal cords or instilled into the
tracheal tube cuff, has been shown to reduce Positioning the patient
coughing and haemodynamic changes.5,6,19 Low
doses of propofol and ketamine, given as a
bolus, can reduce the incidence of coughing. A
number of other drugs have been used to
prevent hypertension and tachycardia
including i.v. magnesium, beta blockers,
glyceryl trinitrate (GTN) and opioids.5,6,19
Steroids such as dexamethasone are useful
in situations where there is direct airway
trauma causing inflammation but do not

447 BJA Education - Volume 21, Number 12, 2021

 Safe tracheal extubation after general anaesthesia

Extubation after anaesthesia was traditionally headup, position improves respiratory

performed with the patient in the left lateral, dynamics, which is beneficial in obese patients

Deliver oxygen until

recovery is complete

Suction oropharynx
(ideally under direct vision)

Insert a bite block

Position the patient

Reverse neuromuscular
block

Establish regular breathing

with adequate minute ventilation

Minimise movements of
head and neck

Allow emergence to an awake

state: eye opening & obeying
commands

Apply positive pressure, deflate cuff

& remove tracheal tube

100% oxygen via breathing circuit,

confirm airway patency and
adequate breathing

Deliver oxygen until

recovery is complete

4
Fig 3 Key steps in performing a ‘low risk’ awake extubation. Adapted from Popat and colleagues.

head down position to protect the airway and those with lung disease, and it also makes
should vomiting or regurgitation of stomach airway management easier should
contents occur.4 In the lateral position the complications occur.4,11 The left lateral, head
tongue falls forwards rather than posteriorly down position for extubation may still be
into the oropharynx, making it is easier to appropriate if the patient is at high risk of
maintain a patent airway; however, respiratory pulmonary aspiration.11
mechanics are less favourable. A 2005 survey Inspired oxygen
of extubation practices amongst anaesthetists There is limited evidence on the optimum
in the UK and Ireland found that less than a fraction of inspired oxygen during emergence
quarter routinely performed extubation after and extubation. Guidelines set by DAS
elective surgery in the left lateral or left lateral, recommend delivering 100% oxygen to raise
head down position.11 The semi-recumbent, or the expired oxygen fraction to more than 0.9,

BJA Education
448
Safe tracheal extubation after general anaesthesia

’ extubation is higher than during intubation,

providing a ‘store of oxygen to delay the onset
especially if the patient coughs. The risks of
of hypoxia should complications occur. 4
transmission can be reduced by appropriate
Conversely, it has been demonstrated that the
use of personal protective equipment and with
use of 100% oxygen leads to alveolar
the use of techniques aimed to reduce patient
atelectasis, increasing the risk of postoperative
coughing at
hypoxia.20,21 Alveolar atelectasis may occur
extubation.6,23
after as little as 6 min delivery of 100%
oxygen.20 A pragmatic approach for extubation
is to deliver 100% oxygen for the shortest time
possible, reducing it to a more appropriate Advanced techniques for
level for the individual patient’s requirement. extubation
The following extubation techniques need to be
Application of positive pressure learnt, practiced and refined in the clinical
Recruitment manoeuvres such as a vital setting, but key points are described below.
capacity volume breath or the application of Deep extubation
positive end-expiratory pressure as the Deep extubation can avoid the effects of airway
tracheal tube is removed aim to reverse irritation, in particular coughing, bucking and
atelectasis induced during anaesthesia. In haemodynamic instability.6,8 It is commonly
theory, a positive pressure gradient from the performed after neurosurgery, ophthalmic
lungs will expel any material that may have surgery and ENT operations where an increase
accumulated above the tracheal tube cuff, in intracranial, intraocular and vascular
preventing it from falling into the airway.5 pressures can cause undesirable effects.
There is no evidence that these manoeuvres
Spontaneous ventilation is established with
improve oxygenation postoperatively, although
adequate depth of anaesthesia using TIVA or
they are regularly performed by anaesthetists
an inhalational agent. The larynx should be
and recommended in the DAS guidelines.4,11,22
suctioned under direct vision, using a
laryngoscope,topreventsoilingofthetracheaonce
Suction thetrachealcuff is deflated. The cuff is gently
Respiratory secretions, gastric contents and deflated and adequate spontaneous ventilation
blood can collect in the upper airway. Airway confirmed before removal of the tube. 4 As the
suction before extubation can prevent soiling of tracheal tube is removed before airway reflexes
the lung’s and stimulation of airway reflex have returned, coughing and straining are less
responses such as coughing and laryngospasm. likely but airway obstruction is still a risk and
Blood in the airway was a frequent feature in airway manoeuvres and adjuncts
cases reported to NAP4, and the airway should mayberequiredtomaintainairwaypatencyuntilt
be carefully inspected before extubation after hepatientis fully awake. Deep extubation
airway surgery.1 Ideally, suctioning should be should only be carried out by those experienced
performed under direct vision with a in the technique. It is not appropriate for
laryngoscope as there is a risk of soft tissue patients at risk of aspiration and in whom bag-
trauma if done blindly. Laryngoscopy at the mask ventilation or reintubation would be
end of surgery may help identify any occult challenging.8 Monitoring by appropriately
blood or clots in the airway and to assess any trained staff is essential until the patient
change in intubation grade. Deep recovers fully from anaesthesia and is awake,
oropharyngeal suctioning is stimulating and breathing spontaneously and not requiring any
should be performed with the patient deeply airway support.4,16
anaesthetised, especially if performed under
direct vision using a laryngoscope.4 Tracheal
Supraglottic airway device exchange
suction may be also be needed, but it is
important to be aware that this will interrupt Exchanging the tracheal tube for a supraglottic
oxygen flow and may deplete oxygen stores.5 airway device (SAD) provides some airway
protection and patency without the
cardiovascular and respiratory stimulation
Aerosol generation and virus transmission
caused by a tracheal tube. This results in
Tracheal extubation can result in the release of
smoother emergence, avoiding major
airborne particles from the respiratory tract,
haemodynamic changes and respiratory
resulting in spread of infectious diseases
complications such as breath holding, coughing
transmitted by droplets or airborne
and bucking.6,24 SAD exchange is performed
transmission. The recent severe acute
after suctioning of the airway under direct
respiratory syndrome coronavirus 2 (SARS-
vision before the patient is breathing
CoV-2) pandemic has highlighted this risk. The
spontaneously. To avoid complications of
production of aerosol particles during

449 BJA Education - Volume 21, Number 12, 2021

 Safe tracheal extubation after general anaesthesia

airway stimulation the patient, must be deeply threaded over the wire should reintubation be
anaesthetised. This technique was originally needed.
described by Bailey using a Classic LMA
inserted with the tracheal tube still in situ as
this holds the epiglottis anteriorly and prevents Postoperative care
it from folding and obstructing the larynx After extubation it is important to consider
when the SAD is inserted.25 postoperative care and recovery. Oxygen
should be given during transfer and in the
PACU until recovery is complete.1,4,6 In
Remifentanil
situations where there is concern about airway
Remifentanil is a potent, ultra-short acting or respiratory compromise, humidified high-
opioid receptor agonist and, like other opioids, flow nasal oxygen may be beneficial. The Royal
it obtunds cardiovascular and respiratory College of Anaesthetists and Association of
reflexes.6 Infusion of remifentanil during Anaesthetists have clear recommendations on
emergence and extubation allows spontaneous minimum requirements for staffing and
breathing to be established with the tracheal monitoring in recovery and PACUs.16 If airway
tube in situ without the associated coughing, management has been difficult there must be
straining and haemodynamic changes.4,6,19 clear written and verbal handover. It is good
There may already be a remifentanil infusion
’
used during surgery or it may be started practice to document an ‘airway plan in the
specifically for extubation. When the patient is event of an airway emergency or return to
able to follow commands and ventilation is theatre.1,4 This plan can be summarised on an
adequate, the tracheal tube can be removed. ’
‘airway management bed head to aid
This technique requires practice to get the
communication. All at-risk patients should be
timing right and careful titration to prevent
handed over to the anaesthesia team on call.
respiratory depression. The infusion rate or
Complications and adverse events should be
target effect site concentration to reliably
recorded in the patient’s medical notes and on
prevent coughing varies, depending on the
a local database. It is important to explain
patient and on the presence of other
events to the patient, when this is possible, and
anaesthetic and analgesic agents.
provide them with a written summary that
should be copied to their general practitioner.4
Airway exchange catheter
An airway exchange catheter (AEC) may be
considered for extubation of a difficult airway. Summary
They are hollow, semi-rigid catheters that are Complications during emergence and
narrow enough to be tolerated by an awake extubation are common; fortunately, they are
patient, but rigid enough to provide a guide for usually minor and easily treated. Airway and
reintubation should it be necessary.4,7,12 The respiratory complications are the most
catheter is placed into the trachea via the frequent and can result in significant
tracheal tube before extubation. Distance morbidity and mortality. Tracheal extubation
markings in centimetres allow correct requires a clear strategy to avoid complications
positioning within the airway to reduce the risk and keep patients safe. This strategy should
of trauma to the trachea and bronchial tree. In include risk assessment, planning and
adults they should never be inserted to a depth preparation. The patient and situational
greater than 25 cm from the lips.4,13 factors should be optimised before extubation
Catheters may have a 15 mm connector to and fully monitored during transfer and in the
attach to an anaesthetic circuit, a Luer lock PACU. Written and verbal communication of
connector for jet ventilation, or both; however, any difficulties and plans for airway
this is not recommended because of the high management are important. Tracheal
risk of pulmonary barotrauma.4,12 Patients extubation is an elective procedure; immediate
must be nursed in a high dependency extubation after general anaesthesia may be
environment by staff who have training and inappropriate in some scenarios.
experience in managing patients with AECs.
They may be tolerated for up to 72 h but
should be removed as soon as possible when the Declarations of interest
airway is no longer at risk.4 Some staged The authors declare that they have no conflicts
extubation kits include a soft-tipped wire that of interest.
is placed in the airway rather than a catheter.
Wires may be better tolerated and cause less
MCQs
airway trauma and inflammation. The AEC is The associated MCQs (to support CME/CPD
activity) will be accessible at

BJA Education
450
Safe tracheal extubation after general anaesthesia

www.bjaed.org/cme/home by subscribers to based on anesthesia liability data. J Clin

BJA Education. Anesth 2018; 50: 48e56
14. Raju M, Pandit JJ. Re-awakening the
carotid bodies after anaesthesia: managing
References hypnotic and neuromuscular blocking
1. Cook TM, Woodall N, Frerk C. Fourth agents. Anaesthesia 2020; 75: 301e4.
National Audit Project. Major ***@@[14]
complications of airway management in 15. Hunter JM. Reversal of residual
the UK: results of the Fourth National neuromuscular block: complications
Audit Project of the Royal College of associated with perioperative management
Anaesthetists and the Difficult Airway of muscle relaxation. Br J Anaesth 2017;
Society. Part 1: anaesthesia. Br J Anaesth 2011; 119: i53e62
106: 617e31 16. Klein AA, Meek T, Allcock E et al.
2. Asai T, Koga K, Vaughan RS et al. Recommendations for standards of
Respiratory complications associated with monitoring during anaesthesia and
tracheal intubation and extubation. Br J recovery 2021: Guideline from the
Anaesth 1998; 80: 767e75 Association of Anaesthetists. Anaesthesia
3. Peterson GN, Domino KB, Caplan RA et 2021; 76: 1212e23
al. Management of the difficult airway: a 17. Iwasaki H, Renew JR, Kunisawa T, Brull
closed claims analysis. Anesthesiology SJ. Preparing for the unexpected: special
2005; 3: 33e9 considerations and complications after
4. Popat M, Mitchell V, Dravid R, Patel A, sugammadex administration. BMC
Swampillai C, Higgs A. Difficult Airway Anesthesiol 2017; 17: 140e8
Society Guidelines for the management of 18. Jones CPL, Fawker-Corbett J, Groom P et
tracheal extubation. Anaesthesia 2012; 67: al. Human factors in preventing
318e40 complications in anaesthesia: a systematic
5. Miller KA, Harkin CP, Bailey PL. review. Anaesthesia 2018; 73: 12e24
Postoperative tracheal extubation. Anesth 19. Tung A, Ferguson NA, Ng N et al.
Analg 1995; 80: 149e72 Medications to reduce emergence coughing
6. Wong TH, Weber G, Abramowicz AE. after general anaesthesia with tracheal
Smooth extubationand smooth emergence intubation: a systemic review and network
techniques: a narrative review. Anesthesiol metaanalysis. Br J Anaesth 2020; 124:
Res Pract 2021; 2021. 480e95
https://doi.org/10.1155/ 2021/8883257 20. Gerber D, Guensch DP, Theiler L, Erdoes
7. Hartley M, Vaughan RS. Problems G. When less is more: why extubation with
associated with tracheal extubation. Br J less than routine 100% oxygen
Anaesth 1993; 71: 561e8 maybeareasonablestrategy.AnesthAnalg20
8. Cavallone LF, Vannucci A. Extubation of 19;129:1433e5
the difficult airway and extubation failure. 21. Lumb AB, Walton LJ. Perioperative
Anesth Analg 2013; 116: 368e83 oxygen toxicity. Anesthesiol Clin 2012; 30:
9. Naguib M, Kopman AF, Ensor JE. 591e605
Neuromuscular monitoring and 22. Lumb AB, Greenhill SJ, Simpson MP,
postoperative residual curarisation: a Stewart J. Lung recruitment and positive
metaanalysis. Br J Anaesth 2007; 98: airway pressure before extubation does
302e16 not improve oxygenation in the
10. Bhattacharya M, Kallet RH, Ware LB, postanaesthesia care unit: a randomized
Matthay MA. Negative-pressure clinical trial. Br J Anaesth 2010; 104:
pulmonary oedema. Chest 2016; 150: 643e7
927e33 11. Rassam S, Sandby Thomas M, 23. Brown J, Gregson FKA, Shrimpton A et
Vaughan RS, Hall JE. Airway al. A quantitative evaluation of aerosol
management before, during and after generation during tracheal intubation and
extubation: a survey of practice in the extubation. Anaesthesia 2021; 76: 174e81
United Kingdom and Ireland. Anaesthesia 24. Suppiah R, Rajan S, Paul J, Kumar L.
2005; 60: 995e1001 Respiratory and hemodynamic outcomes
12. Jubb A, Ford P. Extubation after following exchange extubation with
anaesthesia: a systematic review. Update laryngeal mask airway as compared to
Anaesth 2009; 25: 30e6 traditional awake extubation. Anesth
13. Kellner DB, Urman RD, Greenberg P, Essays Res 2016; 10: 212e7
Brovman EY. Analysis of adverse 25. Nair I, Bailey PM. Use of the laryngeal
outcomes in the post-anesthesia care unit mask for airway maintenance following

451 BJA Education - Volume 21, Number 12, 2021

 Safe tracheal extubation after general anaesthesia

tracheal extubation. Anaesthesia 1995; 50:

174e5

BJA Education
452