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Extubation: Making
The Unpredictable Safer
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RAM ROTH, MD FAIEJA CHOWDHURY ELIZABETH A.M. FROST, MD

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Assistant Professor of Anesthesiology Student Professor of Anesthesiology

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Mount Sinai School of Medicine Stony Brook University Mount Sinai School of Medicine
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New York, New York Stony Brook, New York New York, New York
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The authors report no relevant financial conflicts.

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irway management is a fundamental aspect of anesthesiology comprising

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mask ventilation, laryngoscopy, endotracheal intubation, and extubation.

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Considerable research and development has focused on the first 3 aspects of

airway management, but relatively little consideration has been given to extubation—
despite the fact that many preventable complications result from the improper
extubation of patients.

A N E S T H E S I O L O G Y N E W S G U I D E T O A I R WAY M A N A G E M E N T 2 0 1 2 69
 literature for the 2 keywords “intubation” and “extu-
Table. Routine Extubation Criteria10 bation,” about 90% of articles included “intubation”
whereas only 10% mentioned “extubation.”
Awake, alert, able to follow commands There are established strategies to perform intuba-
tion and algorithms to aid in other difficult situations
• Sustained eye opening for pediatric patients or
in anesthesiology. A plethora of research has been
patients unable to understand commands
conducted to create new guidelines, procedures, and
Vital signs stable predictive approaches and management of difficult tra-
cheal intubation. In 1993, the guidelines of the American
• Blood pressure, pulse rate, temperature
Society of Anesthesiologists (ASA) for the manage-
• Respiratory rate ≤30 breaths per minute ment of the difficult airway established a protocol for
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intubation, but not for extubation. Those guidelines

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• O2 saturation indeed have had the desired effect. A 2005 analysis

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Protective reflexes returned of the Closed Claims database showed that the num-
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ber of claims for death and brain death associated with

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• Gag
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intubation had decreased since the incorporation of

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the guidelines. However, the number of claims linked to

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• Swallow
extubation has not fallen.
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• Cough Indeed, extubation now appears to be more danger-

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ous than intubation. A 1998 study by Asai et al found

Adequate reversal of neuromuscular blockade
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that the overall rate of complications associated with

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• Train-of-4 stimulation 4/4, sustained tetany at extubation was 7.4% greater than that for intuba-
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tion. Respiratory events include coughing, desatura-

tion, breath holding, airway obstruction, laryngospasm,
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• Strong hand grip

apnea, hypoventilation, inadequate reversal, vomiting,
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• Usassisted head lift (>5 sec) and masseter spasm. Cardiovascular complications
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consist of arterial hypertension, tachycardia, and dys-

Arterial blood gases reasonable with FiO2 40
rhythmias. Other complications include laryngeal and
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• pH >7.30 supraglottic edema.

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• PaO2 ≥60 mm Hg Limited Guidance

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• PaCO2 <50 mm Hg
Extubation quality depends on the anesthesiologist.
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The lack of a standard makes it difficult to teach extuba-

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Respiratory mechanics adequate tion to residents or to have a meaningful discussion that

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would improve the quality of care. What few extuba-

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• Tidal volume >5 mL/kg

tion guidelines exist, in fact, involve methods for reduc-
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• Vital capacity >15 mL/kg ing complications in specific cases in order to treat
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or minimize injury. For example, if a patient exhibits

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• Negative inspiratory force >–20 cm H2O

post-extubation stridor, the textbook Miller’s Anesthe-
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For patients at risk for laryngeal edema, consider sia recommends that helium be used to improve oxy-
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cuff leak test and airway inspection genation and increase tidal volume in the extubated
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patient to prevent reintubation. If a patient develops

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• Evaluation by fiber-optic bronchoscopy

severe hypoxemia, succinylcholine and reintubation are
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recommended.
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The ASA suggests that anesthesiologists should have

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a “preformulated” strategy for extubation that includes

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Magill and Macintosh popularized endotracheal tube constant oxygen management, ventilation, and a rein-
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(ETT) intubation shortly after World War I. It was intro- tubation strategy to prevent such complications from
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duced to protect the patient from aspiration and sus- occurring.

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tain ventilation while under anesthesia. Clearly, the ETT Two algorithms for extubation of the difficult air-
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should be removed only after surgery is completed and
patients can maintain ventilation.
Quality improvement in the field of anesthesiology
has focused largely on intubation rather than extuba-
tion. Conferences and workshops for difficult intuba-
tion are manifold. Most vendors develop equipment for
improving intubation rather than extubation. Anesthesi-
ology textbooks focus on intubation, not extubation. It
is interesting to note that in a search of peer-reviewed
way have been proposed, but they may not be practi-
cal for many situations. The recently revised Hagberg
Extubation Algorithm of Patients with a Difficult Airway
(Figure 1) is not a tool for teaching basic extubation.
Routine extubation criteria recently revised by Hag-
berg, call for the patient to be awake and cooperative
(Table). Using these criteria patients who are in coma,
have Alzheimer’s disease, are children, or speak a for-
eign language cannot be extubated. Airway reflexes

70 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
 Routine extubation No
Postpone extubation
criteria met?

Yes

Place tube exchanger

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Adequate ventilation/
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Yes No
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SpO2
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Inadequate ventilation/
Timely tube exchanger Improvement
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SpO2
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• O2 insufflation
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• Jet ventilation
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Reintubate over tube

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exchanger using direct

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or video laryngoscopy
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No Yes
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Remove
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Yes
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tube exchanger Admit to intensive

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Continued at B
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Bag-mask ventilation care unit

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adequate?
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Continued at A

Figure 1. The Hagberg Algorithm for Extubation of the Difficult Airway.a

Pathways A and B refer to reintubation strategies.
a
Multiple attempts at direct vision or use of alternative device because of expected difficulty performing direct vision
b
If there is no evidence of laryngeal edema or respiratory difficulty

A N E S T H E S I O L O G Y N E W S G U I D E T O A I R WAY M A N A G E M E N T 2 0 1 2 71
may be identified before the patient is fully awake and
extubation can be achieved with less discomfort. There
should be flexibility in evaluation of the respiratory rate,
which can be adjusted pharmacologically (eg, using
narcotics). A minimum tidal volume of 5 mL/kg may be
impractical in certain cases such as overweight patients.
The tidal volume should be measured while the patient
is still under anesthesia and unconscious. A more useful
tidal volume may be 3 mL/kg with the expectation that
once anesthesia is discontinued, the volume will increase.
The routine extubation criteria also recommend a vital
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capacity and blood gas evaluation. Vital capacity is
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not practical because it also requires patient coopera-
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tion, and may cause discomfort and lead the patient to
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struggle. The evaluation of blood gas levels is unrealis-
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tic because analyses are not available for every case. An
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unassisted head lift longer than 5 seconds also requires
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comprehension and cooperation. Reversal is not always
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necessary, and even with full reversal extubation may be
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premature. While these criteria may be of value in many
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situations, they are not universally applicable.
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The 2003 ASA Task Force Extubation Algorithm for
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the Difficult Airway similarly targets only the difficult
airway and does not give basic extubation guidance.
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The detailed algorithm proposes several extubation
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options. The most prominent segment of this algo-
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rithm directs the anesthesiologist to “go to ASA Diffi-
cult Airway” intubation algorithm. This does not inspire
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confidence. Choosing one of these strategies is not
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unlike playing Russian roulette: The anesthesiologist
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must choose from options A, B, C, or D, and the result
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is either a successful or failed extubation.
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The process of developing algorithms creates an
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opportunity for teamwork to solve a common problem.
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Atul Gawande stated in Checklist Manifesto that check-
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lists like algorithms “remind us of minimum necessary
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steps and make them explicit. They not only offer the
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possibility of verification but also instill a kind of dis-
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cipline of higher performance.” An algorithm for extu-
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bation will increase safety and quality of procedures
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by standardizing protocols. In anesthesiology, the
machine check is our “preflight check.” Our flight plan
is determined by the preoperative examination. In many
instances, the “take-off checklist” is propofol, succinyl-
choline, and tube. The ASA difficult airway algorithm
exists in the event of an emergent complicated intu-
bation. Pilots have a checklist for standard landings,
but anesthesiologists do not for our counterpart. There
exists little guidance for the “preformulated” strategy
mentioned by the ASA.
The following algorithm for extubation is being pro-
posed to improve the process of extubation, minimize
failures, and enable teaching in a more practical man-
ner. It includes step-by-step considerations to guide an
effective smooth procedure.
VSS+4S+2S
The VSS+4S+2S mnemonic has been created in
order to help remember and identify the steps of the
72 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
algorithm easily (Figure 2). The first part, VSS, is a well-
known notation that all vital signs and monitored data
are stable. “Stable vital signs” is often unstated before
successful extubations, but should be explicitly doc-
umented or addressed. Complicated or sick patients
clearly require intensive care and postoperative ventila-
tion, but many extubation failures result from attempts
while vital signs are unstable.
The second part of the algorithm is 4S, which repre-
sents Stent, Strength, Spontaneous, and Suction, and is
performed on the anesthetized patient. Too often, the
initial but incorrect step in extubation is turning off all
anesthetic agents. The patient may awaken by jump-
ing off the table enraged or may be conscious but fully
paralyzed while the anesthesiologist yells or physically
stimulates him or her to “open your eyes.” Continuing
1 MAC of inhalational anesthetic, total IV anesthesia, or
any balanced technique allows the anesthesiologist to
evaluate and prepare for extubation while maintaining
full control of the patient.
Stent indicates that the anesthesiologist must con-
sider whether the ETT is needed after surgery. In certain
situations, the ETT may effectively be a stent maintain-
ing patency of the airway. Removing the ETT may lead
to compression of the larynx by airway edema, fluid
overload, local trauma, or hemorrhage. If total collapse
of the airway is predicted, the anesthesiologist must
use the red portion of the algorithm and not discon-
tinue anesthesia. Post-extubation obstruction of the
upper airway may occur due to obesity, obstructive
sleep apnea, or lack of dentition, among other causes.
Most of the Hagberg algorithm can be inserted into
the stent section of this guide to extubation. The leak
test now may be used to help determine if there is sig-
nificant laryngeal edema. Techniques of the ASA Task
Force Extubation Algorithm for the Difficult Airway
may be applied at this point such as extubation over
an airway catheter, or fiber-optic scope may be con-
sidered. Other methods may be as simple as planning
a jaw thrust after extubation or inserting an oral airway
just prior to extubation.
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Strength represents a majority of published extuba-
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tion criteria. Head lift, following commands, measures of
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volumes and capacities as well as measures of negative
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inspiratory force and twitch responses, etc, all represent
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strength. Yet, they are not strictly applied to all extu-
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bations and are not established in any well-accepted
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algorithm. Here, strength is evaluated in a practical and
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simplified manner. The anesthesiologist evaluates the
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tidal volume of a spontaneously respiring patient while
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under anesthesia. Use of neuromuscular blocker rever-
sal, which may or may not be required, can be evalu-
ated at this point. Tetanus for 5 seconds without fade
and trend in end-tidal carbon dioxide, or ETCO2, lev-
els provide further information in the evaluation of ade-
quate strength.
Spontaneous respiratory drive is absolutely neces-
sary for managing extubation and is closely related
to strength; neither can be assessed alone. Cellular
 Vital signs Stable
No
Yes

Stent No potential obstruction

No
Yes
Manage
Consider
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Strength Tidal volume, tetanus, ETCO2 appropriate continuing

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ventilation
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Yes
Reassess
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Spontaneous Normal respiratory rate

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Yes
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Suction Secretions cleared

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DISCONTINUE ANESTHESIA Deep extubation

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Swallow Airway reflexes intact Sedated extubation

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Secure Ease of reintubation Awake extubation

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Figure 2. The “VSS+4S+2S” proposed algorithm for extubation.

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metabolism generates CO2, which stimulates the apneus- about 3 mL/kg, and spontaneous respiratory drive with
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tic center in the pons, creating a respiratory drive. Despite a rate of about 18 breaths per minute, and the orophar-
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intraoperative narcotic administration and maintenance ynx is clear. Extubation, if carried out at this point, is
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of anesthesia, supernormal levels of CO2 will result in a considered a deep extubation and is classically rec-
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spontaneous drive that will lead to respiratory efforts, ommended in patients with severe asthma. If a deep
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only if the patient is not paralyzed. With strength and extubation is not indicated, the green portion of the
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spontaneous drive established, the fifth vital sign—pain— algorithm represents the next phase in which anesthe-
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can be evaluated. Rate of respiration may indicate pain sia is discontinued.

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and can be addressed by titrating narcotics.
Suction is the final step in the preparation for extu-
bation performed on the anesthetized patient. The only
acceptable purpose for suction is to clear the airway of
secretions or blood. If suction is applied to a lightly con-
scious or conscious patient, it may cause irritation and
result in bucking, breath holding, and discomfort.
At this point, the anesthetized patient has stable vital
signs, a patent airway, strength with a tidal volume of
The final part of the algorithm is 2S, consisting of
Swallow and Secure.
Swallow indicates that the anesthesiologist must
observe and detect the return of airway reflexes. Air-
way reflexes require strength to be present which
already has been established earlier in the algorithm.
The patient may begin swallowing, moving the tongue,
gagging or coughing. Commonly, anesthesiologists
delay extubation until after the patient is “fully” awake.

A N E S T H E S I O L O G Y N E W S G U I D E T O A I R WAY M A N A G E M E N T 2 0 1 2 73
This delay often results in choking or bucking, and may
lead to throat pain or injury.
Now, with anesthesia discontinued, the patient has
stable vital signs, a patent airway, strength demon-
strated with a tidal volume of about 3 mL/kg, spon-
taneous respiratory drive with a rate of 18 breaths per
minute, and airway reflexes. The oropharynx has been
suctioned if necessary. Extubation may be achieved
with the patient still sedated if there are no concerns
for aspiration, such as full stomach. Immediately after
extubation, a few minutes of jaw thrust may be neces-
A
Conclusion
This new extubation algorithm reminds anesthesiolo-
gists of the steps necessary for the extubation process
and evaluates each step along the way in a set order. If
integrated into general practice, it may allow for a reli-
able and safer extubation. The algorithm provides an
understandable teaching method, enabling anesthe-
siologists to discuss extubation in a universal manner
and encourage further planning to improve the art of
extubation.
Selected Readings

sary to prevent upper airway obstruction in the sedated

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patient. Asai T, Koga K, Vaughan RS. Respiratory complications associated

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Secure, the final step in the algorithm, reflects the with tracheal intubation and extubation. Br J Anaesth. 1998;80(16):
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767-775.
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comfort level and experience of the anesthesiologist. If

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Brambrink AM, Hagberg CA. The ASA Difficult Airway Algorithm: anal-
rig ed.

extubation has not occurred up to this point in the algo-

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ysis and presentation of a new algorithm. In: Benumof and Hagberg’s

rithm, it may be because it is a known difficult airway.
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Airway Management. 3rd ed. Elsevier; 2012:222-239 (In press).

Perhaps surgery has affected the anatomy of the air-
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Berkow LC. Strategies for airway management. Best Pract Res Clin
way. In this situation, the anesthesiologist may not feel Anaesthesiol. 2004;18(4):531-548.
20

secure about regaining control of the airway in case of Clinical Anesthesia. 6th ed. Barash PG, Cullen BF, Stoelting RK, Caha-
12
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an emergency. Reintubation as a rescue maneuver is lan MK, Stock MC, eds. Philadelphia, PA: Lippincott Williams & Wilkins;
2009.
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not an option in this algorithm. Therefore, a fully awake

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extubation is warranted and the risks for patient dis- Finucane BT, Tsui BCH, Santora AH. Extubation strategies: the extu-
bation algorithm. In: Principles of Airway Management. New York, NY:
comfort, awareness, or injury are secondary to a safe
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Springer; 2011.
extubation.
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Gawande A. The Checklist Manifesto. New York, NY: Henry Holt and
Within each step of the checklist, if the patient devi- Company; 2009.
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ates from the ideal conditions, appropriate measures are

Hales BM, Pronovost PJ. The checklist—a tool for error management
recommended (represented in red). Return to full anes-
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and performance improvement. J Crit Care. 2006;21(3):231-235.

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thesia and assessment of the situation are indicated.

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Hartley M, Vaughan RS. Problems associated with tracheal extubation.

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Emergence is commonly defined as the period dur- Br J Anaesth. 1993;71(4):561-568.

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ing which maintenance agents are discontinued, the Henderson J. Airway management in the adult. In: Miller’s Anesthe-
or

patient begins to wake up, spontaneous respirations sia. 7th ed. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP,
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resume, airway reflexes return, and he/she is prepared Young WL, eds. Philadelphia, PA: Churchill Livingstone; 2009.
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for extubation and transport to the recovery room.

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Medical Foundation of Epsom College. Reports of Societies. BMJ.

1949;1(4591):26-28.
Medications may be given to control pain, decrease or
un ou
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prevent nausea, and reverse the effects of nondepolar- Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW.
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Management of the difficult airway: a closed claims analysis. Anesthe-

izing muscle relaxants. This description of emergence
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siology. 2005;103(1):33-39.
is inherently flawed and the sequence should be rear-
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Practice guidelines for management of the difficult airway. Anesthesi-

ranged into a more logical order.
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ology. 1993;78(3):597-602.
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74 I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G