Extubation

Coming out is deceptively the riskier end of the case. You are deliberately removing a secured airway and handing breathing back to a patient who may still be partly anesthetized or weak. Laryngospasm, obstruction, aspiration, and negative-pressure pulmonary edema all live here.

Don't let your guard down at the end. Keep suction, an Ambu bag, reintubation equipment, and induction/paralytic drugs in the room until the patient is safely breathing on their own.

Confirm all of these:

• Neuromuscular blockade reversed — TOF ratio ≥ 0.9 (sustained head lift ≥ 5 s, strong grip are crude surrogates). Reverse with neostigmine/glycopyrrolate or sugammadex as indicated.
• Awake and responsive — follows commands, eyes open (for an awake extubation).
• Adequate spontaneous ventilation — reasonable tidal volumes and rate, acceptable EtCO₂, SpO₂ stable on low FiO₂.
• Protective airway reflexes returning — swallow, gag, cough.
• Hemodynamically stable, normothermic, not bleeding.
• Reversal agents and antiemetics given as needed.

Awake vs. deep: Awake extubation (patient following commands) is the default and safest for aspiration risk and difficult airways. Deep extubation (still anesthetized, reflexes suppressed) reduces coughing/bucking — reserved for select patients with an easy airway and low aspiration risk.

1. 100% O₂ for a few minutes — preoxygenate for the apnea you might create.
2. Suction the oropharynx (and down the tube if needed) — clear blood and secretions.
3. Confirm the patient meets criteria; have them take a breath / follow commands.
4. Deflate the cuff fully.
5. Remove the tube on a positive-pressure breath (or peak inspiration) — this helps blow out secretions sitting above the cuff and discourages laryngospasm.
6. Immediately apply a face mask with O₂, confirm the patient is moving air, watch the EtCO₂/SpO₂.
7. Be ready to support: jaw thrust, oral/nasal airway, CPAP, or reintubate.

Laryngospasm is reflex closure of the cords, classically in the light plane as the tube comes out or with secretions/blood irritating the cords.

• Signs: stridor (partial) or silent total obstruction, paradoxical chest/abdominal movement, falling SpO₂.
• Treatment ladder:
• 1. Remove the stimulus, 100% O₂, jaw thrust + firm CPAP.
• 2. Larson's maneuver — firm pressure at the "laryngospasm notch" behind the earlobes.
• 3. Deepen (small propofol bolus 0.25–0.5 mg/kg).
• 4. If persistent/desaturating: succinylcholine (e.g., 0.1–1 mg/kg IV, or IM if no IV) and ventilate / reintubate.
• Watch afterward for negative-pressure pulmonary edema (pink frothy secretions, hypoxia) from forceful inspiration against a closed glottis.