Difficult Airway Society Guidelines for the management of tracheal extubation
Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Anaesthesia 2012, 67, 318–340. http://www.ncbi.nlm.nih.gov/pubmed/22321104
This guideline is aimed to reduce the morbidity and mortality related to extubation by following a stepwise approach. From the fourth National Audit Project (NAP4) of the Royal College of Anaesthetists and the US closed claim study, it is vivid that extubation needs more attention. Compared to induction and intubation practice, lack of high grade clinical evidence in extubation practice has limited the authors to rely on expert opinion on many issues.
The guideline has three algorithms and each algorithm has four similar steps with different focus. The four steps are plan extubation, prepare for extubation, perform extubation and post extubation care. The core focus of the “basic algorithm” is stratification of extubation as “low risk” and “at risk”, based on the assessment of general and airway risk factors. The “low risk algorithm” mainly focusing on deep vs. awake extubation. The “at risk algorithm” has the key focus on awake vs. advanced techniques of extubation and postpone extubation vs. tracheostomy. The advanced techniques are laryngeal mask exchange, remifentanil technique and the airway exchange catheter.
This guideline has been formatted in such a way that would be useful in day to day practice. It is clearly emphasized that extubation is an elective process and planning is imperative.