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• W3194662531 abstract "Learning objectivesBy reading this article, you should be able to:•List the complications occurring during emergence, extubation and in recovery.•Detail the factors that increase the risks of adverse events.•Explain how to optimise conditions before tracheal extubation.•Discuss techniques to reduce complications at extubation.Key points•Complications during emergence, extubation and in the PACU are common and can be life-threatening.•An extubation plan should be formulated before anaesthesia and consider patient-related, anaesthetic, surgical and human factors.•The patient's clinical condition should be optimised for extubation.•Awake extubation is the standard technique.•Extubation is an elective procedure, and removal of the tracheal tube immediately after general anaesthesia may not always be the safest approach. By reading this article, you should be able to:•List the complications occurring during emergence, extubation and in recovery.•Detail the factors that increase the risks of adverse events.•Explain how to optimise conditions before tracheal extubation.•Discuss techniques to reduce complications at extubation. •Complications during emergence, extubation and in the PACU are common and can be life-threatening.•An extubation plan should be formulated before anaesthesia and consider patient-related, anaesthetic, surgical and human factors.•The patient's clinical condition should be optimised for extubation.•Awake extubation is the standard technique.•Extubation is an elective procedure, and removal of the tracheal tube immediately after general anaesthesia may not always be the safest approach. Tracheal extubation generates less interest than tracheal intubation. Research, guidelines and clinical anecdotes tend to focus on airway management at the beginning of anaesthesia, and it is rare for the challenges of extubation to receive as much attention. Despite the focus on intubation, extubation and emergence from general anaesthesia are not without risk. The Royal College of Anaesthetists and Difficult Airway Society (DAS) 4th National Audit Project (NAP4) found that almost a third of major airway complications occurred during emergence and in the recovery period. Two cases resulted in death and one in severe brain injury, and there were 10 emergency surgical airways attempted.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar Patients undergoing oral or head and neck surgery accounted for almost 50% of these cases and obesity was a common comorbid condition.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar A prospective survey by Asai and colleagues found that respiratory complications after extubation and in the post-anaesthesia care unit (PACU) were much more common than complications occurring with tracheal intubation.2Asai T. Koga K. Vaughan R.S. et al.Respiratory complications associated with tracheal intubation and extubation.Br J Anaesth. 1998; 80: 767-775Abstract Full Text PDF PubMed Scopus (196) Google Scholar Data from the American Society of Anesthesiologists' (ASA) closed claims database found that 18% of insurance claims for death or brain damage arising from management of the difficult airway occurred during or after extubation.3Peterson G.N. Domino K.B. Caplan R.A. et al.Management of the difficult airway: a closed claims analysis.Anesthesiology. 2005; 3: 33-39Crossref Scopus (617) Google Scholar Although complications at emergence and in the PACU may appear minor and transient, the NAP4 project shows that they can result in long-term injury and death.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar This article describes the physiological changes and complications that occur during tracheal extubation and emergence from general anaesthesia. The DAS guidelines on safe extubation after surgery are introduced and approaches to extubation explained.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar We describe specific techniques used to manage the ‘at-risk’ airway. Weaning and extubation in the ICU are beyond the scope of this article. Most of the adverse effects that can occur during emergence and extubation result from airway obstruction or exaggerated 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.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar,6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar The problems encountered are summarised in Table 1. Airway and respiratory complications are the most common.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar,7Hartley M. Vaughan R.S. Problems associated with tracheal extubation.Br J Anaesth. 1993; 71: 561-568Abstract Full Text PDF PubMed Scopus (148) Google Scholar,8Cavallone L.F. Vannucci A. Extubation of the difficult airway and extubation failure.Anesth Analg. 2013; 116: 368-383Crossref PubMed Scopus (98) Google ScholarTable 1Effects of extubation and emergence from general anaesthesia with incidence as percentage where available.2Asai T. Koga K. Vaughan R.S. et al.Respiratory complications associated with tracheal intubation and extubation.Br J Anaesth. 1998; 80: 767-775Abstract Full Text PDF PubMed Scopus (196) Google Scholar,4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar, 5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar, 6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar, 7Hartley M. Vaughan R.S. Problems associated with tracheal extubation.Br J Anaesth. 1993; 71: 561-568Abstract Full Text PDF PubMed Scopus (148) Google Scholar, 8Cavallone L.F. Vannucci A. Extubation of the difficult airway and extubation failure.Anesth Analg. 2013; 116: 368-383Crossref PubMed Scopus (98) Google Scholar, 9Naguib M. Kopman A.F. Ensor J.E. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis.Br J Anaesth. 2007; 98: 302-316Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 10Bhattacharya M. Kallet R.H. Ware L.B. Matthay M.A. Negative-pressure pulmonary oedema.Chest. 2016; 150: 927-933Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar, 11Rassam S. Sandby Thomas M. Vaughan R.S. Hall J.E. Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland.Anaesthesia. 2005; 60: 995-1001Crossref PubMed Scopus (43) Google Scholar, 12Jubb A. Ford P. Extubation after anaesthesia: a systematic review.Update Anaesth. 2009; 25: 30-36Google Scholar, 13Kellner D.B. Urman R.D. Greenberg P. Brovman E.Y. Analysis of adverse outcomes in the post-anesthesia care unit based on anesthesia liability data.J Clin Anesth. 2018; 50: 48-56Crossref PubMed Scopus (13) Google Scholar ∗General anaesthesia for noncardiac surgery.CauseEffectIncidenceAirway irritationCoughing and bucking18–66%Laryngospasm17–25%Desaturation (Spo2 <90%)24%Inadequate reversal5–10%Post-obstructive pulmonary oedema0.1%Bronchospasm1%Reduced level of consciousness/obtunded reflexesBreath holding13–20%Airway obstruction5–19%Apnoea/hypoventilation2–9%Vomiting/aspiration2/0.5%Laryngeal incompetenceCardiovascular changesHypertension/tachycardia10% (haemodynamic instability)Arrhythmias7%∗Raised intracranial pressureRaised intraocular pressureMyocardial ischaemiaFlap disruption/bleeding at surgical siteTraumaDental damage0.02%Airway oedemaDrug effectResidual neuromuscular block5–10%Masseter spasm Open table in a new tab The NAP4 report found that airway obstruction was the primary cause of all airway complications at the end of anaesthesia and in the PACU.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar A patent airway is a prerequisite for successful extubation but there is a high risk of airway obstruction during emergence. Although a difficult airway at induction of anaesthesia is likely to remain difficult, easy airway management at the start of anaesthesia can be falsely reassuring and the anaesthetist may find that the airway they are managing at the end of the procedure is very different. The causes of airway obstruction during emergence and extubation are summarised in Table 2. Factors specific to the patient may be present at induction or exacerbated by surgery and anaesthesia.Table 2Patient-related, surgical and anaesthetic factors that contribute to airway obstruction during emergence and extubation.Patient-relatedObesityObstructive sleep apnoeaSmokerC-spine immobilityHistory of head and neck radiotherapyPharyngeal obstruction (tonsillar/adenoidal hypertrophy)Craniofacial abnormalities (micrognathia, maxillary hypoplasia)Neuromuscular disorders (bulbar weakness)Connective tissue disordersStorage diseasesChronic renal failureLaryngomalaciaSurgicalAirway soiling (blood, secretions)SwellingVocal cord damageNeck haematomaTrendelenburg position (facial and airway oedema)Fixation of cervical spine or facial bones (causes reduced head and neck mobility)AnaestheticAnaesthetic agents (reduce consciousness, impair reflexes, reduce muscle tone)LaryngospasmResidual neuromuscular blockGlottic oedemaAirway device occlusion (from biting, secretions or blood) Open table in a new tab Residual neuromuscular block as a result of incomplete antagonism of neuromuscular blocking drugs (NMBDs) is common and is associated with postoperative airway complications. Residual neuromuscular block most commonly presents as airway obstruction. Respiratory dynamics may appear normal despite a significant degree of residual paralysis because the muscles of the upper airway and pharynx are more sensitive and take longer to recover. Inadequate ventilation and suppression of the hypoxic chemoreflex is common, and together, these factors combine to make the extubation period hazardous unless reversal of neuromuscular block is complete.14Raju M. Pandit J.J. Re-awakening the carotid bodies after anaesthesia: managing hypnotic and neuromuscular blocking agents.Anaesthesia. 2020; 75 (∗∗∗@@[14]): 301-304Crossref PubMed Scopus (5) Google Scholar The most commonly used measure of neuromuscular block is the train-of-four (TOF) ratio, which assesses the strength of muscle twitch response of the fourth stimuli compared with the first. For many years, a TOF ratio of 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 <0.9.15Hunter J.M. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation.Br J Anaesth. 2017; 119: i53-i62Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar 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% <0.9.9Naguib M. Kopman A.F. Ensor J.E. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis.Br J Anaesth. 2007; 98: 302-316Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Use of a neuromuscular monitoring device is mandatory whenever NMBDs are used.16Klein A.A. Meek T. Allcock E. et al.Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists.Anaesthesia. 2021; 76: 1212-1223Crossref PubMed Scopus (43) Google Scholar 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.14Raju M. Pandit J.J. Re-awakening the carotid bodies after anaesthesia: managing hypnotic and neuromuscular blocking agents.Anaesthesia. 2020; 75 (∗∗∗@@[14]): 301-304Crossref PubMed Scopus (5) Google Scholar,16Klein A.A. Meek T. Allcock E. et al.Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists.Anaesthesia. 2021; 76: 1212-1223Crossref PubMed Scopus (43) Google Scholar A TOF ratio of ≥0.9 is recommended before extubation.9Naguib M. Kopman A.F. Ensor J.E. Neuromuscular monitoring and postoperative residual curarisation: a meta-analysis.Br J Anaesth. 2007; 98: 302-316Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar,15Hunter J.M. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation.Br J Anaesth. 2017; 119: i53-i62Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Neuromuscular block can be antagonised with neostigmine or sugammadex, but sugammadex is only effective if rocuronium or vecuronium have been given. Reversal of neuromuscular block is faster with sugammadex than neostigmine and is associated with fewer adverse effects including a lower incidence of residual postoperative paralysis.15Hunter J.M. Reversal of residual neuromuscular block: complications associated with perioperative management of muscle relaxation.Br J Anaesth. 2017; 119: i53-i62Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar A peripheral nerve stimulator should be used with sugammadex as an insufficient dose may result in a recurrence of neuromuscular block after reversal or ‘recurarisation’, caused by the redistribution of free rocuronium from the plasma back to the effect site at the neuromuscular junction.17Iwasaki H. Renew J.R. Kunisawa T. Brull S.J. Preparing for the unexpected: special considerations and complications after sugammadex administration.BMC Anesthesiol. 2017; 17: 140-148Crossref PubMed Scopus (11) Google Scholar After giving sugammadex, it is important to consider how neuromuscular block will be re-established if required for reintubation. The manufacturer recommends using a benzylisoquinolinium NMBD if neuromuscular block is required within 24 h of sugammadex. There is evidence to suggest that rocuronium can be used within this period provided a rapid sequence induction is not required. If neuromuscular block is needed within 3 h of sugammadex, the dose of rocuronium should be increased to 1.2 mg kg−1.17Iwasaki H. Renew J.R. Kunisawa T. Brull S.J. Preparing for the unexpected: special considerations and complications after sugammadex administration.BMC Anesthesiol. 2017; 17: 140-148Crossref PubMed Scopus (11) Google Scholar Laryngeal spasm is a common complication of general anaesthesia and results from direct irritation of the vocal cords by blood, saliva or instrumentation, or indirectly from surgical stimulation. Contraction of the muscles of the larynx causes adduction of the vocal cords and airway obstruction.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar,6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar Partial airway obstruction presents with inspiratory stridor and increased airway pressure but complete obstruction is silent. If untreated, laryngospasm can progress to hypoventilation, hypoxaemia and ultimately hypoxic cardiac arrest.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar,7Hartley M. Vaughan R.S. Problems associated with tracheal extubation.Br J Anaesth. 1993; 71: 561-568Abstract Full Text PDF PubMed Scopus (148) Google Scholar Laryngospasm during emergence and extubation is avoided by ensuring sufficient depth of anaesthesia before manipulation of the airway, removal of airway blood and secretions, and minimising head and neck movements during transfer.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar Specific drugs may also be beneficial (see below). Post-obstructive pulmonary oedema (POPO) can develop after an episode of airway obstruction.6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar It was noted in 10% of all anaesthesia-related airway complications in the NAP4 study.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar This complication is caused by a forced inspiratory effort against a closed glottis or an occluded airway. This generates a negative intrathoracic pressure that alters the Starling forces across the pulmonary capillaries and alters cardiac filling pressures and afterload. The result is movement of fluid into the alveoli and pulmonary interstitium with pulmonary oedema despite normal cardiac function. Direct mechanical stress, acidosis and hypoxia may also contribute by disrupting the alveolar epithelium and pulmonary capillaries.10Bhattacharya M. Kallet R.H. Ware L.B. Matthay M.A. Negative-pressure pulmonary oedema.Chest. 2016; 150: 927-933Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Post-obstructive pulmonary oedema typically occurs in young, muscular adults and can follow airway obstruction of any cause, although laryngospasm is the most common.6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar Patients present with a cough, pink frothy sputum and hypoxia. Chest radiographs show features of pulmonary oedema. Management is supportive with admission to the high dependency unit (HDU) for oxygen supplementation and application of continuous positive airway pressure; in some cases, diuretics have been used.10Bhattacharya M. Kallet R.H. Ware L.B. Matthay M.A. Negative-pressure pulmonary oedema.Chest. 2016; 150: 927-933Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Opioids and anaesthetic agents obtund the central respiratory response to increased Paco2 and hypoxia, reducing ventilatory drive.14Raju M. Pandit J.J. Re-awakening the carotid bodies after anaesthesia: managing hypnotic and neuromuscular blocking agents.Anaesthesia. 2020; 75 (∗∗∗@@[14]): 301-304Crossref PubMed Scopus (5) Google Scholar Poorly controlled pain and residual neuromuscular block may prevent a patient from generating adequate tidal volumes. Pulmonary atelectasis results in ventilation/perfusion mismatch and increases the work of breathing.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar,7Hartley M. Vaughan R.S. Problems associated with tracheal extubation.Br J Anaesth. 1993; 71: 561-568Abstract Full Text PDF PubMed Scopus (148) Google Scholar Although ventilation may be compromised, patients will have an increased oxygen demand at the end of surgery, particularly those with a systemic inflammatory response or sepsis. Human factors also increase the risk of complications during emergence and extubation. The task load for the anaesthetist at the end of surgery is high and the environment is less controlled than at induction. The patient's airway may be less accessible at the end anaesthesia because of positioning for surgery, and there are additional stressors such as extraneous noise and fatigue.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar,18Jones C.P.L. Fawker-Corbett J. Groom P. et al.Human factors in preventing complications in anaesthesia: a systematic review.Anaesthesia. 2018; 73: 12-24Crossref PubMed Scopus (49) Google Scholar There is little evidence from RCTs and meta-analyses for managing extubation but it is clear that there is no one single technique suitable for all patients.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar There is general agreement that the extubation strategy should be considered before anaesthesia, to assess the individual risk for each patient and allow sufficient time for planning and preparation.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar Preoperative plans can then be modified depending on intraoperative events.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar During extubation, as with intubation, the aim is to ensure adequate delivery of oxygen to the lungs. In 2012 DAS published guidelines on the management of tracheal extubation in adults. This was the first guideline to focus specifically on tracheal extubation and is applicable to all adults undergoing general anaesthesia, not just those with a difficult airway. The guidelines present a systematic approach to stratify patients into ‘low’ or ‘at-risk’ groups and outline some extubation techniques (Fig 1, Fig 2).4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google ScholarFig 2Difficult Airway Society (DAS) extubation guidelines: ‘at-risk’ algorithm. Reproduced from Popat and colleagues,4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar with permission from the Association of Anaesthetists and Blackwell Publishing Ltd. HDU, high dependency unit.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Preparation creates conditions that favour safe and successful extubation (Table 3). A safe extubation depends on good communication between the anaesthetist, surgeon and operating theatre team, particularly for the ‘at-risk’ airway.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar Both the patient's clinical condition and situational factors are important. The necessary equipment, monitoring and staff should available.1Cook T.M. Woodall N. Frerk C. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia.Br J Anaesth. 2011; 106: 617-631Abstract Full Text Full Text PDF PubMed Scopus (1102) Google Scholar,4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar,18Jones C.P.L. Fawker-Corbett J. Groom P. et al.Human factors in preventing complications in anaesthesia: a systematic review.Anaesthesia. 2018; 73: 12-24Crossref PubMed Scopus (49) Google ScholarTable 3An ABC approach to extubation: essential considerations when preparing for extubation at the end of surgery.AirwayEnsure the airway is patentPatient is able to protect airway adequatelyConsider inserting a bite blockRemove any throat packsBreathingAdequate ventilation – oxygenation and removal of CO2•Assess Spo2 and Pe′co2•Regular ventilatory pattern, breathing with steady rate and tidal volumes•If using a supported ventilation mode, pressure support and PEEP should be minimal•Give 100% oxygenCirculationStable blood pressure, heart rate and rhythm•Normotension without need for high levels of inotrope or vasopressor support•Adequate fluid balance, normal or improving lactate•No significant acidosis•Arrhythmias treated and controlledDrugsConfirm reversal of neuromuscular blockEnsure adequate analgesiaEnvironmentTemperature•Maintain normothermiaEquipment•Airway management equipment readily availablePositioning•Head up or left lateralLocation•Suitable location with adequate monitoring and assistanceHuman factorsTiming•Consider time of day, staff availability, levels of fatigue•Appropriate assistance/expertise available•Formulate a plan for extubation failure – particularly in high-risk cases Open table in a new tab Extubation should be carried out with the patient either fully awake or deeply anaesthetised as attempting extubation in an intermediate plane of anaesthesia is more likely to result in complications.4Popat M. Mitchell V. Dravid R. Patel A. Swampillai C. Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation.Anaesthesia. 2012; 67: 318-340Crossref PubMed Scopus (6) Google Scholar In the fully awake patient who is breathing spontaneously, airway protective reflexes have returned and the patient is able to protect and maintain a patent airway. The presence of the tracheal tube may trigger coughing, straining and sympathetic activation resulting in tachycardia and hypertension.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar, 6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar, 7Hartley M. Vaughan R.S. Problems associated with tracheal extubation.Br J Anaesth. 1993; 71: 561-568Abstract Full Text PDF PubMed Scopus (148) Google Scholar Tracheal stimulation can be avoided by reducing movement of both the patient and tracheal tube and minimising oropharyngeal suctioning. If the haemodynamic or respiratory effects secondary to coughing and bucking are undesirable, a modified technique such as deep extubation may be considered (see below). Various drugs have been used to reduce coughing and cardiovascular changes at extubation. Lidocaine i.v. or topically, sprayed onto the vocal cords or instilled into the tracheal tube cuff, has been shown to reduce coughing and haemodynamic changes.5Miller K.A. Harkin C.P. Bailey P.L. Postoperative tracheal extubation.Anesth Analg. 1995; 80: 149-172PubMed Google Scholar,6Wong T.H. Weber G. Abramowicz A.E. Smooth extubation and smooth emergence techniques: a narrative review.Anesthesiol Res Pract. 2021; 2021https://doi.org/10.1155/2021/8883257Crossref PubMed Scopus (4) Google Scholar,19Tung A. Ferguson N.A. Ng N. et al.Medications to reduce emergence coughing after general anaesthesia with tracheal intubation:" @default.
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