• Adequate minute volume for VA washout
  • rough endpoint = ETCO2 35
  • any lower, ⬇cerebral BQ with consequent slower washout from cerebral BV
• Criteria = Breathing + Neuro + Other
• Consider recruitment manoeuvres before extubation
• Apply suction on tube when extubating
• Give Sugammadex when ready to extubate
  • skeletal M will start to give lots of sensory input to brain
  • this extra input "wakes patient" up
  • giving too early will interfere with VA washout
• wait until 0.1 MAC then SGX, suction, extubate
• FGF does not need to be 15 LPM
  • 6 LPM is adequate, as long as Finsp is 0
• ETCO2 40 is good target
  • enough CO2 for respiration
  • still reasonable MV for adequate washout
• E+ surge at extubation may be reason for periop MI
  • often very stable intraop, and then at extubation, E surge
  • this is why it is important to keep patients stable at extubation
• lacrimation is sign of maximal E+ stimulation
• inadequate M strength = unable to hold end-inspiratory breath
  • this means the intercostals are unable to maintain contraction
• if patient is obstructed, can turn head = this will often move the base of the tongue away and provide a patent airway
• Deep breaths
  • Normalise physiology = fully reversed, warm, EUC, gas exchange
  • Inspect = FNE / FOB
  • Check for cuff leak
  • Drugs and equipment for urgent reintubation
  • Cook AEC 14 + tape at cheek = CAREFUL depth
    • Irritate carina
    • Will need topicalisation
• 18 G cannula in neck
• Have the same equipment in the room as for INTUBATION

• A = Airway
  • Obstruction = oedema
• B = Respiratory
  • Adequate ventilation
  • Adequate oxygenation
• D = Neurological
  • Adequate GCS to protect airway
  • Airway reflexes = brainstem

• Respiratory
  • Fi < 0.4, ideally 0.3
  • Vt > 5 mL/kg ~ 350 mL
  • VC > 15 mL/kg ~ 1 L (adult)
  • negative inspiratory pressure > 20 cm H2O
  • PEEP 5-8
  • Minimal PS (typically 5/5)
  • Pattern = regular and adequate
  • Cuff leak = may not be a leak
    • negative fluid balance
    • dexamethasone 4 mg QID
    • inspect with FOB / laryngoscope
  • PaCO2
  • CXR
  • Sputum load
  • Cough
• Cardiovascular
  • minimal support
  • optimal fluid status
• Neuro
  • Calm + Cooperative + obeying commands
  • Sedation
    • Appropriate sedation score
  • No NMB
  • Power
    • critical illness weakness
    • arm lift and hold
    • head lift and hold
  • intact bulbar function
• Other
  • Cause for intubation
  • Logistic (another procedure soon?)
  • Time of day
  • Staff / experience
  • Airway difficulty
  • Can extubate electively onto NIV

• PPE
• Limit to 2 personnel
• Turn off ventilator
• Stand behind patient
• Extubate onto FM (not NIV / HFNP)

• Difficult intubation?
• Difficult FONA?
  • Radiotherapy
  • Goitre
• Airway oedema?
  • Massive transfusion
  • Big fluids shifts
  • Prone?
  • Duration (5 hours not that long)

• poor prognostic factor
• 15% patients
• 2 minutes / 2 hours / 2 days
• Early = airway obstruction
  • laryngospasm = CPAP
  • AW oedema = Ad 5 mg nebulised / dex 4-8 mg
  • Delirium = pulling off O2

• Low risk
  1. Fasted
  2. Uncomplicated Airway
  3. No general risk factors
• At risk algorithm
  • Safe to remove ETT?
    • Awake extubation
    • Advanced techniques
      • LMA exchange
      • Remifentanil technique
      • Airway exchange catheter
  • Not safe
    • Postpone extubation
    • Tracheostomy

• HFNP
• Cook 14 in situ
• ETT 6.0 ready to railroad over Cook

• If SV, can deflate cuff gently whilst still deep on Remi
• Remifentanil
• Extubate deep
  • Then FMV
  • LMA
• Titrate labetalol with a specific target (eg. SBP 110, to avoid SBP > 140)

https://www.uptodate.com.acs.hcn.com.au/contents/extubation-following-anesthesia

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2012.07075.x