Airway management

Planning and performing extubation

Reviewed Nov 2026·2 references
New· views rounded down, updated weekly

Extubate after a successful SBT when the patient can protect the airway; stratify risk, use a cuff leak test in high-risk patients, give steroids for a failed leak, use HFNC or NIV after extubation in high-risk patients, and be ready to reintubate.

At the bedside

Timed steps
  1. 1

    Readiness

    Plan

    Passed SBT (module 8), awake and following commands, adequate cough, secretions manageable (suction ≤ every 2 h), haemodynamically stable.

  2. 2

    Risk stratify

    Plan

    Low risk vs at-risk (known difficult airway, airway oedema, prolonged intubation, trauma to airway, obesity, failed previous extubation).

  3. 3

    Cuff leak test (at-risk only)

    Test

    Volume-controlled ventilation: measure Vt with cuff inflated and deflated; leak < 110 mL (or < 10-12%) suggests risk of stridor.

  4. 4

    Steroids

    If leak fails

    Methylprednisolone 20 mg every 4 h for 4 doses (start ≥ 4 h before extubation).

  5. 5

    Extubate

    Do

    Head up, preoxygenate on FiO2 1.0, suction mouth and tube, deflate cuff, remove at peak inspiration with positive pressure, apply O2 or HFNC/NIV.

  6. 6

    Support high-risk patients

    After

    HFNC or prophylactic NIV after extubation in high-risk patients (age > 65, cardiac disease, COPD, hypercapnia). See module 7.

  7. 7

    Treat promptly

    Stridor

    Nebulised adrenaline, heliox if available, IV steroids, head up; NIV is not a cure; reintubate early (smaller tube) if worsening.

Prevent post-extubation stridor after failed cuff leak

Methylprednisolone

IV
Dose
20 mg every 4 h × 4 doses before extubation

Post-extubation stridor

Adrenaline (nebulised)

Nebulised
Dose
1 mg in 4 mL NS (up to 5 mg undiluted)
Red flag · call your senior now
Stridor with rising work of breathing after extubation: senior, airway trolley, reintubation plan.
Red flag
Delayed reintubation after failed extubation increases mortality.
Pitfall
Extubating a patient who cannot cough or has copious secretions despite passing the SBT.
Pitfall
Using rescue NIV to avoid reintubation in established post-extubation respiratory failure (associated with delayed reintubation and harm).
Pearl
For a known difficult airway, consider extubation over an airway exchange catheter (DAS advanced algorithm).

References

  1. 1

    Popat M, Mitchell V, Dravid R, et al. Difficult Airway Society guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318-340

  2. 2

    Girard TD, Alhazzani W, Kress JP, et al. An official American Thoracic Society/American College of Chest Physicians clinical practice guideline: liberation from mechanical ventilation in critically ill adults. Am J Respir Crit Care Med. 2017;195(1):120-133

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Immediately after intubation

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.