Project for Universal Management of Airways: guidelines for tracheal extubation.
Publisher DOI
PubMed ID
42644413
Abstract
INTRODUCTION: Risk evaluation, strategy formulation and preparation are important to decreasing the incidence of adverse events associated with tracheal extubation. The focus of this guideline is tracheal extubation, but many of the principles outlined are relevant to all forms of discontinuation of airway management (tracheal extubation; removal of a supraglottic airway; cessation of facemask support; and tracheostomy removal) and conversion between upper airway lifelines (facemask; supraglottic airway; and tracheal tube) or a neck airway.
METHODS: An international, multidisciplinary working group reviewed existing airway guidelines and published literature. A structured process for generating expert consensus statements was undertaken, which included consultation with an international advisory group comprising both airway operators and assistants, as well as human factors experts. Discrepancies between the results of these two processes were analysed and reconciled. Guidelines were generated and recommendations were categorised according to the American Heart Association classification system.
RESULTS: Risk evaluation for tracheal extubation includes assessing the risk of hypoxaemia, pulmonary aspiration and harm from airway stimulation. The patient's baseline risk as well as any potential changes since tracheal intubation should be considered. In addition to patient risks, team and situation risk factors should be considered when formulating the extubation strategy. Planned extubation is always elective, maximising ability to control the timing, environment and resources available. Deferring extubation is recommended if this will significantly decrease risk. When substituting one lifeline for another, 'conversion procedures', characterised by the presence of a continuous guide to maintain or facilitate rapid restoration of alveolar ventilation, are safer and preferred over airway 'replacement procedures', particularly when airway management is regarded as 'at risk'.
DISCUSSION: These guidelines assist airway practitioners from any discipline to evaluate whether tracheal extubation is 'at risk' and link this to formulating a safe and effective strategy that addresses the specific challenges identified.
WHAT WE DID: A group of airway experts from around the world looked at existing guidelines and research about safely removing a breathing tube from a patient once they are ready to breathe for themselves again. They used this information to create new guidelines for safely removing airway support from any patient.
WHY DID WE DO IT: Removing a breathing tube can be risky, especially if it might be difficult to put the tube back in. To judge the risk, the team needs to think carefully about the patient, the people caring for them and the where the patient will be when the tube is removed. The guidelines were created to help teams from a variety of backgrounds plan ahead and reduce the chance of serious problems.
WHAT WE FOUND: Before removing a breathing tube, doctors should think about the risk of low oxygen, stomach contents entering into the lungs and problems caused by irritating the airway. These risks depend on how the patient was when the tube was put in and whether anything has changed since. If removing the tube seems too risky, it may be safer to wait until conditions improve. Every planned removal of a breathing tube should have a backup plan in case the patient cannot breathe safely afterwards.
METHODS: An international, multidisciplinary working group reviewed existing airway guidelines and published literature. A structured process for generating expert consensus statements was undertaken, which included consultation with an international advisory group comprising both airway operators and assistants, as well as human factors experts. Discrepancies between the results of these two processes were analysed and reconciled. Guidelines were generated and recommendations were categorised according to the American Heart Association classification system.
RESULTS: Risk evaluation for tracheal extubation includes assessing the risk of hypoxaemia, pulmonary aspiration and harm from airway stimulation. The patient's baseline risk as well as any potential changes since tracheal intubation should be considered. In addition to patient risks, team and situation risk factors should be considered when formulating the extubation strategy. Planned extubation is always elective, maximising ability to control the timing, environment and resources available. Deferring extubation is recommended if this will significantly decrease risk. When substituting one lifeline for another, 'conversion procedures', characterised by the presence of a continuous guide to maintain or facilitate rapid restoration of alveolar ventilation, are safer and preferred over airway 'replacement procedures', particularly when airway management is regarded as 'at risk'.
DISCUSSION: These guidelines assist airway practitioners from any discipline to evaluate whether tracheal extubation is 'at risk' and link this to formulating a safe and effective strategy that addresses the specific challenges identified.
WHAT WE DID: A group of airway experts from around the world looked at existing guidelines and research about safely removing a breathing tube from a patient once they are ready to breathe for themselves again. They used this information to create new guidelines for safely removing airway support from any patient.
WHY DID WE DO IT: Removing a breathing tube can be risky, especially if it might be difficult to put the tube back in. To judge the risk, the team needs to think carefully about the patient, the people caring for them and the where the patient will be when the tube is removed. The guidelines were created to help teams from a variety of backgrounds plan ahead and reduce the chance of serious problems.
WHAT WE FOUND: Before removing a breathing tube, doctors should think about the risk of low oxygen, stomach contents entering into the lungs and problems caused by irritating the airway. These risks depend on how the patient was when the tube was put in and whether anything has changed since. If removing the tube seems too risky, it may be safer to wait until conditions improve. Every planned removal of a breathing tube should have a backup plan in case the patient cannot breathe safely afterwards.
Date Issued
2026-08-26
Publication Type
Article
Subject(s)
Subjects
airway management
•
airway strategy
•
difficult airway
•
tracheal extubation
•
tracheal re‐intubation
Language(s)
en
Author(s)
Ellard, Louise | |
Higgs, Andy | |
Cooper, Richard M | |
Hagberg, Carin A | |
Baker, Paul A | |
Kovacs, George | |
Law, J Adam | |
Myatra, Sheila N | |
O'Sullivan, Ellen P | |
Rosenblatt, William H | |
Ross, Christopher H | |
Sakles, John C | |
Sorbello, Massimiliano | |
Chrimes, Nicholas C |
Additional Credits
Journal
Anaesthesia: Peri-operative medicine, critical care and pain
Publisher
Wiley
ISSN
1365-2044
0003-2409
Access(Rights)
metadata.only