Extubation Guidelines in the Operating Theatre for General Anaesthesia

Pre-Extubation Assessment

The American Society of Anesthesiologists recommends assessing whether bag-mask ventilation would be achievable by evaluating for oedema, bleeding, blood clots, trauma, foreign bodies, and airway distortion using direct or indirect laryngoscopy 3
A cuff-leak test should be performed to assess subglottic calibre, as the presence of a large audible leak when the tracheal tube cuff is deflated is reassuring, while absence of a leak around an appropriately sized tube generally precludes safe extubation 3
Ensure complete reversal of neuromuscular blockade using a peripheral nerve stimulator to confirm train-of-four ratio ≥0.9, which reduces postoperative airway complications 3

A difficult airway trolley must be immediately available, along with relevant items such as clip removers and wire cutters, as recommended by the American Heart Association 1, 2, 4
Standard monitoring must be continued, including ECG, non-invasive blood pressure, pulse oximetry, and capnography, as suggested by the American Society of Anesthesiologists 1, 2, 4

Pre-oxygenate with FiO₂ 1.0 to maximize pulmonary oxygen stores, aiming for end-tidal oxygen >0.9 or as close to FiO₂ as possible, as recommended by the European Society of Anaesthesiology 3
Position the patient head-up (reverse Trendelenburg) or semi-recumbent when possible, as this confers mechanical advantage to respiration and is especially useful in obese patients, according to the American College of Cardiology 3

All extubations must be supervised by an anaesthetist, as stated by the American Society of Anesthesiologists 1, 2, 4
At-risk extubations must occur in the operating theatre, with patients with airway concerns either staying in recovery or transferring to a critical care environment, as recommended by the American Heart Association 1, 2, 4

Monitor level of consciousness, respiratory rate, heart rate, blood pressure, peripheral oxygen saturation, temperature, and pain score, as suggested by the European Society of Anaesthesiology 4
Close observation is necessary during recovery, as pulse oximetry alone is insufficient, according to the American Society of Anesthesiologists 1, 2, 4

Nurse patients with airway compromise upright and administer high-flow humidified oxygen, as recommended by the American College of Cardiology 1, 2, 4
Keep the patient starved, as laryngeal competence may be impaired despite full consciousness, according to the American Society of Anesthesiologists 1, 2, 4

For inflammatory airway oedema from direct airway injury, administer steroids equivalent to 100 mg hydrocortisone every 6 hours, starting as soon as possible and continuing for at least 12 hours, as recommended by the American Heart Association 1, 2, 4
If upper respiratory obstruction or stridor develops, administer nebulised adrenaline 1 mg to reduce airway oedema, according to the European Society of Anaesthesiology 1, 2, 4

Only essential staff wearing appropriate PPE should be present for extubation, as recommended by the Centers for Disease Control and Prevention 5
Position the patient upright on a bed or trolley with full reversal of neuromuscular blockade confirmed, according to the World Health Organization 5
Apply a Hudson mask immediately after extubation, then place a surgical facemask over it to cover entrainment vents and reduce contamination risk from coughing, as suggested by the American Society of Anesthesiologists 5