Extubation tends to be treated as the end of the anaesthetic rather than as a procedure in its own right, which is how it comes to be done at the end of a list, in a turnover, with whoever is in the room.
The PUMA framing is worth adopting as a habit even before reading the full guideline. Planned extubation is elective: the timing, the place and the people are all things you control. So the questions are answerable in advance — what is the risk of hypoxaemia, aspiration or harm from airway stimulation, has anything changed since intubation, who is available if the airway is lost, and where would you rather this happened.
If the honest answer is that reintubation would be difficult and the environment is not right, deferring is a recommended option rather than a failure. And when substituting one airway for another, keep a continuous guide in place rather than removing and replacing — the difference between a conversion and a replacement is what you have left if it goes wrong.
- Treat extubation as an elective procedure you schedule, not an ending
- Reassess risk against what has changed since intubation
- Deferring is a recommended option, not a failure
- Keep a continuous guide when converting between airway lifelines
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