The Project for Universal Management of Airways (PUMA), an international multidisciplinary group, produced tracheal extubation guidelines through literature review and a structured expert consensus process that included airway assistants and human factors experts. Recommendations are graded using the American Heart Association system.
Risk assessment covers three hazards: hypoxaemia, pulmonary aspiration and harm from airway stimulation, judged against the patient's baseline and any change since intubation, and alongside team and situational factors. Planned extubation is always elective, so timing, place and resources should be chosen. Deferring extubation is recommended when that significantly lowers risk. When swapping one airway for another, 'conversion procedures' that keep a continuous guide in place are preferred over 'replacement procedures', especially when the airway is at risk.
Most airway guidelines concentrate on getting the tube in. Extubation is where many serious events occur, and this framework applies equally to supraglottic airway removal, stopping facemask support and tracheostomy removal.
The guidance is consensus-based, but it gives departments a shared vocabulary for declaring an extubation 'at risk' and planning for it.
- Before extubation, state aloud the risk of hypoxaemia, aspiration and airway stimulation.
- Consider what has changed since intubation: oedema, surgery to the airway, positioning, fluid balance.
- Include team experience, time of day and location in the decision.
- If the airway is at risk, defer or extubate over a guide such as an airway exchange catheter.
- Have a stated rescue plan before the tube comes out.
Why it matters
It treats extubation as a planned procedure with its own failure plan, not the routine end of an anaesthetic.
Don't overread it
These are consensus recommendations, not trial evidence that the framework reduces adverse events.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for anaesthesiology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free