The Project for Universal Management of Airways has published international guidelines on tracheal extubation, built from a literature review and a structured consensus process including airway assistants and human factors experts. Recommendations are graded by the American Heart Association system.
Risk assessment covers three hazards: hypoxaemia, pulmonary aspiration and harm from airway stimulation. It should consider the patient's baseline, what has changed since intubation, and team and situational factors. Planned extubation is always elective, and deferring it is recommended where that meaningfully lowers risk. When moving from one airway to another, 'conversion' procedures that keep a continuous guide in place — such as an airway exchange catheter — are preferred over 'replacement' procedures when the airway is at risk.
The principles extend to removing a supraglottic airway, stopping facemask support and decannulation. The framework is written for airway practitioners of any discipline, including intensive care and emergency teams.
- Classify each extubation as routine or 'at risk' before emergence, and say so at the team brief.
- Ask what has changed since intubation: oedema, surgery near the airway, positioning, fluids.
- Consider deferring extubation when conditions, staff or time of day raise risk.
- Keep a continuous guide such as an airway exchange catheter in at-risk extubations.
- Plan and state the rescue route before removing the tube.
Why it matters
Most airway guidance focuses on getting the tube in; extubation is where many serious events happen with less planning.
Don't overread it
These are consensus recommendations; the evidence base for extubation strategies is largely observational.
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