Introduction

Below is a checklist to follow when considering extubating a patient.

Approach

Airway

Ensure the patient will be able to protect their own airway and that airway recapture is possible

• protective reflexes are present (cough, gag)
• cuff leak is present (generally after long cases, surgeries near the neck, or Trendelenburg position)
• reintubation or ventilation is feasible (the difficulty of intubation can dictate how conservative extubation must be)

Breathing

Ensure the patient's respiratory drive is adequate for maintaining oxygenation and ventilation

• the patient is triggering the ventilator
• the patient is drawing adequate tidal volumes and minute ventilation (this will be related to the amount of assistance the ventilator is delivering)
• the patient is triggering the ventilator at an appropriate respiratory rate (often targeting RR 10-12 at the end of a case)
• the patient has adequate gas exchange

Circulation

Ensure that the patient's hemodynamics are stable enough for extubation

• change from positive pressure ventilation to negative pressure will be tolerated well
  • especially important in cardiac pathology and pulmonary hypertension
• added work of breathing will be tolerated hemodynamically

Disability/Drugs

Ensure the patient has a level of consciousness that is amenable to extubation. Similarly, ensure there are no drugs in the patient's system that may cause them to fail extubation

• reversal of neuromuscular blockers (train of four > 90%)
• adequate analgesia on board
• condition requiring intubation has been resolved (if intubated in a non-elective setting)
• there is no patient condition that requires control of ventilation (ex. TBI protocol necessitates avoiding hypercapnia)