Extubation "The only real mistake is the one from which we learn nothing". John Powell

Extubation can be as hazardous as intubation. Withdrawal of ventilatory support and extubation are not synonymous. Indication for intubation is important in deciding on conditions for extubation. 1. Surgical access : extubate deep when ventilation is adequate. 2. Full stomach : extubate awake when bucking on EIT, in the left lateral position.

3. Difficult airway : extubate when awake, responding to commands, and able to maintain the airway. Leave a catheter in the trachea in cases where re-intubation maybe required.

4. Suspicion of laryngeal oedema: deflate cuff and listen for air leak before extubation. 5. Obese patient : head up or sitting position to facilitate breathing Extubation procedure 1. Suction the naso-gastric tube, oral cavity, and nose as appropriate.

2. Assist ventilation with 100% oxygen for at least 5 breaths prior to extubation to maintain oxygenation during apnoea which may occur following extubation especially in children.

3. Fill the reservoir bag with closed APL valve. Squeeze the bag to provide a near total capacity breath, deflate the cuff and extubate. The virtual cough created helps to clear the airway of secretions and should reduce the incidence of laryngospasm and breath holding.

4. Give 100% oxygen after extubation till breathing becomes regular and adequate. Hazards of extubation

Extubation under light anaesthesia (specially in healthy, young adults and children) may cause: • Laryngospasm (see page 19.4) • Negative pressure pulmonary oedema (see page 19.10) Extubation before recovery from relaxant can cause in-coordinate muscle movements, respiratory inadequacy and distress. (see page 20.5)