[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [The airway](https://durgical.com/en/anaesthesia/areas/airway/) › Extubation: when and how

# Extubation: when and how

- Technique

Taking out the breathing tube safely at the end of an anaesthetic, once the patient can breathe and protect the airway alone.

Updated Nov 13, 2026

## Key points

- Extubate when the cause for intubation has resolved and the patient can breathe, cough, swallow and follow commands.
- Confirm full neuromuscular reversal with a quantitative train-of-four ratio of at least 0.9; residual block causes hypoxaemia and aspiration.
- Awake extubation is the default; deep extubation avoids coughing but only for low-risk airways and experienced teams.
- At-risk airways need a plan: airway exchange catheter, staged or delayed extubation, and help and equipment ready to reintubate.
- Laryngospasm, airway obstruction, post-obstructive pulmonary oedema and aspiration are the main early complications.

On this page

- The basics Key points
- What it is
- Indications
- Equipment and preparation
- Step by step (and why)
- Next step
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

Extubation is the removal of the tracheal tube, and it is an elective step that deserves as much planning as intubation: many serious airway complications happen at the end of anaesthesia or in recovery rather than at induction. The decision rests on three questions. Is the original reason for intubation gone? Can the patient breathe adequately, with full reversal of neuromuscular block confirmed by a quantitative train-of-four ratio of at least 0.9? And can the patient protect and keep open the airway, with return of consciousness, cough and swallow? The airway is stratified as low risk or at risk; at-risk airways include a difficult intubation, airway surgery or swelling, obesity and obstructive sleep apnoea, and limited access to the airway afterwards. Most patients are extubated awake, after preoxygenation, suction and with the patient able to follow commands. Deep extubation, under anaesthesia, avoids coughing but leaves an unprotected airway and suits only selected low-risk cases. For an at-risk airway, options include an airway exchange catheter left in the trachea, staged extubation or delayed extubation in intensive care. In the ICU, readiness is judged by a spontaneous breathing trial, and a cuff leak test may help when laryngeal oedema is suspected.

## Indications

- The end of a general anaesthetic once surgery is complete and the patient is stable.
- Resolution of the original reason for intubation in the ICU (respiratory failure, coma, airway swelling).
- A successful spontaneous breathing trial in a ventilated patient.
- Accidental or planned removal at the end of a procedure when the patient no longer needs airway protection.

## Contraindications and precautions

- Persistent or worsening airway swelling, bleeding or recent airway surgery: consider delayed extubation or an exchange catheter.
- Residual neuromuscular block, hypothermia or unstable haemodynamics: correct before removing the tube.
- Full stomach or impaired reflexes: extubate awake, never deep.
- Known difficult intubation or restricted access to the airway (halo, wired jaw): extubate with a reintubation plan and senior present.
- Obesity and obstructive sleep apnoea: extubate fully awake, sitting up.

## Equipment and preparation

- Oxygen source, face mask, suction ready and working, and a full set of intubation equipment.
- Quantitative neuromuscular monitor and the reversal agent appropriate to the blocker used.
- Capnography to watch breathing after the tube is out.
- For at-risk airways: airway exchange catheter, a videolaryngoscope and a skilled helper.
- A syringe to deflate the cuff and a clear plan known to the team.

## Step by step (and why)

- Plan extubation before induction and stratify the risk — a difficult airway at the start is often difficult at the end.
- Confirm full reversal with a quantitative train-of-four ratio of at least 0.9 — residual block weakens the pharynx and breathing.
- Preoxygenate with high-flow oxygen via the circuit — it fills the lungs with oxygen and buys time if the airway obstructs.
- Suction the mouth and pharynx under direct vision — blood and secretions trigger laryngospasm and aspiration.
- Insert a bite block and sit the patient up when possible — biting can occlude the tube; upright posture improves breathing.
- Wait until awake: eyes open, following commands, regular breathing — reflexes and tone must be back to protect the airway.
- Deflate the cuff and remove the tube with gentle positive pressure — this helps clear secretions above the cuff.
- Give oxygen by mask, check the airway, breathing and capnography trace — early problems show in the first minutes.

## Complications

- Laryngospasm: sudden stridor or silent obstruction; treat with jaw thrust, continuous positive pressure, deepening anaesthesia and, if needed, a muscle relaxant.
- Upper-airway obstruction from residual sedation, the tongue or laryngeal oedema.
- Post-obstructive (negative-pressure) pulmonary oedema after forceful breathing against a closed airway.
- Aspiration of gastric contents or blood when reflexes are not fully back.
- Hypoxaemia from residual neuromuscular block or opioids, coughing and straining with raised blood pressure or bleeding, and failed extubation needing reintubation.

## Next step

- Hand over in recovery: airway risk, drugs given, reversal confirmed and what to do if the airway obstructs.
- Give oxygen and monitor saturation, breathing and consciousness until the patient meets discharge criteria from recovery.
- Call a senior at once for stridor, rising oxygen need or desaturation; be ready to reintubate.
- For at-risk airways extubated over an exchange catheter, keep it in place until the airway is clearly safe, in a monitored area.
- After a difficult or failed extubation, document what happened and give the patient a written airway alert.

## Test yourself

Think of the answer, then tap the question to see it.

## What three questions decide whether a patient can be extubated?

Has the reason for intubation resolved? Can the patient breathe adequately with full reversal? Can the patient protect and maintain the airway (awake, cough, swallow)?

## How is adequate reversal of neuromuscular block confirmed before extubation?

With quantitative monitoring showing a train-of-four ratio of at least 0.9; clinical signs such as head lift are unreliable.

## What are the advantages and risks of deep extubation?

It avoids coughing and straining, but the airway is unprotected until the patient wakes, so it suits only selected low-risk patients with an empty stomach.

## How is laryngospasm after extubation first managed?

Call for help, give oxygen with continuous positive pressure by a tight mask, jaw thrust, remove the stimulus and deepen anaesthesia; a muscle relaxant if it persists.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/extubation-when-and-how/)

## Elsewhere in DurgiPedia

- [Bag-mask ventilation](https://durgical.com/en/clinical-skills/bag-mask-ventilation/)
- [Airway suctioning: oral, nasal and artificial airways](https://durgical.com/en/nursing/airway-suctioning-oral-nasal-and-artificial-airways/)
- [Oxygen therapy: devices, flows and safety](https://durgical.com/en/nursing/oxygen-therapy-devices-flows-and-safety/)

## Connections

## Related 6

- [The unanticipated difficult airway: plans A to D](https://durgical.com/en/anaesthesia/the-unanticipated-difficult-airway-plans-a-to-d/)
- [Bronchospasm and laryngospasm](https://durgical.com/en/anaesthesia/bronchospasm-and-laryngospasm/)
- [The recovery unit: monitoring and discharge criteria](https://durgical.com/en/anaesthesia/the-recovery-unit-monitoring-and-discharge-criteria/)
- [Weaning and the spontaneous breathing trial](https://durgical.com/en/anaesthesia/weaning-and-the-spontaneous-breathing-trial/)
- [Tracheal intubation](https://durgical.com/en/anaesthesia/tracheal-intubation/)
- [Capnography: the waveform and what it tells you](https://durgical.com/en/anaesthesia/capnography-the-waveform-and-what-it-tells-you/)

## Related conditions 3

- [Obstructive sleep apnoea](https://durgical.com/en/conditions/obstructive-sleep-apnoea/)
- [Obesity](https://durgical.com/en/conditions/obesity/)
- [Aspiration pneumonia and pneumonitis](https://durgical.com/en/conditions/aspiration-pneumonia-and-pneumonitis/)

## In Pharmacology 4

- [Neuromuscular block reversal agents](https://durgical.com/en/pharmacology/classes/neuromuscular-block-reversal-agents/)
- [Sugammadex](https://durgical.com/en/pharmacology/sugammadex/)
- [Neostigmine](https://durgical.com/en/pharmacology/neostigmine/)
- [Dexamethasone](https://durgical.com/en/pharmacology/dexamethasone/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Extubation](https://www.ncbi.nlm.nih.gov/books/NBK539804/) (StatPearls (NCBI Bookshelf), 2023).

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