FUNDAMENTAL PRINCIPLES
Extubation and emergence
Andrew Dalton
Lynsey Foulds
Claire Wallace
Abstract
Emergence and extubation are times of increased risk during anaesthesia.
More complications occur then than at induction. The majority of prob-
lems are airway related due to airway obstruction, hypoxia, aspiration,
airway trauma or post-obstructive pulmonary oedema. Other problems
include a delayed recovery of consciousness, cardiovascular instability
and delirium. Prompt identification and treatment of the underlying
cause is essential to prevent serious morbidity and mortality. The Difficult
Airway Society published extubation guidelines in 2012. These guidelines
provide a step-wise approach to extubation in a four-stage approach
encompassing planning, preparation, performing and then post-
extubation care. The planning phase is aimed at identifying the patients
in whom extubation is a higher risk procedure, based on the presence
or absence of risk factors and clinical assessment. Preparation includes
optimization of the patient and the environment prior to extubation.
The performing stage is a guide to maximize the success of the extubation
process, while the post-extubation care is aimed at ensuring that safe and
appropriate care is ongoing.
Keywords Airway; emergence; endotracheal; extubation; monitoring
Royal College of Anaesthetists CPD Matrix: 1C01, 1C02, 2A01, 3A01
Emergence is defined as the point in the process of recovery from
general anaesthesia at which spontaneous respiration, airway re-
flexes and consciousness are re-established. The majority of sig-
nificant problems at this time are airway related; in fact, more
airway problems occur at emergence and extubation than at in-
duction and intubation. Despite this, emergence and tracheal extu-
bation have traditionally been a relatively neglected topic in airway
discussion, teaching and training. To try and overcome this, the
Difficult Airway Society (DAS) published guidelines for manage-
ment of tracheal extubation in 2012.1 These guidelines highlight the
potential problems associated with emergence and extubation and
provide a strategic, step-wise approach to extubation.
Problems occurring at emergence
The common problems encountered at emergence are summarized
in Box 1.
Andrew Dalton MB ChB FRCA* is a Specialty Registrar in Anaesthesia at
Ninewells Hospital, Dundee, UK. Conflicts of interest: none declared.
*
Lynsey Foulds MB ChB FRCA is a Specialty Registrar in Anaesthesia at
Ninewells Hospital, Dundee, UK. Conflicts of interest: none declared.
Claire Wallace MB ChB FRCA is a Consultant Anaesthetist at Ninewells
Hospital, Dundee, UK. Conflicts of interest: none declared.
* Denotes co-first author.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
10.1016/j.mpaic.2015.06.019
Learning objectives
After reading this article, you should be able to:
C recognize and manage the problems associated with extubation
and emergence
C assess a patients readiness for extubation
C describe a structured approach for safe tracheal extubation
C identify risk factors for failure of extubation
Airway obstruction
The most common cause of upper airway obstruction at emer-
gence is laryngospasm. Other less common causes include
laryngeal oedema, trauma, haemorrhage and vocal cord paraly-
sis/dysfunction. Laryngospasm is the sustained closure of the
vocal cords resulting in partial or complete airway obstruction.
The most common trigger is the presence of blood, secretions or
surgical debris in the airway, with spasm more likely to occur if
the patient is in a light plane of anaesthesia. Treatment involves
opening and clearing the oropharynx, applying continuous pos-
itive airway pressure (CPAP) with 100% oxygen followed by
deepening of anaesthesia with propofol and/or paralysing with
suxamethonium 1 mg/kg intravenously. If the intravenous route
is not available, suxamethonium can be administered via the
intra-muscular (2e4 mg/kg), intra-lingual (2e4 mg/kg) or intra-
osseous (1 mg/kg) routes.
Post-obstructive pulmonary oedema
Post-obstructive pulmonary oedema (POPO) is a complication
that occurs secondary to upper airway obstruction at emergence
and has an incidence of approximately 1 in 1000 anaesthetics.2
Often referred to as negative pressure pulmonary oedema,
POPO is caused by the huge negative intrathoracic pressures
generated by the patient to try and overcome the obstruction.
Consequently, fluid is pulled out of the vasculature down the
negative gradient created. Symptoms and signs of POPO usually
develop immediately after extubation and include respiratory
distress, haemotypsis and bilateral radiological changes consis-
tent with pulmonary oedema. The vast majority of patients
improve within 24 hours with supportive treatment including
oxygen therapy and CPAP. For those patients who fail to improve
quickly, consideration should be given to early re-intubation and
positive pressure ventilation. If the cause is due to biting on the
Problems occurring at emergence
C Airway obstruction
C Post-obstructive pulmonary oedema
C Hypoxia
C Aspiration
C Airway trauma
C Delayed recovery of consciousness
C Delirium
C Cardiovascular disturbance
Box 1
1 2015 Elsevier Ltd. All rights reserved.
 FUNDAMENTAL PRINCIPLES
tracheal tube, letting the cuff down can help relieve the
obstruction. Traditional measures used to treat pulmonary
oedema such as diuretics, nitrates and opiates, have no place due
to the different pathophysiological processes involved.
Hypoxia
The causes of early postoperative hypoxia are multiple and
include airway obstruction, hypoventilation, ventilation/
perfusion mismatch, diffusion hypoxia, shivering and a
decrease in cardiac output. If not treated promptly, hypoxia
may progress to brain damage, cardiovascular dysfunction and
ultimately death. The key to management is rapid, effective
administration of oxygen combined with methodical assess-
ment of the patient to determine the underlying cause. Pre-
oxygenation should be considered a vital step at emergence,
as it is at induction, to maximize pulmonary oxygen stores.
Furthermore, administration of oxygen therapy should be the
default in all patients during transfer and in the recovery room
as this has been shown to decrease the incidence of early post-
operative hypoxia.
Aspiration
Aspiration can be defined as the inhalation of material (e.g.
gastric content, blood) into the airway below the level of the true
vocal cords. Over one-third of aspirations occur at extubation.3
The clinical consequences of pulmonary aspiration range from
no sequelae to severe pneumonitis and acute respiratory distress
syndrome (ARDS). Aspiration was the single biggest cause of
death as a result of airway complications in the Royal College of
Anaesthetists 4th National Audit Project (NAP4).3
The anaesthetic technique should be modified accordingly in
patients with risk factors for aspiration, both at induction and
emergence. If aspiration is suspected, position the patient in the
head-down position to limit pulmonary contamination and suc-
tion any contaminants from the oropharynx. This should be
followed by administration of 100% oxygen, rapid sequence in-
duction and tracheal intubation and ideally tracheal suction
before commencement of positive pressure ventilation. The most
effective measures to protect against aspiration at emergence
include reducing the volume of gastric contents by suctioning
through a gastric tube and ensuring the patient is awake with
adequate return of airway reflexes prior to extubation. In cases
where aspiration has occurred, routine antibiotics are not indi-
cated. However, if the patient develops clinical signs of infection
then they should be prescribed.
Airway trauma
Airway trauma encompasses a wide range of airway-threatening
issues that can be caused by surgical or anaesthetic in-
terventions. Any surgery around the airway can cause trauma
and therefore problems following extubation, with bleeding,
haematoma formation and oedema the most common causes of
airway compromise. Less common issues include vocal cord
paralysis (after vagal or recurrent laryngeal nerve damage) and
tracheomalacia. Anaesthetic causes of airway trauma relate to
use of airway adjuncts (including supraglottic airways), laryn-
goscopy, intubation, use of intubation aids such as stylets or
bougies, blind pharyngeal suctioning and nasogastric tube
insertion. While minor laryngeal trauma is common and rarely
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Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
10.1016/j.mpaic.2015.06.019
has serious consequences, significant damage can occur. The
American Society of Anesthesiologists Closed Claims analysis
showed that the vast majority of lower airway and esophageal
injuries were associated with difficult intubation, while laryngeal
injury occurred after routine intubation in 80% of the cases re-
ported.4 Repeated laryngoscopy attempts increases the incidence
of trauma and morbidity, therefore multiple laryngoscopy at-
tempts should be avoided. Additionally, procedures such as
pharyngeal suctioning and bougie insertion should be carried out
under direct vision wherever possible. The use of prophylactic
steroids may be beneficial in reducing complications due to
oedema. A high index of suspicion is essential and if the airway is
likely to be at risk postoperatively then advanced extubation
techniques, or a decision not to extubate immediately, should be
considered. In the event of airway threatening extratracheal
haematoma, removal of the skin clips and neck decompression
can be life saving.
Delayed recovery of consciousness
Residual drug effects: problems may arise at emergence and in
the early postoperative period due to the residual effects of
pharmacological agents. Many drugs used in anaesthesia have
effects on conscious level and respiratory drive. The effects of
these drugs on the patient and the patients ability to eliminate
them can vary, resulting in a patient whose recovery can be
significantly delayed. For example, opioids and benzodiazepines
may delay recovery of consciousness after anaesthesia and used
together can have a pronounced effect on respiratory depression,
producing hypercapnia and coma.
Inadequate reversal of the effects of neuromuscular blocking
drugs (NMBD), also known as postoperative residual curariza-
tion (PORC), may in severe cases mimic unconsciousness in the
conscious patient or cause hypoventilation, hypercapnia and
coma. Even minimal residual paralysis causes unpleasant
symptoms of diplopia and generalised weakness for the patient
and increases the risk of aspiration, upper airway obstruction
and hypoxaemia.5 It is also an independent risk factor both for
increased length of stay in the recovery room and overall mor-
tality. The 5th National Audit Project concerning Accidental
Awareness Under General Anaesthesia (NAP5) recently reported
that 18% of cases of awareness occurred during the emergence
phase of anaesthesia.6 Almost all of these cases were as a result
of PORC and caused distress to the patients involved. PORC is
largely preventable through the use of a nerve stimulator,
allowing correctly timed delivery of reversal agents with main-
tenance of anaesthesia until a patient is fully reversed. In patients
with clinical evidence of PORC, management is largely support-
ive but may require administration of (additional) reversal agents
including sugammadex if available and/or re-establishment of
general anaesthesia until the patient is fully reversed.
Non-pharmacological causes: non-pharmacological causes
must also be considered in the differential diagnosis and can be
classified into metabolic abnormalities, respiratory failure and
neurological events. As part of the initial assessment, it is
imperative to check the patients temperature and capillary
blood glucose to exclude hypo/hyperglycaemia and hypother-
mia, as these are easily reversible causes of a depressed
conscious level. This should be followed by a full clinical
2 2015 Elsevier Ltd. All rights reserved.
 FUNDAMENTAL PRINCIPLES
examination, with particular attention to respiratory and
neurological systems, appropriate blood tests and arterial blood
gas sampling. Further investigations such as a chest radiograph
or CT head scan and ongoing management should be directed by
clinical findings.
Delirium
Delirium at emergence is most common in elderly patients where
it occurs in approximately 10% of cases.7 It is also more common
in those with underlying psychiatric conditions. Signs and
symptoms of delirium include disorientation, inappropriate
behaviour (such as shouting, thrashing around the bed) and not
complying with instructions or commands. Delirium is a diag-
nosis of exclusion. Therefore, before commencing treatment for
delirium, physiological and pharmacological causes for the
behaviour (e.g. hypoxia, residual drug effects, electrolyte
disturbance) must be ruled out. Treatment for delirium is pri-
marily supportive, but if the delirium is severe then benzodiaz-
epines (e.g. diazepam) and antipsychotics (e.g. haloperidol) can
be used.
Cardiovascular response
Significant haemodynamic changes can occur during extubation.
In patients who have undergone surgery to the head or neck,
hypertension and tachycardia can cause significant morbidity.
Additionally, while healthy patients may tolerate hypertension
and tachycardia those with cardiovascular disease are at
increased risk of ischaemic damage related to this cardiovascular
disturbance. Attempts should be made to ensure adequate anal-
gesia is provided prior to reversing the effects of general
anaesthesia.
The cardiovascular response can be attenuated using a variety
of methods. Pharmacological options include remifentanil or
propofol infusions, lidocaine (either intravenous at 1 mg/kg or
by topical application to the larynx), b-blockade (e.g. esmolol) or
a nitrate infusion. Adaptations to the anaesthetic technique
include deep extubation or replacing the endotracheal tube (ETT)
with a better tolerated and less stimulating supraglottic airway
prior to reducing the depth of anaesthesia. Both of these are
advanced techniques and appropriate patient selection is
important as there is a risk in removing a secure airway prior to
full recovery of consciousness.
Managing extubation
NAP4, published in 2011, showed that approximately one third
of the reported major airway complications (death, brain dam-
age, the need for emergency surgical airway or unanticipated ICU
admission) occurred during emergence or recovery. Recognizing
that this phase of anaesthesia was underemphasized in training
and the published literature, DAS published guidelines for the
management of tracheal extubation in 2012.1 These are based
largely on expert opinion due to the lack of evidence in the form
of randomized controlled trials or meta-analyses. The guidelines
provide a strategic, step-wise approach to extubation (in a similar
style to their widely adapted guidelines for the management of
the unanticipated difficult airway). A four-stage approach is
proposed:
 Step 1: Plan extubation
 Step 2: Prepare extubation
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Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
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 Step 3: Perform extubation
 Step 4: Post-extubation care
Step 1: Plan extubation
Planning for extubation should begin at the preoperative visit
and should take into consideration the presence of both airway
and general risk factors. Airway risk factors include an airway
that was difficult at induction, an airway that has deteriorated
during surgery due to distorted anatomy, haemorrhage or
oedema and restricted access to the airway because of either
shared access or restricted head and neck movements (e.g.
cervical spine fixation and halo fixation procedures). General
risk factors may also be present and include respiratory
impairment, cardiovascular instability, neurological impairment
and metabolic disturbances. Patients without any risk factors
are defined low-risk (Figure 1). In contrast, patients who have
airway and/or general risk factors present are deemed at-risk
of potential complications and should be managed accordingly
(Figure 2).
Step 2: Prepare extubation
Preparation for extubation aims to ensure optimization of the
patient and the overall environment prior to embarking on
extubation to maximize the success of safe extubation. This in-
cludes reassessment of the airway to ensure that the extubation
plan remains appropriate. The patient factors to be optimized are
respiratory and neuromuscular function and the cardiovascular
and metabolic parameters. The situational factors to be consid-
ered include the most appropriate location to undertake extu-
bation, the availability of skilled help/assistance, appropriate
monitoring and availability of all equipment that may be
required. It is essential to assess if successful airway manage-
ment (both facemask ventilation and re-intubation if required)
would be possible if the extubation failed. If this is considered
unlikely, then a strong argument for postponing extubation to
improve the conditions can be made. A cuff-leak test can be
helpful in this assessment if there are concerns regarding airway
oedema; if there is no evident leak on cuff deflation then airway
patency following extubation may be compromised. Respiratory
function, both in terms of oxygen requirements and adequacy of
ventilation, should be optimized. The use of a peripheral nerve
stimulator and an appropriate dose of reversal agent to establish
a train-of-four ratio of 0.9 or above should be the gold standard
for ensuring return of appropriate muscle function. Cardiovas-
cular stability, normal body temperature, normal acid-base status
and appropriate analgesia will all improve the success of the
extubation process. Extubation should take place in a suitably
staffed environment with skilled assistance and equipment to
hand. The exact assistance and equipment required may differ
depending on both the anaesthetist and the situation. On occa-
sion it may be best to consider transferring the patient to achieve
this, for example from radiology to an anaesthetic room or from
ICU to an ENT theatre with surgical assistance present for a high-
risk extubation.
Step 3: Perform extubation
Prior to extubation, the patient should be pre-oxygenated to an
end tidal oxygen above 90%. Consideration should be given to
the position for extubation. While head-up position is the most
3 2015 Elsevier Ltd. All rights reserved.
 FUNDAMENTAL PRINCIPLES

Difficult Airway Society extubation guidelines: low-risk algorithm

Step 1 Plan Low-risk extubation

Plan extubation Assess airway and Fasted
general risk factors Uncomplicated airway
No general risk factors

Step 2 Prepare Optimize patient factors Optimize other factors

Prepare for Optimize patient and Cardiovascular Location
extubation other factors Respiratory Skilled help/ assistance
Metabolic/temperature Monitoring
Select deep or awake extubation Neuromuscular Equipment

Step 3 Deep extubation Awake extubation Perform awake extubation

Perform Preoxygenate with 100% oxygen
extubation Suction as appropriate
Advanced technique
Insert a bite block (e.g. rolled gauze)
Experience essential
Position the patient appropriately
Vigilance until fully awake
Antagonize neuromuscular blockade
Establish regular breathing
Ensure adequate spontaneous ventilation
Minimize head and neck movements
Wait until awake (eye opening/obeying commands)
Apply positive pressure, delfate the cuff and remove tube
Provide 100% oxygen
Check airway patency and adequacy of breathing
Continue oxygen supplementation

Step 4 Recovery and follow-up Safe transfer Analgesia

Post-extubation Handover/communication Staffing
care O2 and airway management Equipment
Observation and monitoring Documentation
General medical and surgical management

The technique described for awake extubation is a suggested approach.

Practice may vary in experienced hands.

Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal
extubation. Anaesthesia 2012; 67: 318340, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing
Ltd

Figure 1

commonly used, if there is a significant aspiration risk then a
lateral, head-down position should be considered. Direct vision
pharyngeal suctioning should be performed. Suctioning of the
lower airway using suction catheters and gastric tube aspiration
can also be performed. Obstruction of the ETT or supraglottic
airway device caused by the patient biting is prevented by the
insertion of a bite block. A Guedel oropharyngeal airway will not
always prevent a patient biting down and occluding an ETT and
additionally may increase the risk of dental damage. A purpose-
designed bite block (e.g. BreatheSafe Bite BlockTM, OGM Ltd,
Yarnton, UK) or a roll of gauze, inserted between the molars is
the better option.8 Awake extubation is the normal default in
both a low-risk and at-risk airway. For this, adequate spon-
taneous ventilation should be achieved (after ensuring full
antagonism of neuromuscular blockage) and the patient should
be awake and obeying commands prior to the ETT being
removed. Deep extubation and other advanced techniques such
as laryngeal mask airway exchange or a remifentanil extubation
should only be considered if the anaesthetist is appropriately
experienced in the technique. It is beyond the scope of this article
to describe the process for these techniques.
Step 4: Post-extubation care
Many of the problems arising at extubation and emergence can
present in the recovery room. Therefore, it is essential to have a
strategy in place to allow early recognition and prompt man-
agement of these potentially life threatening complications if they
arise. During transfer from theatre to the recovery room, oxygen

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Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
10.1016/j.mpaic.2015.06.019
 FUNDAMENTAL PRINCIPLES

Difficult Airway Society extubation guidelines: at-risk algorithm

Step 1 Plan At-risk extubation

Plan extubation Assess airway and Ability to oxygenetate uncertain
general risk factors Reintubation potentially difficult and/or
general risk factors present

Step 2 Prepare Optimize patient factors Optimize other factors

Prepare for Optimize patient and Cardiovascular Location
extubation other factors Respiratory Skilled help/assistance
Metabolic/temperature Monitoring
Key question: Neuromuscular Equipment
is it safe to remove the tube?

Step 3 Yes No
Perform
extubation

Advanced techniques*
Awake 1. Laryngeal mask exchange Postpone
Tracheostomy
extubation 2. Remifentanil technique extubation
3. Airway exchange catheter

Step 4 Recovery/HDU/ICU
Post-extubation
care
Safe transfer Analgesia
Handover/communication Staffing
O2 and airway management Equipment
Observation and monitoring Documentation
*Advanced techniques: require training and experience General medical and surgical management

Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal
extubation. Anaesthesia 2012; 67: 318340, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing
Ltd

Figure 2

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ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 5 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
10.1016/j.mpaic.2015.06.019
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College of Anaesthetists and difficult Airway Society. Report and
Findings. In: Major complications of airway management in the United
Kingdom. London: Royal College of Anaesthetists, March 2011. ISBN:
978-1-9000936-03-3.
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thesia. Contin Educ Anaesth Crit Care Pain 2006; 6: 114e8.

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 6 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Dalton A, et al., Extubation and emergence, Anaesthesia and intensive care medicine (2015), http://dx.doi.org/
10.1016/j.mpaic.2015.06.019