***There is no guarantee that a patient will extubate successfully even when following these suggestions. Always be prepared to re-intubate if needed. Know ahead of time if it was a difficult airway where ENT or anesthesia should be present at the time of extubation!

Ventilator considerations

  • Minimal PEEP (usually 5-6)
  • Low rates (5-10 unless pt was intubated for short term)
  • Low oxygen requirement
  • Tolerating pressure support trials (especially if intubated for a longer period of time)

Other considerations

  • Sedation - is the pt awake enough, minimal pain/sedation gtts or prns given prior to extubation
  • Secretions - no recent changes to suggest pneumonia, not requiring frequent suctioning
  • Neuro exam - is it appropriate for age
  • Leak around ETT tube - does pt need steroids prior to extubation
  • CXR - did you review last film (no effusions or pneumo)
  • Supplies and drugs - know what drugs you would use for reintubation and have intubation supplies ready if needed
  • Any upcoming procedures or imaging where sedation may be needed, which may delay extubation

Immediately prior to extubation

  • Pre-oxygenate pt - FiO2 to 100% unless limiting oxygen
  • Suction - suction ETT prior to extubation and have supplies ready to suction mouth immediately after extubation
  • Oxygen/CPAP/BiPAP - have supplies ready in the room if you anticipate a transition to anything but room air
  • Head of bed elevated
  • Aerosols - have racemic epinephrine ready if any concern about leak or swelling. Consider albuterol if hx of asthma/airway hyperreactivity
  • Supplies and drugs - always have nearby and know what you will use if reintubation is needed