6.4 Tracheal extubation: 

Taking of endotracheal tube out from the trachea after general anesthesia, it requires skill and judgment learned through experience. The patient must be either deeply anesthetized or fully awake at the time of tracheal extubation. Tracheal extubation during a light level of anesthesia (disconjugate gaze, breath-holding, coughing, and not responsive to command) increases the risk for laryngospasm. A patient reaching for the endotracheal tube might indicate a localizing response to noxious stimulation in the absence of sufficient awakening from anesthesia.

Awake extubation after looking the patient to follow commands such as strong hand grip, raise head for 20 seconds, opening eyes are good clinical sign for safe extubation especially in patient with difficult airway. It is not advisable to extubate the patient deep in the context of difficult airway, old age, pediatrics, obese, because of the risks of hypoventilation and airway obstruction. The possibility of air way edema after repeated attempts at intubation should always be borne in mind. The patient should be fully conscious and able to demonstrate breathing efforts prior to extubation. It is always safer to be on the safe side of caution and leave the endotracheal tube in situ if any doubt exists regarding patient's respiratory efforts air way patency post extubation. Extubation at deep plane of anesthesia may decrease the incidence of cough, laryngospasm, hypertension, tachycardia, increased intracranial pressure and intraocular pressure but may risk for regurgitation and aspiration from unprotected air way or hypoxia and hypercarbia up to cardiac arrest if respiration is not monitored and supported.

6.4.1 Techniques/ steps of extubation:

• Positioning – supine or lateral
• Suctioning - The oropharynx is suctioned just before tracheal extubation. The endotracheal tube cuff is deflated and the trachea tube rapidly removed from the patient's trachea and upper airway while a positive-pressure breath is delivered to help expel any secretions.
• Preoxygenation. Spontaneous breathing with 100% oxygen is established before tracheal extubation.
• Defilation of the tube- The cuff should not remain deflated for any significant period before tracheal extubation because the vocal cords cannot effectively close around the endotracheal tube and supraglottic secretions can be aspirated
• Remove the tube following the curvature of tube during exhalation phase. Timing tracheal extubation at the peak of inspiration is intended for the following exhalation or cough to eliminate any aspirated secretions from the trachea. After tracheal extubation, oxygen is delivered by facemask.
• The effects of neuromuscular blocking drugs should be fully reversed.
• If tracheal intubation was difficult at the beginning of the procedure awake extubation is recommended to ensure that the patient is capable of breathing spontaneously and maintaining oxygenation and ventilation.

6.4.2 Immediate and delayed complications after tracheal extubation:

• Laryngospasm and inhalation of gastric contents are the two most serious potential immediate complications after tracheal extubation. Laryngospasm is unlikely if the depth of anesthesia is sufficient during tracheal extubation (laryngeal reflexes suppressed) or the patient is allowed to awaken before tracheal extubation (laryngeal reflexes intact).
• Pharyngitis is the most frequent complaint after tracheal extubation, particularly in females, presumably because of thinner mucosal covering over the posterior vocal cords than in males. Pharyngitis usually disappears spontaneously without any treatment in 48 to 72 hours. Some degree of laryngeal incompetence may be present in the first 4 to 8 hours after tracheal extubation.