DAS: Extubation Guidelines

Question 1

DAS extubation guidelines: Basic algorithm

Answer 1

Plan extubation
- Assess airway: known difficulty, deterioration during surgery, OSA, obesity, aspiration risk
- General: CV, metabolic, neuro stable

Prepare for extubation
- Optimise: CV, resp, metabolic factors, ensure full reversal
- Low risk: fasted, uncomplicated airway, no general factors
- At risk: ability to oxygenate uncertain, potential difficulty re-intubating
- General: location, skilled help, monitoring, equipment

Perform extubation
- Low-risk algorithm
- At risk algorithm

Post-extubation care
- Safe transfer with O2 and monitoring
- Observation in recovery or HDU

Question 2

DAS extubation guidelines: Low-risk algorithm

Answer 2

• Consider deep extubation only if experienced and the patient is fully monitored until awake

Awake extubation
- Pre-oxygenate
- Suction
- Bite block
- Antagonise NMBD
- Establish adequate spontaneous ventilation
- Wait until awake
- Apply positive pressure and remove ETT
- Check airway patency and continue oxygen supplementation

Question 3

DAS extubation guidelines: At risk algorithm

Answer 3

If not safe to remove ETT
- Postpone extubation and transfer to ICU
- Consider tracheostomy

If considered safe
- Awake extubation
- Laryngeal mask exchange
- Wake on remifentanyl