Project for Universal Management of Airways: guidelines for tracheal extubation

Introduction: Risk evaluation, strategy formulation and preparation are important to decreasing the incidence of adverse events associated with tracheal extubation. The focus of this guideline is tracheal extubation, but many of the principles outlined are relevant to all forms of discontinuation of airway management (tracheal extubation; removal of a supraglottic airway; cessation of facemask support; and tracheostomy removal) and conversion between upper airway lifelines (facemask; supraglottic airway; and tracheal tube) or a neck airway. Methods: An international, multidisciplinary working group reviewed existing airway guidelines and published literature. A structured process for generating expert consensus statements was undertaken, which included consultation with an international advisory group comprising both airway operators and assistants, as well as human factors experts. Discrepancies between the results of these two processes were analysed and reconciled. Guidelines were generated and recommendations were categorised according to the American Heart Association classification system. Results: Risk evaluation for tracheal extubation includes assessing the risk of hypoxaemia, pulmonary aspiration and harm from airway stimulation. The patient's baseline risk as well as any potential changes since tracheal intubation should be considered. In addition to patient risks, team and situation risk factors should be considered when formulating the extubation strategy. Planned extubation is always elective, maximising ability to control the timing, environment and resources available. Deferring extubation is recommended if this will significantly decrease risk. When substituting one lifeline for another, 'conversion procedures', characterised by the presence of a continuous guide to maintain or facilitate rapid restoration of alveolar ventilation, are safer and preferred over airway 'replacement procedures', particularly when airway management is regarded as 'at risk'. Discussion: These guidelines assist airway practitioners from any discipline to evaluate whether tracheal extubation is 'at risk' and link this to formulating a safe and effective strategy that addresses the specific challenges identified.