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Extubation management in the adult intensive care unit

Extubation management in the adult intensive care unit
Literature review current through: Jan 2024.
This topic last updated: Apr 27, 2023.

INTRODUCTION — Extubation refers to removal of the endotracheal tube. It is the final step in liberating a patient from mechanical ventilation.

Assessing the safety of extubation, the technique of extubation, and postextubation management are described in this topic. Extubation following anesthesia, and methods of weaning from mechanical ventilation are reviewed separately. (See "Extubation following anesthesia" and "Emergence from general anesthesia" and "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults".)

ASSESSING SAFETY OF EXTUBATION — Extubation should not be performed until it has been determined that the patient's medical condition is stable, a weaning trial has been successful, the airway is patent, and any potential difficulties in reintubation have been identified. Most patients are extubated during daytime hours, although nocturnal extubation is appropriate in select circumstances.

Stable medical condition — Patients cannot be extubated unless the condition for intubation is improved and the clinical criteria for weaning have been met (table 1). Readiness for weaning is discussed separately. (See "Weaning from mechanical ventilation: Readiness testing".)

Successful weaning trial — In general, most patients in the intensive care unit (ICU) should not be extubated unless a successful weaning trial has been passed. Exceptions include postoperative patients who are recovered for short periods in the ICU (eg, 24 hours) and patients undergoing terminal extubation. One study showed a decrease rate of reintubation at 48 hours when patients were rested back on the ventilator for an hour before extubation after the completion of a spontaneous breathing trial. This observation awaits further confirmation [1]. Further details on weaning including terminal weaning and weaning of patients requiring prolonged mechanical ventilation are provided separately. (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit", section on 'Withdrawal of ventilatory support' and "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults" and "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Weaning' and "Weaning from mechanical ventilation: Readiness testing", section on 'Rapid shallow breathing index'.)

Assess airway protection — Airway protection is the ability to guard against aspiration during spontaneous breathing. It requires sufficient cough strength and an adequate level of consciousness, each of which should be assessed prior to extubation. The amount of secretions should also be considered prior to extubation because airway protection is significantly more difficult when secretions are increased or difficult to expectorate (eg, dry or thick).

Universally accepted threshold levels of cough strength, level of consciousness, and suctioning frequency that prohibit extubation have not been established. For many patients, it is reasonable to delay extubation if the cough strength is weak, the Glasgow Coma Score (GCS) is <8 (table 2), or suctioning is required more frequently than every two to three hours. However, the final decision to delay or proceed with extubation should be made on a case-by-case basis since delayed extubation is associated with adverse outcomes, such as ventilator-associated pneumonia and increased length of stay [2].

Extubation failure is highest when a combination of risk factors affecting airway patency is present. As an example, in one study when reduced cough peak expiratory flow rate (PEF ≤60 L/minute), increased sputum volume (>2.5 mL/hour), and impaired neurologic function (inability to follow commands) were present, the incidence of extubation failure was 100 percent, compared with 3 percent when none of the risk factors were present (relative risk [RR] 23, 95% CI 3.2-167) [3].

Cough strength and secretion clearance — The ability of the patient to cough and clear their own secretions following extubation should be assessed prior to extubation.

Secretions – Although the volume of secretions can be measured at the bedside (via the suction canister), most clinicians assess secretion clearance by the frequency of suctioning. In general, those who require suctioning more than every two to three hours should not be extubated. The nature of secretions (eg, thick or thin) can also be examined bedside but thick secretions on their own is not a contraindication to extubation unless the cough is borderline or weak.

Cough – In most patients, cough strength is assessed informally during deep (endotracheal) suctioning at the bedside with or without gag reflex evaluation. However, a formal assessment may be useful in patients noted to have a weak cough on endotracheal suctioning or patients with neuromuscular disorders (eg, Parkinson disease, critical care myopathy). Several tests are available:

Spirometry – A spirometer (specifically designed for mechanical ventilators) is inserted into the ventilator circuit and the patient is then instructed to cough. The PEF during the cough is measured. Most experts use a cutoff of PEF ≤60 L/minute since this indicates a high likelihood of failure. Patients with a PEF ≤60 L/minute are five times more likely to require reintubation than patients with a PEF >60 L/minute [4,5].

Index card – The endotracheal tube (ETT) is detached from the ventilator circuit and a card (eg, an index card) is held approximately 1 to 2 cm from the proximal end of the ETT. The patient is then instructed to cough. A patient who is unable to moisten the card with 3 to 4 coughs is three times more likely to fail extubation than a patient who can moisten the card [6].

The importance of cough strength and the amount of secretions was illustrated by several observational studies reporting that successful extubation directly correlated with strength of the spontaneous cough and inversely correlated with the frequency of suctioning [2,3,6-8]. As examples:

An observational study of 130 patients who had passed a spontaneous breathing trial demonstrated that extubation failure was more likely among patients who were unable to cough on command or who had a PEF rate during a cough of <35 L/minute (24 versus 3.5 percent, RR 6.9, 95% CI 2.0-24) [7].

Another observational study enrolled 88 patients who had passed a spontaneous breathing trial [3]. Patients were more likely to fail extubation if their PEF during a cough was ≤60 L/minute (RR 4.8, 95% CI 1.4-16.2) or their secretions were >2.5 mL/hour (RR 3.0, 95% CI 1.0-8.8).

A prospective observational study examined predictors of extubation failure in 225 patients who were mechanically ventilated for more than 24 hours. Ineffective cough was the strongest predictor of extubation failure and requirement for reintubation within one week (adjusted odds ratio [OR] 5.03, 95% CI 1.80-14.1) [8]. Additional risk factors included abundant secretions (OR 3.32, 95% CI 1.21-9.13) and duration of mechanical ventilation greater than seven days (OR 2.87, 95% CI 1.11-7.41). This study was limited by the use of semi-objective measures of cough strength and secretion volume.

Mental state — Ideally, patients are extubated awake, alert, following commands, and preferably off sedatives. However, this is not always feasible and a small proportion of patients who are cooperative and arousable upon stimulation or receiving minimal sedation (eg, patients with resolving delirium on stable low-dose dexmedetomidine who are arousable) may be extubated with vigilant monitoring of the airway and mental status and prompt weaning of sedatives, once extubated.

The importance of level of consciousness has been demonstrated in observational studies:

In a study of 100 neurosurgical patients, patients with a GCS ≥8 (table 2) were significantly more likely to undergo successful extubation than patients with a GCS <8 (75 versus 37 percent) [9].

In another observational study of 88 patients, the inability to complete four commands (open eyes, follow object with eyes, grasp hand, stick out tongue) was associated with an increased risk of extubation failure (RR 4.3, 95% CI 1.8-10.4) [3].

The potential benefit of daily interruption of sedation in mechanically ventilated patients is discussed separately.

Assess risk for postextubation stridor — Prior to extubation, all patients should be assessed for the risk of postextubation stridor. Postextubation stridor occurs in less than 10 percent of critically ill patients and is associated with increased rates of reintubation, prolonged duration of mechanical ventilation, and longer length of ICU stay [10]. Most cases are due to vocal cord edema related to the ETT; others include laryngeal injury, secretions, vocal cord dysfunction, and rarely tracheal stenosis or lesions. In those considered at high risk of postextubation stridor (see 'Risk factors' below), most experts use the cuff leak test to facilitate the decision to extubate. The cuff leak test is not performed in unselected patients since it has been demonstrated to be neither sensitive nor specific in this setting. Unfortunately, despite assessment, many cases may not be detectable until after extubation when patients present with postextubation stridor that may require reintubation. (See 'Patients who fail due to postextubation stridor' below.)

Risk factors — Risk factors for postextubation stridor include [11-18]:

Prolonged intubation (variably defined as ≥36 hours to ≥6 days)

Age greater than 80 years

A large ETT (>8 mm in men, >7 mm in women)

A ratio of ETT to laryngeal diameter greater than 45 percent on computed tomography

A small ratio of patient height (in mm) to ETT diameter (in mm)

An elevated acute physiology and chronic health evaluation (APACHE) II score

A GCS score <8 (table 2)

Traumatic intubation

Female gender

A history of asthma

Excessive tube mobility due to insufficient fixation

Insufficient or lack of sedation

Aspiration

Patients not at risk — Patients who have no risk factors for postextubation stridor should be extubated in the same manner as other patients and no assessment of the cuff leak test is necessary. (See 'Extubation equipment and technique' below.)

Patients at risk — Patients who have one or more risk factors for postextubation stridor should undergo a cuff leak test.

Cuff leak — A "cuff leak" refers to normal airflow around the ETT after the cuff of the ETT is deflated. The absence of a leak suggests there is reduced space between the ETT and the larynx. This may be due to laryngeal edema, laryngeal injury, secretions, stenosis, or a large ETT within a relatively small larynx. Patients without a cuff leak are at increased risk for postextubation stridor.

The cuff leak can be detected qualitatively or quantitatively:

Qualitative assessment is performed by deflating the cuff and then listening for air movement around the ETT using a stethoscope placed over the upper trachea. Air movement indicates that a cuff leak is present while no air movement suggests that it is absent and may indicate laryngeal obstruction.

Quantitative assessment is performed by deflating the ETT cuff and measuring the difference between the inspired and expired tidal volumes of ventilator-delivered breaths during volume-cycled mechanical ventilation. The lowest three expired tidal volumes obtained over six breaths are averaged and then subtracted from the inspired tidal volume to give the cuff leak volume [19]. Although ill-defined, we and other experts consider cuff leak volumes less than 110 mL or less than 12 to 24 percent of the delivered tidal volume as thresholds for determining diminished airway patency and risk for postextubation stridor from laryngeal edema (ie, "reduced" or "absent" cuff leak) [12,14,19-22]. Cuff leak volumes greater than or equal to 110 mL or greater than 24 percent of the delivered tidal volume is considered a normal cuff leak test.

The decision with how to proceed based upon the results of the cuff leak test is challenging. In general, for patients with risk factors for postextubation stridor, we use the following guidelines:

In patients with a sufficient cuff leak (eg, sufficient air movement around the ETT or greater than or equal to 110 mL or greater than 24 percent of the delivered tidal volume), we proceed with extubation. (See 'Extubation equipment and technique' below.)

In patients with an absent or reduced cuff leak, we delay extubation and treat with glucocorticoids (for presumed laryngeal edema) for at least six to eight hours before re-assessing with another cuff leak test and/or extubation. (See 'Risk factors' above and 'Glucocorticoids' below.)

In the event that a cuff leak test is inadvertently performed in a patient without risk factors for postextubation stridor and in whom the leak is absent or reduced, glucocorticoid administration before extubation should be considered on an individual basis. If extubated, the threshold for reintubation should be low.

The absence of a cuff leak alone is an imperfect predictor of postextubation stridor with a reported sensitivity of 15 to 85 percent and a specificity of 70 to 99 percent [10,12,13,19-21,23-26]. The wide ranges likely reflect variability in the patient populations, how the cuff leak was measured, and what was considered an acceptable cuff leak. Best illustrating the poor sensitivity of the cuff leak test is a pooled analysis of nine studies that found a sensitivity and specificity of 56 and 92 percent, respectively [23]. A meta-analysis of 14 observational studies estimated that when used in select populations, the cuff leak test resulted in reduced rates of reintubation (2.4 versus 4.2 percent) and postextubation stridor (4 versus 7 percent) but at the expense of delayed extubation (9 percent absolute increase) [27]. In addition, certain conditions such as tracheomalacia may affect the utility of the test since it may increase the likelihood of a cuff leak.

Other tests — Several other methods for evaluating the risk of postextubation stridor have been proposed but are not well-validated:

Laryngeal ultrasonography is a simple, rapid, and noninvasive way to evaluate the width of the laryngeal air column during cuff deflation, thereby assessing the likelihood of postextubation stridor [28,29]. Although promising, this modality is not recommended for routine use until controlled clinical trials are performed.

Simultaneous assessment of both cough and cuff leak may improve prediction of postextubation stridor. After the cuff is deflated, the ETT is occluded and the patient is instructed to cough. The absence of both an audible cough and a cuff leak indicates the patient is 10 times more likely to develop postextubation stridor [11].

Glucocorticoids — We and others limit glucocorticoid therapy to patients who are assessed to be at high risk of postextubation stridor and who have a reduced or absent cuff leak [27,30,31] (see 'Assess risk for postextubation stridor' above) and to patients who have failed extubation due to postextubation stridor. Since the overall incidence of postextubation laryngeal edema requiring reintubation is low (less than 5 percent), we believe this approach focuses therapy on those who are most likely to benefit and avoids unnecessarily prolonging mechanical ventilation for glucocorticoid therapy. We suggest that patients who have a reduced or absent cuff leak receive a short course of glucocorticoid therapy before extubation (four hours or more). Methylprednisolone (20 mg) administered intravenously every four hours for a total of four doses prior to extubation is an acceptable regimen. Alternatively, a single dose of 40 mg of methylprednisolone administered four hours prior to extubation may be used. Choosing one over the other should be at the discretion of the physician and depends upon the assessed risk of postextubation stridor in a given patient.

Supporting this strategy are the following studies:

Randomized trials and meta-analyses of patients at increased risk for postextubation stridor, have found that the administration of multiple doses of glucocorticoids prior to extubation reduces the rates of postextubation stridor and reintubation [14,15,27,31-39]. As an example, a 2017 meta-analysis of three randomized trials reported that in patients who failed a cuff leak test, glucocorticoid administration resulted in reduced rates of reintubation (6 versus 17 percent; RR 0.32; 95% CI, 0.14-0.76) and postextubation stridor (11 versus 32 percent; RR 0.35;95% CI 0.20-0.63) [27].

In contrast, trials that enrolled unselected patients and administered a single dose of glucocorticoids shortly prior to extubation did not find significant improvement in the rates of postextubation stridor and reintubation [33,34].

The inconsistency among these studies may relate to differences in the risk of postextubation stridor among the patients studied and/or the duration of glucocorticoid therapy prior to extubation. We believe that selecting patients at risk for postextubation stridor for glucocorticoid therapy is a more important factor than the number of doses administered. This is supported by a randomized trial of 71 patients with a cuff leak of less than 24 percent of the tidal volume administered which reported that compared with placebo, a single dose of 40 mg of methylprednisolone four hours prior to extubation resulted in significantly decreased rates of postextubation stridor (16 versus 39 percent) and reintubation (8 versus 30 percent) [36].

Assess potential difficulty with reintubation — Patients should be evaluated for any potential difficulty with reintubation, should extubation fail. This evaluation should focus on identifying factors that impair the ability of patients to protect their airway (eg, sedation, obesity, difficulty with first intubation) as well as factors that affect the operators ability to reintubate (operator fatigue, availability of experts skilled with difficult airways). These issues are discussed separately. (See "Extubation following anesthesia", section on 'Difficulty re-establishing an airway'.)

Assess optimal timing (day or night) — The optimal timing for extubation, (daytime [7 am to 6:59 pm] versus nighttime hours [7 pm to 6:59 am]) is unknown. Our practice is to extubate patients once successful weaning and extubation parameters have been met, provided that appropriate personnel are available. In general, this occurs during daytime hours. However, while not absolutely contraindicated, clinicians may perform after hours extubation among selected individuals in whom the risk of reintubation is assessed to be low (eg, patients undergoing terminal extubation, postoperative patients at low risk of reintubation). (See "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults" and 'Assessing safety of extubation' above.)

Whether or not patients should be extubated only during daytime hours has not been prospectively studied and retrospective observational data have yielded conflicting information:

In a retrospective study of 2240 patients, 31 percent were extubated at night and no differences in reintubation rates, length of stay, or mortality were reported when compared with patients extubated during day time hours [40]. Similarly, a retrospective study of almost 21,000 cardiac surgery patients reported no difference in the mortality or reintubation rates among those extubated during daytime or nighttime hours [41], although this study may have been biased by the selection of patients who were only undergoing routine extubation within 24 hours of surgery, and therefore likely to be at low risk of death and reintubation.

In contrast, another retrospective study of almost 20,000 patients who were extubated at night, reported that compared with propensity-matched control patients extubated during day time hours, patients who were extubated at night time had increased ICU mortality (6 versus 5 percent for those intubated <12 hours; 11 versus 6 percent for those intubated ≥12 hours) [42]. Compared with daytime extubation, nocturnal extubation had an inconsistent effect on the reintubation rate and length of stay. Methodologic flaws including the retrospective nature of the study, incomplete capture of the circumstances surrounding extubation, and analysis of older data (2000 to 2009) prohibit firm conclusions from this study.

EXTUBATION EQUIPMENT AND TECHNIQUE — We typically use the following equipment and procedure when extubating patients. Tube feeds are typically held for one hour, sometimes more (eg, high residual volumes during feeding noted) prior to extubation, although limited data suggest no difference in the rate of extubation failure if enteral feeds are continued or held prior to extubation [43].

Equipment — The equipment needed includes separate oral and endotracheal suction catheters and tubing, tape cutters, a 10 mL syringe, and several types of oxygen delivery systems including low-flow and high-flow nasal cannulae, and high-flow simple facemasks. Ideally, the clinicians should estimate roughly how much oxygen will be needed to maintain peripheral oxygen saturations (SpO2) and set a target SpO2 before extubation. In addition, equipment for noninvasive ventilation (NIV) should also be readily available for those in whom NIV is indicated or for those at increased risk of failing extubation. The SpO2, heart rate, respiratory rate, and blood pressure are monitored throughout the extubation process. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults" and "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications" and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation".)

Position — The patient is placed into an upright position or as upright as concomitant medical or surgical conditions allow. The technique is explained to the patient before and during removal.

Removal — Both the oral cavity and the lower airways (via the endotracheal tube [ETT]) are suctioned (two individual suction systems are advised). All ties or other securement devices holding the ETT in position are removed, carefully making sure that the ETT is not displaced in the process; this often requires two individuals, one to secure the ETT in place and one to free the ETT from securement devices. The syringe is attached to the cuff. Instructions are then given to the patient to take a deep breath and then exhale or cough. During exhalation/coughing, the cuff is quickly deflated and the ETT is removed in a single, smooth motion. The patient typically coughs during removal and residual oral secretions are suctioned again to avoid aspiration. Alternatively, many experts deflate the cuff with the inline suction catheter in place and then remove the ETT during exhalation or coughing while simultaneously suctioning residual secretions during ETT removal. Orogastric tubes are typically removed simultaneously, although some remain in place if a vital indication is present. Following extubation, supplemental oxygen is typically administered to reach the predefined peripheral saturation goal, although in some cases NIV is administered. (See 'Postextubation management' below.)

POSTEXTUBATION MANAGEMENT — All patients should be closely monitored following extubation in the ICU. We adopt an individualized approach to postextubation support since one study has shown that a protocolized approach that supports all patients with either humidified high-flow oxygen via nasal cannulae (HFNC) or noninvasive ventilation (NIV) does not appear to impact the outcome [44].

Most patients are at low risk of reintubation (approximately 80 to 85 percent), although the proportion varies and depends upon the ICU population [45]. Low-risk patients typically do well on low-flow oxygen and can be discharged from the ICU after 12 to 24 hours, provided no other indications for ICU care are present. (See 'Patients at low risk of postextubation respiratory failure' below.)

However, some patients are at high risk of reintubation (approximately 15 to 20 percent). Aggressive monitoring and management with continued medical therapies, oxygenation, and airway clearance measures may prevent reintubation in this population. Some experts extubate directly to HFNC or NIV, in select patients, to prevent reintubation. (See 'Patients at high risk of postextubation respiratory failure' below.)

A small proportion of patients (up to 14 percent) develop postextubation respiratory failure, which can be early (within minutes up to 12 hours after extubation), or delayed (>12 hours after extubation). Therapies targeted at the suspected etiology of respiratory failure (eg, poor secretion clearance, heart failure/ischemia, increased work of breathing) should be promptly implemented. This may include suctioning (oral and nasotracheal), bronchodilator therapy, diuresis. In some cases, a trial of humidified HFNC and/or NIV may be necessary to avoid reintubation. (See 'Patients with established postextubation respiratory failure' below.)

Patients at low risk of postextubation respiratory failure

Low-flow versus high-flow oxygen — Every patient should be oxygenated following extubation. We prefer using devices that provide adequate oxygenation and comfort for the patient. For most patients, this goal is achieved with low-flow devices (nasal prongs, simple or venturi facemasks).

When higher flows of oxygen are required, simple high-flow facemasks or humidified high-flow nasal cannulae (HFNC) may be applied. Choosing among low-flow devices or HFNC should be individualized and depend upon factors including oxygen requirement, the etiology of respiratory failure, and patient preferences. For example, in patients with minimal oxygen requirements, low-flow devices often suffice, while patients with higher oxygen requirements (eg, patients with interstitial lung disease or pulmonary hypertension) may be suitable for HFNC. HFNC, in addition to improved oxygenation, may also provide a small amount of positive end-expiratory pressure (PEEP), and be better tolerated when compared with oxygen delivered through low or high-flow facemasks [46,47]. The mechanisms and benefits of HFNC are discussed separately (table 3). (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications", section on 'Mechanisms of clinical benefit'.)

The efficacy of HFNC in the postextubation setting was best illustrated in a trial of 527 patients (mixed postsurgical and medical) who were mechanically ventilated for an average of only one to two days and considered to be at low risk for reintubation following extubation [48]. Compared with conventional low-flow oxygen therapy, at 72 hours, HFNC reduced the rate of reintubation (5 versus 12 percent) and the rate of respiratory failure (14 versus 8 percent). However, methodologic flaws such as imperfect blinding and the high proportion of postsurgical and neurologic patients, where HFNC may have improved secretion clearance, may have biased results in favor of HFNC. Although encouraging, this trial does not support the routine use of HFNC following extubation and further trials in select populations are needed. In contrast, a randomized trial of 220 patients who were extubated to either HFNC or standard low-flow oxygen following major abdominal surgery (not risk stratified) reported no difference in the rate of hypoxemic respiratory failure or other pulmonary outcomes; mortality was not reported [49].

HFNC is not routinely available in all institutions for adult use and it should only be administered by staff educated in its application. Technical details regarding its application and the use of HFNC as a treatment for acute respiratory failure in medical patients and postoperative populations as well as its efficacy compared with NIV in postextubation patients are discussed separately. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure' and 'High-flow oxygen via nasal cannulae' below and "Continuous oxygen delivery systems for the acute care of infants, children, and adults", section on 'Nasal cannula'.)

Arterial blood gases and chest imaging are not routinely obtained in patients at low risk of reintubation but may be necessary in patients who deteriorate after endotracheal tube (ETT) removal. (See "Arterial blood gases".)

Patients at high risk of postextubation respiratory failure — For patients who are deemed at risk of postextubation respiratory failure, options include observation or a preventive intervention with NIV or HFNC, or both (see 'At-risk patients' below). While some institutions routinely utilize HFNC in the "at risk" population, there are no robust data to support routinely extubating patients at risk of postextubation respiratory failure to HFNC or NIV. Consequently, practice varies significantly with much of this decision at the discretion of the treating physician/respiratory therapist. We believe the choice between observation, and NIV and/or HFNC should be individualized and depends upon factors including the assessed degree of risk and type of respiratory failure (eg, hypoxic, hypercapnic), and oxygen and positive end expiratory pressure requirements of the patient, as well as local availability of and expertise in HFNC and NIV. In our practice, most patients at risk of postextubation respiratory failure undergo a brief period of observation with close monitoring, while a select few who are considered to be at the highest risk of failure may be extubated directly to NIV and/or HFNC (eg, patients who have already failed extubation previously, patients with neuromuscular disorders with a very weak cough who have declined tracheostomy, patients with a high oxygen requirement, and patients with hypercapnic COPD or heart failure). For example, patients with severe hypoxemic respiratory failure or a high oxygen requirement may benefit from HFNC [50], while those with hypercapnic respiratory failure or with cardiac failure may benefit from NIV.

The duration of such interventions is also unclear. However, most studies showing benefit have used either NIV or HFNC for roughly 6 to 24 hours following extubation. In all cases, follow up with clinical examination is necessary, so that a decision can be made to wean support should patients improve, or reintubate, earlier rather than later, should the patients fail either or both interventions. Early recognition of failure, with prompt reintubation is an important consideration whenever either of these modalities are employed.

Arterial blood gases are not routinely obtained in this population but may be helpful a few hours after extubation to ensure adequate gas exchange. Follow up imaging is also not routine unless the patient deteriorates following extubation.

At-risk patients — It is estimated that 12 to 14 percent of patients who undergo planned extubation require reintubation within 48 to 72 hours, most within the first 24 hours [8,45,51-54]. Risk factors for reintubation that can be identified prior to extubation include:

A weak cough (cough peak expiratory flow rate ≤60 L/minute) (see 'Cough strength and secretion clearance' above)

Frequent suctioning (eg, every one to two hours, sputum volume >2.5 mL/hour)

Glasgow Coma Score <8 (table 2)

A positive fluid balance during the 24 hours preceding extubation

Pneumonia as the reason for the initial intubation

Patients who are ≥65 years old with severe chronic cardiac or respiratory disease

A reduced or absent cuff leak, those with altered mental status (eg, delirium) (see 'Cuff leak' above)

Noninvasive ventilation — Noninvasive ventilation (NIV) is not routinely administered following extubation as a preventive measure against reintubation but may be used in select patients assessed to be at risk of extubation failure. Among high risk patients, we and others [55] agree that patients likely to benefit are patients who have compensated hypercapnic respiratory failure during their pre-extubation spontaneous breathing trial (eg, patients with severe chronic obstructive pulmonary disease [COPD]) as well as patients with cardiac failure. Data from meta-analyses and randomized trials support the value of NIV as a preventive measure in these subgroups. However, despite data which suggest that NIV lowers the reintubation rate in this select group, our experience also suggests that many patients in this same setting can be successfully extubated without NIV. Thus, while not an absolute indication, the threshold to apply NIV following extubation should be low in this population. The role of NIV in patients with established acute hypercapnic respiratory failure which develops soon after extubation is discussed below. (See 'Patients with established postextubation respiratory failure' below.)

Evidence from randomized trials and meta-analyses of patients considered to be at risk of postextubation respiratory failure suggests that NIV may prevent postextubation respiratory failure if it is applied immediately after extubation [56-61]:

One 2013 meta-analysis of 16 trials included 994 patients intubated for acute respiratory failure. Compared with invasive mechanical ventilation weaning strategies (eg, slow ventilator wean with decremental support), the early application of NIV following extubation reduced all-cause mortality (risk ratio [RR] 0.53, 95% CI 0.37-0.8) [60]. The mortality benefit was greatest in patients with respiratory failure complicating COPD when compared with mixed populations of patients intubated for other reasons (eg, postoperative, pneumonia, non-COPD) (RR 0.36, 95% CI 0.25-0.56 versus 0.81, 95% CI 0.47-1.4). Additional benefits included reduced length of ICU and hospital stay (mean difference 5.6 days and 6 days, respectively) and reduced rates of ventilator-associated pneumonia (RR 0.25, 95% CI 0.15-0.43). All benefits occurred without an increased risk of extubation failure and reintubation (RR 0.65, 95% CI 0.44-0.97). Methodologic differences in weaning strategies between studies and significant heterogeneity in the outcomes studied may limit confidence in the results.

An updated 2022 meta-analysis of 28 trials totaling over 2000 patients with acute respiratory failure, almost half of whom had COPD, confirmed similar results [62]. NIV reduced mortality (RR 0.57, 95% CI 0.44-0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43-0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22-0.41; high quality), and ICU length of stay (mean difference -4.62 days, 95% CI -5.91 to -3.34). Benefits were most pronounced in patients with COPD compared with other patient populations.

One trial randomly assigned 162 patients considered at risk of developing postextubation respiratory failure to receive conventional medical therapy with or without NIV for 24 hours immediately following extubation [57]. Patients were considered at risk of postextubation respiratory failure if they were 65 years or older, had an Acute Physiology and Chronic Health Evaluation (APACHE) II score >12 on the day of extubation, or had required intubation due to cardiac failure. NIV was associated with lower ICU mortality (3 versus 14 percent), but not a lower reintubation rate, hospital mortality, or 90-day mortality. A pre-defined subgroup analysis found that the benefit of NIV was limited to patients who had hypercapnia (arterial carbon dioxide tension [PaCO2] >45 mmHg) during a pre-extubation spontaneous breathing trial, 98 percent of whom had chronic lung disease.

Another trial randomly assigned 208 patients with chronic hypercapnic respiratory failure to undergo conventional extubation, followed by supplemental oxygen, or extubation followed by immediate NIV [63]. The group that received immediate NIV was less likely to develop postextubation acute respiratory failure, defined as tachypnea (>30 breaths/minute), bradypnea (<12 breaths/minute), hypoxemia (arterial oxygen saturation [SpO2] <90 percent, arterial oxygen tension [PaO2] <64 mmHg, or PaO2/fraction of inspired oxygen [FiO2] ≤130 mmHg despite supplemental oxygen at a flow rate >6 L/minute or an FiO2 ≥50 percent), respiratory acidosis (PaCO2 increase of ≥10 percent and a pH ≤7.35), or clinical signs of acute respiratory failure (eg, diaphoresis, use of accessory respiratory muscles). However, there was no difference in the mortality or reintubation rates.

Use of NIV in patients with established acute respiratory failure following extubation is discussed below. (See 'Patients with established postextubation respiratory failure' below.)

Use of NIV in patients to extubate those who are ready to wean but have failed their spontaneous breathing trial (ie, early extubation) is discussed separately. (See "Initial weaning strategy in mechanically ventilated adults", section on 'Weaning failure'.)

High-flow oxygen via nasal cannulae — Humidified high-flow oxygen delivered via nasal cannulae (HFNC) is not routinely administered following extubation as a preventive measure against reintubation but may be used in select patients assessed to be at high risk of extubation failure as an alternative to NIV [50]. Those considered at risk and the principles of choosing among these modalities are discussed above. (See 'At-risk patients' above and 'Patients at high risk of postextubation respiratory failure' above.)

Trials that compare HFNC and NIV in the prevention of postextubation respiratory failure have been conflicting and suffer from flaws including a lack of standardized approach to oxygenation and ventilatory support following extubation, variable duration of therapy, and issues of inconsistency, indirectness, and imprecision [50,64-68]. As examples:

Network meta-analyses suggest that both NIV and HFNC reduce the rate of intubation when compared with conventional oxygen therapy, with no advantage of one modality over the other. One meta-analysis of nine trials reported that compared with conventional oxygen therapy, HFNC reduced reintubation rates (relative risk [RR] 0.46, 95% CI 0.30-0.70) and the incidence of postextubation respiratory failure (RR 0.52, 95% CI 0.30-0.91) [50]. However, compared with NIV, HFNC had no effect on the rates of reintubation or postextubation respiratory failure. Another meta-analysis of 36 randomized trials reported similar results [64]; both NIV and HFNC reduced re-intubation rates following extubation when compared with conventional oxygen therapy, but rates were no different when NIV was compared with HFNC. Combining HFNC and NIV may be superior to either alone [64].

HFNC and NIV were compared in a randomized trial of 604 patients (mixed surgical and medical populations) who were extubated following mechanical ventilation and were deemed at risk of reintubation (eg, age >65 years, APACHE II score >12, body mass index [BMI] >30, excess secretions, difficulty weaning, moderate to severe chronic obstructive lung disease, prolonged mechanical ventilation, airway patency issues) [65]. HFNC administered for 24 hours after extubation resulted in similar rates of reintubation when compared with NIV (23 versus 19 percent) and also resulted in a nonsignificant reduction in the rate of postextubation respiratory failure (26 versus 40 percent). While the ICU length of stay was lower in those treated with HFNC, there was no difference in the rates of mortality, sepsis, or multiorgan failure.

Although there were 20 percent moderate to severe COPD patients included in this trial, these data are insufficient to make a robust recommendation in favor of HFNC for patients with COPD with chronic hypercapnia, a population in whom the evidence and guidelines favor NIV. (See 'Noninvasive ventilation' above.)

In patients determined to be at "very high risk" of reintubation, NIV may be superior to HFNC. In a randomized trial of 162 such patients having at least four risk factors for reintubation, the rate of reintubation was lower in the NIV group compared with the HFNC group (23.3 versus 38.8 percent) [68]. Risk factors included age >65 years, APACHE II score >12 on extubation day, BMI >30, inadequate secretions management, difficult or prolonged weaning, two or more comorbidities, acute heart failure indicating mechanical ventilation, moderate to severe COPD, airway patency problems, prolonged mechanical ventilation, or hypercapnia on finishing the spontaneous breathing trial.

In post-cardiothoracic surgery patients, HFNC was reported to be equivalent to NIV in preventing reintubation [66]; this study included patients both at risk for and with overt respiratory failure following extubation. However, in abdominal surgery patients, NIV has been found to be superior to HFNC in preventing reintubation [67]. These trials are discussed in detail separately. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure'.)

HFNC has also been compared with oxygen delivered via a venturi mask in a randomized trial [69]. Reintubation rates did not differ between the groups, although less rescue NIV was used in patients treated with HFNC.

The effect of HFNC on intubation rates in medical patients with acute respiratory failure [70] is discussed separately. (See "Continuous oxygen delivery systems for the acute care of infants, children, and adults", section on 'Nasal cannula'.)

NIV plus HFNC — While HFNC combined with NIV is not routinely administered as a preventive measure against reintubation in patients assessed to be at high risk of extubation failure, it may be an alternative to HFNC alone. The addition of NIV to HFNC was shown in one randomized trial to reduce reintubation rates in 648 patients at high risk of postextubation failure (11.8 versus 18.2 percent on day 7) without impacting mortality (6 versus 9 percent) [71]. This trial comprised mostly medical patients in whom "high risk" was defined as those with underlying cardiac or respiratory disorder or patients older than 65 years of age. NIV was administered (8 cm [inspiratory pressure] and 5 cm [expiratory pressure]) for at least 12 hours per day for 48 hours (mean total duration was 22 hours and mostly delivered at night during sleep) alternating with HFNC at 50 L/minute in between NIV sessions (mean total duration 42 hours). Post-hoc subgroup analysis suggested that patients with hypercapnic respiratory failure (at the end of their spontaneous breathing trial) are most likely to benefit (reintubation rates 8 versus 21 percent). In addition, 28-day mortality was lower in hypercapnic patients who had received NIV prior to developing postextubation respiratory failure than those who had received HFNC (3 versus 31 percent, p = 0.006), although the absolute numbers were small [72]. The benefit to the alternating strategy of NIV with HFNC, including reintubation and ICU mortality, was limited to patients who were obese or overweight (BMI >25) [73]. Limitations of this analysis include the lack of blinding, use of HFNC as a comparator, use of NIV as a rescue therapy in one-third of patients in the HFNC group, and the considerable experience of the participating ICUs in NIV use, which may reduce generalizability of the NIV/HFNC combination. We continue to suggest an individualized approach to selecting postextubation support for patients at high risk of postextubation failure.

Patients with established postextubation respiratory failure — Up to 14 percent of patients who undergo planned extubation require reintubation, mostly within the first 24 hours. Similarly, over half of patients who undergo unplanned extubation require immediate reintubation. (See 'At-risk patients' above and 'Patients with unplanned extubation' below.)

Postextubation respiratory failure typically manifests as falling peripheral oxygen saturation, increasing respiratory rate, respiratory distress, and sometimes stridor. The most common etiologies are atelectasis from poor secretion clearance, heart failure, aspiration, bronchospasm, and laryngeal edema. The clinician should re-examine the patient for potential etiologies and, provided immediate re-intubation is not needed, in most cases an arterial blood gas (ABG) and chest radiograph are performed to help elucidate the nature and severity of respiratory failure and shed some light on the etiology.

As soon as it is suspected that a patient may be failing extubation, therapies targeted at the suspected etiology of respiratory failure and a simultaneous trial of HFNC or NIV should be immediately implemented rather than waiting for overt respiratory failure to occur on low-flow oxygen. The European Respiratory Society/American Thoracic Society suggest not using NIV once respiratory failure has already developed in the postextubation setting [55]. However, they acknowledge that the data are flawed and that more studies are required. Furthermore, the American College of Physicians made a recommendation that HFNC rather than low-flow oxygen be used in patients with postextubation respiratory failure [74] but did not extend their recommendation to facilitate the choice between HFNC and NIV. The principles that influence the choice between NIV and HFNC are discussed above. (See 'Patients at high risk of postextubation respiratory failure' above.)

Data regarding the role of NIV and HFNC in treating established postextubation respiratory failure are discussed in this section.

NIV – Most experts individualize NIV application in this setting since the role of NIV is unclear in patients with postextubation respiratory failure. While anecdotal evidence suggests that NIV may avoid intubation in some cases, available data suggest that NIV may be less effective and even potentially harmful when its application is delayed [75-77]. Thus, in this population, if NIV is administered, it should be started as soon as extubation failure is suspected and trials should be short (eg, one to two hours); if benefit is not demonstrated, the threshold to re-intubate should be low.

Questionable benefit of NIV in this population was illustrated by a trial of 221 patients who developed respiratory failure after extubation and then were randomly assigned to receive conventional medical therapy with or without NIV [75]. Respiratory failure was defined as two or more of the following: respiratory acidosis (pH <7.35 with a PaCO2 >45 mmHg), clinical signs of respiratory fatigue (ie, use of accessory muscles, intercostal retractions, paradoxical motion of the abdomen), a respiratory rate >25 breaths/minute for two consecutive hours, or hypoxemia (arterial oxygen tension <80 mmHg or arterial oxyhemoglobin saturation <90 percent despite a fraction of inspired oxygen >50 percent). All-cause mortality increased in the NIV group (25 versus 14 percent), resulting in early termination of the trial. However, the increased mortality seen in this trial may have been related to delayed reintubation since the median time from respiratory failure to reintubation was longer in the NIV group (12 versus 2.5 hours). In another meta-analysis of three trials that compared NIV with HFNC, both modalities had similar impact on mortality and reintubation rate, although a small increase in these outcomes among those treated with HFNC could not be excluded [77].

HFNC – Data are limited to support the use of HFNC in this population. In one meta-analysis of three studies of a mixed population of patients with acute postextubation respiratory failure (eg, medical and surgical patients, COPD), HFNC had little or no impact mortality or intubation rates compared with NIV [77]. When compared with low-flow oxygen, HFNC reduced reintubation rate (odds ratio [OR] 0.60, 95% CI 0.23-1.61) and improved patient comfort. However, this analysis was limited by heterogeneity, risk of bias, and imprecision. These limited data have led the American College of Physicians to make a recommendation that HFNC rather than low-flow oxygen be used in patients with postextubation respiratory failure [74]. Trials that discuss the role of HFNC in postoperative respiratory failure (that sometimes includes postextubation respiratory failure) are discussed in detail separately. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure'.)

Despite therapy, some patients fail and require reintubation. During reintubation a careful inspection of the vocal cords (edema erosions, abnormal movement or masses) and upper airway (masses, secretions) are prudent. Measures should be taken to continue treatment before a second attempt is made to extubate (often one to two days or longer). Patents who fail extubation on more than one occasion generally require a tracheostomy, although exceptions exist when a clear cause for failure is identified and easily reversed. (See "Tracheostomy: Rationale, indications, and contraindications".)

The impact of reintubation may depend upon the patient population. In medical ICU patients, reintubation is associated with increased hospital mortality, a longer ICU stay, longer hospitalization, and nosocomial pneumonia [54,78,79]. Mortality is highest among those who fail extubation late (>12 hours after extubation) or who require reintubation for reasons unrelated to the airway (ie, respiratory failure, heart failure, or encephalopathy) [51]. Similarly, in most surgical patients, respiratory failure requiring reintubation in the postoperative period is associated with high morbidity, leading to a longer hospital stay, and increase in 30-day mortality [80-82]. In contrast, reintubation in cardiac surgery patients has not been shown to be associated with increased mortality [83,84].

Special populations

Patients with unplanned extubation — Unplanned extubation occurs in 3 to 12 percent of intubated patients [52,85-93]. It is more common in patients who are orally intubated than those who are nasally intubated [85,90-93]. It is also more frequent in patients whose ETT is not well secured or who are agitated, have low levels of sedation, or are physically restrained [91,92,94,95]. Most unplanned extubations occur within one day of planned extubation and are deliberate maneuvers by the patients rather than accidental [96].

Most patients who undergo unplanned extubation should be promptly assessed with a low threshold to reintubate immediately. This strategy is based upon reports which suggest that delayed reintubation is associated with increased mortality [51]. Increased mortality may be due to the technical difficulty associated with reintubation in this setting [85,97,98] and that unplanned extubation is associated with a longer duration of mechanical ventilation, ICU stay, and hospitalization [99]. In support, approximately 50 percent of patients who have undergone unplanned extubation require reintubation, often within 12 hours [52,91]. Reintubation is more common following accidental unplanned extubation and among patients who require full ventilatory support, have higher sedation scores, and have a significant oxygen requirement (ie, FiO2 >50 percent) [85,90,92,94,97].

Careful observation is appropriate for select patients who are clinically stable, have low ventilatory and oxygenation requirements, have a patent airway, and can protect their airway. These patients are at risk of reintubation and should be managed as such. (See 'Patients at high risk of postextubation respiratory failure' above.)

Strategies to avoid unplanned extubation are discussed separately. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Displacement and unplanned extubation'.)

Patients who fail due to postextubation stridor — For patients whose initial trial of extubation failed due to stridor, prompt reintubation is warranted (sometimes with a smaller-sized ETT). Careful examination of the oral cavity upper airway and vocal cords for edema, and of the airway for size and secretions and abnormal lesions is prudent in order to determine a cause for stridor. In this population, we perform the following:

Treat with a short course of glucocorticoids for presumed or observed laryngeal edema. (See 'Glucocorticoids' above.)

Perform a cuff leak test following treatment, provided the patient meets all other extubation criteria again (see 'Cuff leak' above):

If an appropriate cuff leak is detected, bedside extubation is generally safe. (See 'Extubation equipment and technique' above.)

If a cuff leak is reduced or absent despite a course of glucocorticoid therapy, extubation over an airway exchange catheter (AEC; eg, a Cook catheter) may facilitate successful reintubation without delay, if necessary [100]. AECs generally require supervision by anesthesiologists with expertise in difficult airway management and are discussed in detail separately. (See "Extubation following anesthesia".)

Patients who fail a second trial of extubation generally require a tracheostomy. (See "Tracheostomy: Rationale, indications, and contraindications".)

REFEEDING — There is little evidence and no guidelines to predict clinically significant swallowing dysfunction that may predispose a patient to aspiration following extubation. In our opinion, clinicians should weigh the benefits of feeding against the risk of aspiration in all cases and seek formal testing when patients are suspected to have a high risk of aspiration. Thus, the point at which patients can eat following extubation should be individualized and depends upon factors including duration of intubation, mental status, and underlying comorbidities (eg, neuromuscular disorders, critical care myopathy, poor level of consciousness) which may predispose patients to dysphagia and aspiration.

As a general rule, patients intubated for short periods (eg, less than one week) can generally eat within a few hours after extubation; swallowing is initially typically observed with small amounts of ice chips or water and if tolerated, a solid diet is slowly introduced over the ensuing few days.

However, many clinicians do not allow patients who have been intubated for a prolonged duration (eg, two weeks or longer) to eat for approximately 12 to 24 hours following extubation. In this population many experts request a bedside, and sometimes a formal radiographic and/or fiberoptic endoscopic evaluation of swallowing (FEES), before allowing the patient to eat; although such evaluations are thought to minimize the risk of aspiration from swallowing impairment, they ultimately lead to a delay in receiving adequate nutrition. As an example, in one case series, only around a quarter of patients received adequate nutrition (defined as at least 75 percent of their predicted daily requirement) during the first week following extubation [101]. (See "Oropharyngeal dysphagia: Clinical features, diagnosis, and management".)

SUMMARY AND RECOMMENDATIONS

Definition – Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a patient from mechanical ventilation. (See 'Introduction' above.)

Assessment – Extubation should not be ordered until it has been determined that the patient's medical condition is stable, a weaning trial has been successful, the airway is patent, and any potential difficulties in reintubation have been identified. Most patients are extubated during daytime hours, although nocturnal extubation is appropriate in select circumstances. (See 'Assessing safety of extubation' above.)

For most patients whose medical condition is improving, who passed their spontaneous breathing trial (table 1) with normal cough strength (eg, cough peak expiratory flow >60 L/minute), Glasgow Coma Score ≥8 (table 2), and in whom suctioning is needed no less than every two to three hours, extubation is considered safe. In contrast, for most patients without any one of these features, extubation should be delayed while the etiology is corrected.

For most patients, a cuff leak does not need to be performed unless risk factors for postextubation stridor from laryngeal edema are present (eg, prolonged duration of intubation, traumatic intubation, large ETT, aspiration). (See 'Patients at risk' above.)

In patients with risk factors for postextubation stridor who have a cuff leak volume ≥110 mL or >24 percent of the delivered tidal volume, we proceed with extubation. (See 'Cuff leak' above.)

For patients with risk factors for postextubation stridor who have a reduced or absent cuff leak, we suggest administering a short course of glucocorticoid therapy at least four hours prior to extubation, rather than no glucocorticoid therapy (Grade 2B). Typical regimens include methylprednisolone (20 mg) intravenously every four hours for a total of four doses prior to extubation or a single dose of 40 mg administered four hours prior to extubation. (See 'Glucocorticoids' above.)

Technique – The equipment needed for extubation includes oral and endotracheal suction catheters and tubing, tape cutters, and a 10 mL syringe, as well as several types of oxygen delivery systems including low-flow and high-flow nasal cannulae, high-flow simple facemasks, and access to noninvasive ventilator (NIV) equipment. The patient is placed into an upright position and the ETT is removed with the cuff deflated following oral and tracheal suctioning. (See 'Extubation equipment and technique' above.)

Postextubation management – Patients should be closely monitored following extubation in the intensive care unit (ICU). (See 'Postextubation management' above.)

Low-risk of reintubation – For most patients who are at low risk of reintubation, we suggest low-flow oxygen (nasal prongs, simple, or venturi facemasks) rather than oxygen delivered via high-flow nasal cannulae (HFNC) (Grade 2C). Most patients are in this category and can be discharged from the ICU after 12 to 24 hours, provided no other indications for ICU care are present. When higher flows of oxygen are required, HFNC may offer improved oxygenation and provide a small amount of positive end-expiratory pressure (PEEP). (See 'Patients at low risk of postextubation respiratory failure' above.)

High-risk of reintubation – For patients at high risk of reintubation, aggressive monitoring and management with continued medical therapies, oxygenation, and airway clearance measures should be performed to prevent reintubation. (See 'Patients at high risk of postextubation respiratory failure' above.)

-We do not routinely extubate patients at risk of postextubation respiratory failure to NIV or HFNC, or HFNC/NIV. However, select patients at the highest risk may benefit. Practice varies significantly with much of this decision at the discretion of the treating physician/respiratory therapist. We believe the choice between observation and NIV and/or HFNC should be individualized and depend upon factors including the degree of risk and type of respiratory failure (eg, hypoxic, hypercapnic), oxygen and positive end expiratory pressure requirements of the patient, and local availability of and expertise in HFNC and NIV.

-We extubate directly to HFNC or NIV (for roughly 6 to 24 hours) in a select group of patients who are assessed as having the highest risk. For example, patients with compensated hypercapnic respiratory failure during their pre-extubation spontaneous breathing trial (eg, patients with severe chronic obstructive pulmonary disease [COPD]) and patients with cardiac failure are more likely to benefit from NIV while patents with high oxygen requirements are more likely to benefit from HFNC. Patients who benefit from NIV may also benefit from combining NIV alternating with HFNC for non-NIV periods.

Established postextubation respiratory failure – A small proportion of patients (<15 percent) develop postextubation respiratory failure, most of whom fail within the first 24 hours. As soon as it is suspected that a patient may be failing extubation, therapies targeted at the suspected etiology of respiratory failure (eg, poor secretion clearance, heart failure/ischemia, increased work of breathing) and a simultaneous trial of HFNC or NIV should be immediately implemented, rather than waiting for overt respiratory failure to occur. For patients who fail such therapy or develop definitive respiratory failure before treatment can be initiated, prompt reintubation is advised. (See 'Patients with established postextubation respiratory failure' above.)

Special populations – For many patients who undergo unplanned extubation, the threshold to reintubate should be low since 50 percent of patients require reintubation within the first 12 hours and delayed reintubation is associated with increased mortality. Careful observation is appropriate for select patients who are clinically stable, have low ventilatory and oxygenation requirements, have a patent airway, and can protect their airway. For patients whose initial trial of extubation failed due to stridor, prompt reintubation with careful examination of the upper airway and vocal cords for edema, secretions, and abnormal lesions is warranted. Suspected etiologies should be treated and extubation reattempted at a later date. (See 'Special populations' above.)

Nutrition – Following extubation, clinicians should assess the safety of refeeding. The timing of refeeding is individualized and depends upon factors including duration of intubation, mental status, and underlying comorbidities (eg, neuromuscular disorders, critical care myopathy, poor level of consciousness). Typically, most patients intubated for short periods (eg, less than one week) can generally eat within a few hours after extubation under direct supervision, while those who have been intubated for more prolonged periods or with comorbidities that increase the risk of aspiration may need formal assessment within 24 to 48 hours before feeding. (See 'Refeeding' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Kristy Bauman, MD, who contributed to earlier versions of this topic review.

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Topic 1634 Version 49.0

References

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