Anaesthesia, 2005, 60, pages 995–1001 doi:10.1111/j.1365-2044.2005.04235.

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Airway management before, during and after extubation:

a survey of practice in the United Kingdom and Ireland
S. Rassam,1 M. SandbyThomas,1 R. S. Vaughan2 and J. E. Hall3
1 Specialist Registrar, 2 Consultant Anaesthetist, 3 Senior Lecturer, Anaesthetic Department, University Hospital of
Wales, Heath Park, Cardiff CF14 4XW, UK

Summary
Complications at extubation remain an important risk factor in anaesthesia. A postal survey was
conducted on extubation practice amongst consultant anaesthetists in the United Kingdom and
Ireland. The use of short acting drugs encourages anaesthetists to extubate the trachea at lighter
levels of anaesthesia. The results show that oxygen (100%) is not routinely administered either
before extubation or en route to the recovery area. A trend towards a head up or sitting position at
extubation is emerging. However, further research into the use of these positions is required.
Airway related complications at extubation are relatively frequent but are usually dealt with by
simple basic measures. The role of drugs such as propofol in decreasing the incidence of these
complications needs further evaluation. Some of these results give concern for patient safety and for
training. The importance of teaching and adherence to continued oxygenation until complete
recovery is strongly emphasised. Nerve stimulators should be used continually as standard moni-
toring throughout the anaesthetic period when muscle-relaxing drugs are part of the anaesthetic
technique.
. ......................................................................................................
Correspondence to: Ralph S. Vaughan
E-mail: ralphvaughan@btopenworld.com
Accepted: 7 April 2005

It has been shown that there are more adverse incidents survey were twofold. The first was to ascertain extubation
associated with extubation than intubation and these are practices with regard to the type of surgery, timing,
occurring not only during extubation itself, but also position and techniques. The second was to estimate the
during the time spent in the recovery room [1–5]. The incidence of problems associated with extubation and
increased incidence of complications has been correlated how these were treated.
with the pre-operative physical status, depth of anaesthe-
sia at extubation, increasing age and gender with a male
Methods
preponderance [2, 6]. These complications remain con-
sistent regardless of the type of operation [1]. A postal survey was conducted in May 2004. A total of 845
The problems associated with extubation may be Consultant Anaesthetists were randomly selected from the
broadly categorised into cardiovascular and respiratory membership database of the Association of Anaesthetists of
complications. Cardiovascular complications include Great Britain and Ireland (AAGBI). These anaesthetists
tachycardia, hypotensive and hypertensive episodes [7– were sent the questionnaire, which they were asked to
10], which may be significant in patients with pre-existing complete and return anonymously in the stamped,
ischaemic heart disease [11, 12], pre-eclampsia [13] and in addressed envelope provided. The questionnaire (Fig. 1)
those undergoing neurological procedures [14]. Respirat- was a structured document with a tick-box format for the
ory complications include local trauma, coughing, desat- most appropriate answer(s) but also gave room for expan-
uration, breath-holding, masseter-spasm, laryngospasm, sion or open comments if necessary. There were four main
airway obstruction and aspiration [7, 15–18]. sections:
An on-line journal search revealed a lack of recent • Section one aimed to ascertain the anaesthetic experi-
investigations or statistical data in these areas. This survey ence of the respondents and the techniques used before
was performed with this in mind. The main aims of the performing extubation.

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Figure 1 Questionnaire form (survey of airway management after extubation).

• Section two dealt with the timing of extubation in a

Results
variety of situations.
• Section three explored the extubation techniques and A total of 845 questionnaires were sent out and 593
positioning of the patient used during extubation in questionnaires were returned (70% response rate). The mean
emergency or elective cases and in the obese patient. number of years of experience in anaesthesia was 20 (range
• Section four was concerned with complications of 7–38 years). The experience of the respondents was similar
extubation and subsequent treatment. to the study population. The levels of anaesthesia targeted at
Responses to the questions provided descriptive extubation are given in Table 1. The majority of respond-
information about extubation techniques, positions and ents indicated that extubation was performed with the
complications. patient either awake or while at a light plane of anaesthesia.

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Anaesthesia, 2005, 60, pages 995–1001 S. Rassam et al. Æ Airway management and extubation
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Figure 1 (Continued).

The management of tracheal extubation and position of

Table 1 Level of anaesthesia at extubation. Data are expressed in
the patients at extubation are shown in Tables 2 and 3,
percentages (%).
respectively. The majority of respondents stated that they
used 100% oxygen and reversed the muscle relaxant while
Always awake 31%
Light anaesthesia 22% still in the operating theatre before extubation, which was
Always deep 2% performed at the end of inspiration. Of all respondents,
Variable levels
18% stated that they occasionally used a nerve stimulator
Awake if indicated* 28%
Deep if indicated* 17% to guide their practice. In elective surgery, the supine and
head up positions were generally used, with the latter
*Examples are shown in Fig. 1. favoured, particularly in the obese. However, in the

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Table 2 Management of tracheal extu-

Always Mostly Occasionally Never bation and transfer to the Recovery
Room. Data are expressed as percentage
100% oxygen for 2–5 min prior to extubation 54 32 10 4 (%).
Reversal agents* 32 37 13
Direct laryngoscopy and suction 11 20 44 25†
Trachea extubated at end of inspiration‡ 30 33 35
Trachea extubated in the theatre 65 26 9
Exchanging the LMA for a tracheal tube 0 8 26 73
Transfer to recovery area breathing oxygen– 63 18 14 4

*18% guided by nerve stimulator, †suction only, ‡4 not completed, –3 not completed.

Table 3 Position(s) at extubation. Table 5 Treatment methods at extubation and their frequency.

Left Left lateral Complication(s)

Category Head up Supine lateral and head down treated with: n

Elective* 171 334 121 24 Oxygen 413

Emergency* 78 90 312 140 Jaw support 294
Obesity* 338 79 152 30 Airway 112
Propofol 41
Midazolam 5
*The total number is > 593 as more than one position was selected.
Reversal drugs 47
Suxamethonium 23
Table 4 Incidence of complications at extubation. Re-intubation 20
CPAP 49

Complications n (%)

Level of anaesthesia before extubation (timing

Coughing 81 (18)
Breath holding 65 (13)
of extubation)
Airway obstruction 27 (5.5) It has been shown that the incidence of respiratory
Laryngospasm 123 (25) complications after tracheal extubation is higher when the
Desaturation (< 94%) 105 (22)
Inadequate reversal 49 (10)
patient is deeply anaesthetised regardless of the type of
Apnoea 10 (2) operation performed [1, 6]. On the other hand, tracheal
Vomiting 12 (2) extubation under deep anaesthesia has been recommen-
Aspiration 3 (0.5)
Haemodynamic instability 10 (2)
ded in operations where avoiding the responses to
Total 485
extubation is thought to be beneficial [3, 6]. These
patterns are reflected in this survey.
The vast majority of anaesthetists performed extubation
emergency patients, the use of the lateral position was with the patient awake, although 22% extubated the
significant. trachea at a light level of anaesthesia. In the accompanying
Problems after tracheal extubation during the pre- comments, the latter technique was related to the use of
ceding three months were reported by 219 anaesthetists short acting anaesthetic drugs and many considered this
(37%) and a total of 485 problems were recorded. The level of anaesthesia at extubation rather similar to the
incidences and management of complications at tracheal awake category. A recent editorial by Asai [19] highligh-
extubation are shown in Tables 4 and 5, respectively. ted the importance of removing supraglottic airways only
The incidence of post extubation problems was pre- after the patient spontaneously regained consciousness
dominantly linked to the respiratory system, with approxi- to avoid vomiting and pulmonary aspiration. Similarly,
mately 16% reporting a decrease in saturation (i.e. below at tracheal extubation, it is equally important not to
94%). The majority of patients were treated by simple precipitate airway irritation as this could provoke vom-
techniques. However, intravenous agents were also used. iting, laryngeal spasm and aspiration of stomach contents.
Only 2% used deep levels of anaesthesia as the preferred
option for tracheal extubation.
Discussion
The results show that complications at extubation remain Managing tracheal extubation
an important risk factor in anaesthesia and raise some areas The questions referring to the management of tracheal
of concern. extubation in both the awake and deeply anaesthetised

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patients were based on guidelines suggested by Hartley exchanging the laryngeal mask for a tracheal tube is a well
[20]. recognised method of avoiding problems at extubation
These guidelines were not universally followed and [23]. The reported occasional use of this technique in this
there were several major deviations including: survey is 26%. Obviously, the use of an airway and deep
• The recommended use of 100% oxygen before extu- anaesthesia can achieve the same goal. However, in the
bation. This was only administered in every case by paralysed patient with a high risk of upper airway
54% of anaesthetists. sensitivity, replacing the tracheal tube with laryngeal
• Nerve stimulators were used by only 18% of anaes- mask can provide a gradual transit to a spontaneous
thetists. breathing state and smooth extubation conditions.
• The reservoir bag, with the Airway Pressure Limiting
Valve (APL) closed, was always squeezed by 30% of Patient position at extubation
anaesthetists just before extubation. In elective operations, extubation was more frequently
• Transfer to recovery area with the patient breathing performed in the supine and head up positions. In
oxygen-enriched air was always administered by 63% emergency operations the left lateral position was usually
of respondents. chosen. In obese patients, however, most anaesthetists
Some anaesthetists argued that administering 100% preferred a head up or sitting position before tracheal
oxygen before extubation was not required following extubation followed by the left lateral position (Table 3).
minor operations and in fit patients. Some also said that This is a changing trend and has been highlighted
the non-adherence to breathing oxygen-enriched air in recent articles [2, 26]. The factors that have been
during transfer was related to the near location of the suggested to contribute to this change include: better
recovery rooms. patient preparation, more provision of pre-operative clear
The routine use of oxygen before extubation, after fluids, obesity, chronic smoking induced lung diseases,
extubation and during transfer to the recovery room is a and the increased use of the laryngeal mask and its
simple safety measure used in anaesthesia. Airway prob- association with a lighter level of anaesthesia. Other
lems can arise unexpectedly, even in the fit spontaneously factors include the use of short acting anaesthetic drugs,
breathing patient. The onset of hypoxia can be delayed better equipment in recovery areas, staff training and
by first breathing 100% oxygen followed by oxygen- anaesthetists availability and, finally, familiarity in securing
enriched air en route to the recovery room and this will the airway in the supine position should that became a
allow a longer time to institute other necessary therapy. necessity. It is obviously difficult to recommend from the
If nitrous oxide has been used during anaesthesia, the current available evidence the best position at extubation
treatment of diffusion hypoxia is to administer oxygen. If as it may vary between individual patients. As this survey
consultants are not using oxygen at these times, does it represents a large sample of experienced anaesthetists,
mean that their trainees are not being taught this valuable the results confirm that a change in patient position at
safety measure? extubation is emerging.
Incomplete reversal of muscle relaxation was reported
as being related to complications at extubation in 22% of Complications at extubation and management
incidents. The use of nerve stimulators is recommended Major airway and respiratory complications are still com-
by the AAGBI [21] whenever muscle relaxant drugs are mon. Of particular interest, the incidence of laryngeal
used during anaesthesia. As nerve stimulators are generally spasm was 20% of the total complications. This is a much
available, this should be a preventable complication. higher percentage than the previously reported incidence
The practice of squeezing the reservoir bag with the APL of less than 1% [27]. However, minor degrees of airway
valve closed before extubation is a simple basic manoeuvre. irritation could also have been reported as laryngeal
The positive pressure generated before removing the spasm. This assumption is supported indirectly by the
tracheal tube helps to prevent secretions from tracking into relatively simple measures used to treat the conditions, i.e.
the laryngeal inlet and potentially precipitating laryngeal additional oxygen with or without an airway in most
spasm. An increase in the use of this manoeuvre may help to cases. Nevertheless, the frequent reporting has at least
reduce peri-extubation problems. demonstrated the high incidence of airway complications
The use of the laryngeal mask is one possible way of at extubation. It is also evident that simple measures are
decreasing the incidence of complications in both tracheal usually enough to manage the situation, highlighting the
intubation and extubation [22, 23]. In spite of the low importance of basic skills for all anaesthetists and partic-
incidence of aspiration associated with the laryngeal ularly recovery staff.
mask [24], it should be used with caution in patients Propofol is claimed to be a useful drug to treat laryngeal
at increased risk of aspiration [25]. The practice of spasm [28]. In this survey, as only 8% use TIVA, a

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S. Rassam et al. Æ Airway management and extubation
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relationship between the type of anaesthetic (inhalational
vs. intravenous) and the incidence of laryngeal spasm or
respiratory complications cannot be inferred. A further
study to investigate the effect of propofol in decreasing
the incidence of post extubation respiratory complications
needs to be performed.
Suxamethonium chloride was used in the treatment of
complications arising after extubation in 10% of cases.
Consequently, its use in managing certain problems after
extubation still seems appropriate. It appears sensible that
succinylcholine chloride availability remain a standard
practice at all locations where anaesthesia is administered
[29, 30].
There was a reported incidence of vomiting greater
than 2%. Unfortunately, no correlation can be made
between vomiting and any single factor from this survey.
However, the calculated incidence of aspiration in this
survey was 0.05%. This level is at the higher end of the
accepted range of between 0.02% and 0.06% [27]. In a
recent article [24], the complications following aspiration
were significant. Of 20 specific worldwide reports relating
to anaesthesia, the laryngeal mask and pulmonary aspir-
ation, one patient died and one was left brain damaged.
Consequently, vomiting and subsequent aspiration should
always be considered following extubation, particularly in
the at risk patient.
It is agreed that the anaesthetist is responsible for his
or her patient from induction to full recovery [31]. If
complications do arise after extubation which cause
permanent injury, it follows that it is the anaesthetist
who is responsible and therefore potentially liable. Thus,
the training and techniques for extubation should be
evidenced based. The authors strongly reinforce the
recommendation made by Asai that the new emerging
methods used at extubation should be well researched and
used appropriately for the benefit and safety of patients.
Acknowledgements
We would like to thank the Association of Anaesthetists
of Great Britain and Ireland and all the consultants who
responded to the questionnaire.
References
1 Asai T, Koga K, Vaughan RS. Respiratory complications
associated with tracheal intubation and extubation. British
Journal of Anaesthesia 1998; 80: 767–75.
2 Beard K, Jick H, Walker AM. Adverse respiratory events
occurring in the recovery room after general anesthesia.
Anesthesiology 1986; 64: 269–72.
3 Miller KA, Harkin CP, Bailey PL. Postoperative tracheal
extubation. Anesthesia and Analgesia 1995; 80: 149–72.
1000
Anaesthesia, 2005, 60, pages 995–1001
4 Hines R, Barash PG, Watrous G, O’Connor T. Compli-
cations occurring in the postanesthesia care unit. Anesthesia
and Analgesia 1992; 74: 503–9.
5 Peskett MJ. Clinical indicators and other complications in
the recovery room or postanaesthetic car unit. Anaesthesia
1999; 54: 1143–9.
6 Parr SM, Robinson BJ, Glover PW, Galletly DC. Level of
consciousness on arrival in the recovery room and the
development of early respiratory morbidity. Anesthesia and
Intensive Care 1991; 19: 369–72.
7 Hartley M, Vaughn RS. Problems associated with tracheal
extubation. British Journal of Anaesthesia 1993; 71: 561–8.
8 Edde RR. Cardiovascular responses to extubation. Anes-
thesiology 1979; 51: S195.
9 Dyson A, Isaac PA, Pennant JH, Giesecke AH, Lipton JM.
Esmolol attenuates cardiovascular responses to extubation.
Anesthesia and Analgesia 1990; 71: 675–8.
10 Wohlner EC, Usubiaga LJ, Jacoby RM, Hill GE.
Cardiovascular effects of extubation. Anesthesiology 1979;
51: S194.
11 Elia S, Liu P, Chrusciel C, Hilgenberg A, Skourtis C, Lappas
D. Effects of tracheal extubation on coronary blood flow,
myocardial metabolism and systemic haemodynamic
responses. Canadian Journal of Anaesthesia 1989; 36: 2–8.
12 Wellwood M, Aylmer A, Teasdale S, et al. Extubation and
myocardial ischaemia. Anesthesiology 1984; 61: A132.
13 Hodgkinson R, Husain FJ, Hayashi RH. Systemic and
pulmonary blood pressure in parturients with gestational
hypertension. Canadian Anaesthetists Society Journal 1980; 27:
389–93.
14 Muzzi DA, Black S, Losasso TJ, Cucchiara RF. Labetolol
and Esmolol in the control of hypertension after intracranial
surgery. Anesthesia and Analgesia 1990; 70: 68–71.
15 Castella X, Gilabert J, Perez C. Arytenoid dislocation after
tracheal intubation: an unusual case of acute respiratory
failure? Anaesthesiology 1991; 74: 613–5.
16 Chatterji S, Gupta NR, Mishra TR. Valvular glottic
obstruction following extubation. Anaesthesia 1984; 39: 246–
7.
17 Blanc VF, Tremblay NAG. The complications of tracheal
intubation: a new classification with a review of the litera-
ture. Anesthesia and Analgesia 1974; 53: 202–13.
18 Burgess GE, Cooper JR, Marino RJ, Peuler MJ, Warriner
RA. Laryngeal competence after tracheal extubation.
Anaesthesiology 1979; 51: 73–7.
19 Asai T. Who is at increased risk of pulmonary aspiration?
British Journal of Anaesthesia 2004; 93: 497–500.
20 Hartley M. Difficulties at tracheal extubation. In: Latto IP,
Vaughn RS, eds. Difficulties in Tracheal Intubation, 2nd edn.
London: W.B. Saunders, 1997: 347–70.
21 Association of Anaesthetists of Great Britain and Ireland.
Recommendations for Standards of Monitoring during Anaesthesia
and Recovery. London: Association of Anaesthetists, 2000
[WWW document]. http://www.aagbi.org.
22 Silk JM, Hill HM, Calder I. Difficult intubation and the
laryngeal mask. European Journal of Anaesthesiology Supplement
1991; 4: 47, 51.

2005 Blackwell Publishing Ltd
Anaesthesia, 2005, 60, pages 995–1001 S. Rassam et al. Æ Airway management and extubation
. ....................................................................................................................................................................................................................

23 George SL, Blogg CE. Role of the LMA in tracheal extu-
bation? British Journal of Anaesthesia 1994; 72: 610.
24 Brimacombe J, Berry A. The incidence of aspiration asso-
ciated with the laryngeal mask airway – a meta-analysis of
published literature. Journal of Clinical Anesthesia 1995; 7:
297–305.
25 Keller C, Brimacombe J, Bittersohl J, Lirk P, von Goedecke
A. Aspiration and the laryngeal mask airway: three cases and
a review of the literature. British Journal of Anaesthesia 2004;
93: 579–82.
26 Vaughan RS. Extubation – yesterday and today. Anaesthesia
2003; 58: 945–50.
27 Olsson GL, Hallén B. Laryngospasm during anaesthesia;
a computer-aided follow-up study in 136,629 patients.
Acta Anaesthesiologica Scandinavica 1984; 28: 567–75.
28 Nawfal M, Baraka A. Propofol for relief of extubation
laryngospasm. Anaesthesia 2002; 57: 1036.
29 Gurung AM, Tomlinson AA. Pre-preparation of succinyl-
choline: significant waste for questionable benefit. Anaes-
thesia 2004; 59: 211–2.
30 Vaughan RS. Preparation of succinylcholine. Anaesthesia
2004; 59: 824–5.
31 Taylor T. Postoperation recovery. Medical Protection Society
Journal 1996; 7: 4–7.

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