Pitfalls of difficult extubation in the ICU; when is the right time to extubate a patient?

Abstract

Extubation in the intensive care unit continues to be a problematic decision, with a fairly large number of extubations requiring reintubation, resulting in higher patient morbidity and mortality. In order to maximise success rates of tracheal extubation, it is vital to have an airway management plan in place prior to attempting extubation. As compared to the rate of reintubation after planned post-operative extubations in the Operating room (OR), reintubation following unsuccessful extubation in the Intensive care unit (ICU) is a fairly common event, occurring in up to 25% of cases. The recent literature, including retrospective studies, meta-analyses and national society guidelines, prove that extubation in the ICU remains a risk for critically ill patients. Established procedures are intended to enhance and refine respiratory mechanics and airway protection, while also preparing for an extubation strategy. Extubation in the ICU remains a non-compulsory act, depending on the clinician’s evaluation. When addressing prior difficult intubation, extubation should follow thoughtful steps, guided by an airway expert. If reintubation is needed, an easily reproducible approach should be followed, supervised by the aforementioned airway expert.