Two decisions share one name. At the end of an anesthetic, the question is how to take the tube out safely. In the ICU, it's whether the patient can stay extubated, and what support follows. Both end with a rescue plan.
Gate → airway risk → awake or deep → technique
Readiness → SBT → airway → reintubation risk → support
Every item is checked before the tube moves. The first three are hard stops.
Reversal is a number. Subjective fade can't be detected above a train-of-four ratio of about 0.4, so the ASA 2023 guideline calls for quantitative monitoring and a ratio of at least 0.9 before extubation.
The DAS guidelines classify every extubation as low risk or at risk before choosing a technique. Any one of these makes it at risk:
| Classification | Technique |
|---|---|
| At risk | Awake only. Consider an airway exchange catheter, supraglottic airway exchange, remifentanil infusion, or postponing extubation. State the rescue plan out loud. |
| Low risk, coughing harmful to the repair | Awake by default; deep extubation acceptable in a patient with an easy airway, no aspiration risk, and a clinician ready to rescue it. |
| Low risk | Awake extubation. |
Daily. Pair it with a sedation interruption; protocolized sedation minimization is an ATS/ACCP recommendation.
Stop the trial for any of:
A rapid shallow breathing index under 105 (Yang & Tobin) predicts success, but no single index should decide extubation on its own.
Passing an SBT proves the patient can breathe, not that they can protect the airway. Check:
Cuff-leak test, for patients at high risk of post-extubation stridor: traumatic or difficult intubation, intubation for more than 6 days, a large tube, female sex, or reintubation after an unplanned extubation.
Failed leak (a leak below 110 mL or below 12 to 24% of the delivered tidal volume): give systemic steroids at least 4 hours before extubation (for example methylprednisolone 20 mg IV 12 hours before, then every 4 hours); a repeat leak test is not required.
Hernández 2016: any one factor defines high risk. Count them; more factors, more risk.
| Risk factor |
|---|
| Age over 65 |
| APACHE II above 12 today |
| BMI above 30 |
| Poor secretion management |
| Difficult or prolonged weaning (failed the first trial) |
| Two or more comorbidities |
| Heart failure was the main reason for ventilation |
| Moderate to severe COPD |
| Airway patency problems (high risk of laryngeal edema) |
| Ventilated for more than 7 days |
The ≥1 threshold puts most ICU patients in the high-risk group, so the count matters more than the label.
| Risk | Support | Evidence |
|---|---|---|
| Low | High-flow nasal cannula, 24 h | Reintubation 4.9% vs 12.2% with conventional oxygen (Hernández 2016) |
| High | Prophylactic NIV, or HFNC | ATS/ACCP 2017 recommends preventive NIV; HFNC was noninferior to NIV for reintubation (22.8% vs 19.1%; Hernández 2016) |
| High, tolerating it | HFNC alternating with NIV | Day-7 reintubation 11.8% vs 18.2% with HFNC alone (HIGH-WEAN 2019) |
The companion tool ends with a printable handoff card carrying these four answers, the risk classification, and the support plan.