Airway extubation: a narrative review
Review Article

Airway extubation: a narrative review

Lucy T. Li1 ORCID logo, Klea Gjuzi2 ORCID logo, Puhan He3 ORCID logo, Rodrigo J. Daly Guris1 ORCID logo

1Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; 2University of Pennsylvania, Philadelphia, PA, USA; 3Department of Oral and Maxillofacial Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA

Contributions: (I) Conception and design: LT Li, K Gjuzi, RJ Daly Guris; (II) Administrative support: LT Li, K Gjuzi; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Rodrigo J. Daly Guris, MBBS, MSc, FAAP. Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, 9th Floor, Philadelphia, PA, USA. Email:

Background and Objective: Airway extubation is a fundamental component of an anesthetic but carries a risk of complications and failure associated with morbidity, particularly in specific patient populations. This narrative review aims to provide a comprehensive summary of approaches to airway extubation and special extubation strategies in the context of oral and maxillofacial surgery.

Methods: A search spanning from June 1989 to November 2023 was conducted on PubMed, Central, Cochrane Library, and UpToDate to identify publications pertaining to airway extubation. The selected publications included narrative reviews, scoping reviews, meta-analyses, approved guidelines, and cohort studies. Exclusion criteria included case reports, non-human studies, publications in languages other than English, those unavailable online, and those not related to anesthesiology or oral and maxillofacial surgery. The literature review was independently conducted by all authors and the final selection of relevant papers was reached by consensus among all authors.

Key Content and Findings: We discuss the approach to elective awake extubation and special considerations for oral and maxillofacial patients who may benefit from deep extubation, cough reduction on extubation, and delayed extubation. Special equipment and airway management techniques are highlighted for patients with a potential difficult extubation, the medically frail, and the pediatric population. We also discuss factors that can determine extubation success and complications that may occur with extubation.

Conclusions: Airway extubation is almost always an elective procedure that should be undertaken in optimal conditions. The process must be given careful consideration in an individualized manner for each patient and surgical procedure, particularly in patients who undergo oral and maxillofacial surgery.

Keywords: Oral and maxillofacial anesthesia; airway extubation; difficult airway; prolonged intubation

Received: 26 February 2024; Accepted: 17 May 2024; Published online: 14 June 2024.

doi: 10.21037/joma-24-3


Airway extubation is a critical stage of an anesthetic and an important component of a patient’s recovery from surgery. Much consideration is given to planning a safe and thoughtful anesthetic induction, and the same care must be taken as a patient undergoes the process of emergence and extubation—landing the plane requires as much expert preparation and execution as the takeoff.

However, extubation is often overlooked, with limited guidance regarding its safe practice even though it carries a high risk of complication and failure. In the United States, the American Society of Anesthesiologists Closed Claims Project found that adverse respiratory events associated with brain injury or death were more commonly related to extubation than intubation, and that while improvements were seen in intubation-related injury between the 1990s and the early 2000s, there was no improvement in extubation failure rates or severity of extubation complications (1,2). In the United Kingdom, the 4th National Audit Project found that approximately one-third of major airway complications occur at extubation or in recovery, leading to a mortality rate of 5% (3).

In addition to respiratory complications like obstruction, laryngospasm, bronchospasm, aspiration, pulmonary edema, and airway trauma, patients may undergo physiological derangements including hypertension, tachycardia, and increased myocardial oxygen consumption upon emergence from anesthesia or sedation. Together with postsurgical changes, these complications may lead to an inability to tolerate extubation, a need for reintubation, and potentially increased difficulty in resecuring the airway. Extubation failure is also more commonly associated with certain procedures and with prolonged duration of intubation. Among critically ill patients in the intensive care unit (ICU), the rate of extubation failure has been found to be as high as 25% (4).

This narrative review aims to present an in-depth overview of the available literature on airway extubation for oral and maxillofacial patients, with a focus on considerations for the delayed or difficult tracheal extubation, special equipment and airway management techniques, prediction factors, and potential extubation complications. To the best of our knowledge, this is the first paper that provides a comprehensive summary of extubation techniques for oral and maxillofacial surgeries. We present this article in accordance with the Narrative Review reporting checklist (available at


A search of PubMed, Central, Cochrane Library, and UpToDate was performed to identify publications related to airway extubation. All selected publications spanned from June 1989 to November 2023 and included narrative reviews, scoping reviews, meta-analyses, approved guidelines, and cohort studies. The literature review was conducted independently by all authors. Titles and abstracts were assessed, and those considered relevant to the paper were included in the final selection. Consensus on the selected papers was reached by discussion (Table 1, Figure 1).

Table 1

The search strategy summary

Items Specification
Date of search Nov 2, 2023
Databases and other sources searched PubMed, Central, Cochrane Library, and UpToDate
Search terms used Airway extubation, Extubation methods, Extubation instruments, Extubation standards, Extubation criteria, Extubation techniques, Extubation guidelines, Difficult airway, Difficult extubation, Extubation strategy, Pediatric patients, Deep extubation, Airway management, Airway control, Intensive care unit, Maxillofacial surgery, Oral surgery, Surgical airway, Airway exchange, Airway exchange catheter, Supraglottic airway, Tracheostomy, Cough reduction, Extubation outcomes, Extubation complications, Extubation adverse events
Timeframe June 1989 to November 2023
Inclusion and exclusion criteria All articles classified as narrative reviews, scoping reviews, meta-analyses, approved guidelines, and cohort studies were analyzed and included in the literature search. Those not published in English, not available online, not related to anesthesia techniques or oral and maxillofacial surgery, case reports, and non-human studies were not included
Selection process The selection process was conducted independently by each author. Consensus on selection was reached by discussion. Final selections were approved by the first author
Figure 1 PRISMA flow diagram of narrative review inclusion and exclusion.

Elective extubation for surgical procedures

While not all operations require tracheal intubation, those that do require an eventual extubation. That said, it is important to remember that the timing, technique, and venue of tracheal extubation are all modifiable factors. In the context of oral and maxillofacial surgery, these considerations are ever more important as the neck and supraglottic airway anatomy may be affected before, during, and after surgery.

When elective tracheal extubation is planned to take place in the operating room, there are some general principles to follow. The patient should first be assessed for both preoperative airway risk factors and new postoperative airway risk factors caused by surgical changes to the airway (5,6). The patient should have cardiovascular and physiologic stability, unimpaired respiratory function while spontaneously breathing, and no evidence of relevant neurological impairment (5). Neuromuscular blockade must be fully reversed, and the patient should receive adequate analgesia and antiemetics (5,6). Conditions should be optimized for reintubation if necessary—for example, positioning the operating room table close to the anesthesiologist and ventilator, and having all equipment required for reintubation readily available (5).

There is debate around what fraction of inspired oxygen (FiO2) should be utilized. While conventional practice has been an FiO2 of 1.0, studies have shown that this increases absorption atelectasis; a recruitment maneuver using a moderate FiO2 as low as 0.4 can decrease postoperative atelectasis (7-10). Often, the optimal patient position is in a head-up position, particularly for obese patients (6). The supraglottic airway (and, if necessary, the trachea) should be suctioned of secretions and debris to decrease the risk of laryngospasm and aspiration, and a bite block should be considered to prevent occlusion of the endotracheal tube (ETT) and subsequent risk of negative pressure pulmonary edema (5). To mitigate inevitable atelectasis, some advocate for alveolar recruitment maneuvers like providing sustained positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) while the patient emerges from anesthesia (5).

Deep extubation

Deep extubation is the process of removing the ETT while a patient remains anesthetized. As a patient emerges from general anesthesia, upper airway reflexes like the gag reflex return, and stimulation of the larynx or trachea (such as by the presence of an ETT) can lead to coughing, bucking, and breath-holding. During a deep extubation, the ETT is removed while the patient is still “deep” under anesthesia, prior to return of upper airway reflexes, to create a “smoother” emergence. While this does not guarantee that a patient will not cough on extubation, it can decrease the risk (11-13). Von Ungern-Sternberg et al. found that children who were extubated when fully awake had a higher incidence of persistent coughing at 60% compared to those who were extubated deep at 35% (P=0.03) (13). This is a useful technique when coughing on emergence could have detrimental effects due to patient-specific factors (e.g., patients with significant cerebrovascular or cardiac disease or those with hyperreactive airways) or surgical factors (e.g., airway and oral maxillofacial surgery with potential for bleeding or disruption of complex flap closures).

As deep extubation occurs before return of upper airway reflexes, appropriate patient selection is crucial. Patients who have difficult airways preoperatively or potentially postoperatively, high risk of airway obstruction (either preoperatively or due to postsurgical edema), or risk of aspiration may not be suitable candidates unless the benefits clearly outweigh the risks. Patients at an increased risk of oozing or bleeding into the airway—for example, patients with open intraoral wounds left to heal by secondary intent—may not be ideal candidates for deep extubation.

When undertaking a deep extubation, several steps should be observed to ensure success. The patient must be sufficiently deep under general anesthesia to minimize the risk of laryngospasm triggered by laryngotracheal stimulation (5). Common teaching is that, under inhalational anesthetic maintenance, the patient should be under at least one minimum alveolar concentration (MAC) of volatile agent and should not react to suctioning or jaw thrust, while breathing spontaneously with minimal or no ventilator support (5). Intravenous anesthetics or analgesics and patient-specific factors may increase or decrease the optimal MAC value for a deep extubation; deep extubations can be safely performed utilizing appropriately deep total intravenous anesthetic techniques (5). Prior to extubation, the airway should be suctioned thoroughly, and some practitioners suction under direct visualization with laryngoscopy to ensure adequate airway clearance (5). Extra care should be taken for procedures with soiling of the upper airway like nasal or oral cavity surgery, sinus surgery, and oral and maxillofacial surgery. Insertion of an airway adjunct like a nasopharyngeal or oropharyngeal airway help maintain airway patency but may act as a stimulating foreign body and perturb the surgical site (5). After extubation, patients should be observed carefully for any obstruction and need for airway support (5).

While deep extubation can decrease the incidence of coughing, there is still a risk of complications such as persistent coughing, desaturation, airway obstruction, stridor, laryngospasm, bronchospasm, aspiration, and need for reintubation (14,15). If performed carelessly, a deep extubation can conceal an inadequate level of analgesia that only presents postoperatively as the patient emerges from anesthesia in the recovery room (12). One meta-analysis found that deep extubation from an ETT or laryngeal mask airway (LMA) decreased the risk of overall airway complications [odds ratio (OR) 0.56, P=0.04], cough (OR 0.30, P=0.007), and desaturation (OR 0.49, P=0.04) in pediatric patients, but that the risk of obstruction was higher in the deep extubation group (OR 3.38, P=0.0005) (16). The analysis did not find any difference in the risk of breath-holding or laryngospasm (16). A study by Von Ungern-Sternberg et al. specifically found that there was a decreased incidence of respiratory complications in pediatric patients with awake versus deep extubation from an ETT [relative risk (RR) 0.75, P<0.0001] but increased incidence in those who had awake versus deep LMA removals (RR 1.28, P=0.001) (17).

Cough reduction on extubation

Coughing on emergence and during extubation occurs 40–75% of the time (18,19). This can lead to patient harm and surgical complications, including negative pressure pulmonary edema, mesh or drain dislodgement, and elevated intracranial or intraocular pressure. In oral and maxillofacial surgery, coughing and the associated hemodynamic effects of tachycardia and hypertension can lead to untoward effects like increased bleeding. In the setting of maxillomandibular fixation, where the upper and lower arch bars of the jaw are wired together, this significantly increases the difficulty of clearing secretions from the oropharynx. In cases of complex flap closures, coughing can lead to development of wound dehiscence or hematoma. Due to these potential adverse physiological sequelae, there has been considerable research into how to reduce the incidence and severity of coughing to achieve a “smooth emergence” (11-13).

As described above, deep extubation can be used to reduce the risk of coughing (11-17). In addition, various medications have been studied as pharmacological options for cough reduction, including dexmedetomidine, fentanyl, remifentanil, and lidocaine (which has been studied by intravenous, topical, intracuff, and tracheal routes) (5,10,19,20). A meta-analysis by Tung et al. found that all these medications had favorable odds in reducing the incidence of moderate and severe coughing on extubation compared with placebo or no medication (19). Dexmedetomidine was found to be the most effective (OR 0.17), followed by remifentanil (OR 0.21) and fentanyl (OR 0.21), intracuff lidocaine (OR 0.23), topical or tracheal lidocaine (OR 0.24), and intravenous lidocaine (OR 0.26) (19). Remifentanil was most effective at reducing severe cough, and intracuff lidocaine increased the odds of a prolonged extubation time (19). The dosages of the medications varied among the seventy studies included in the meta-analysis. Dexmedetomidine doses ranged from 0.25 to 1 µg/kg administered over various intervals of time (19). Remifentanil doses ranged from 1 ng/kg to 1 µg/kg (19).

Delayed tracheal extubation

The decision to either extubate in the operating room or delay tracheal extubation should be guided by a thorough evaluation of the patient’s ability to maintain adequate respiratory function and airway protection post-extubation with consideration for potential surgical complications. In certain circumstances, it may be advisable to delay tracheal extubation. A common reason for this in oral and maxillofacial surgery is anticipated significant swelling.

Microvascular reconstruction with free flaps is an increasingly common technique in oral and maxillofacial oncology but can result in significant postoperative edema that precludes safe extubation immediately after surgery (21). It carries a high risk of flap failure in the first 24 to 48 hours and may require urgent return to the operating room, so maintaining an ETT in place can simplify and expedite a take-back operation (21).

Odontogenic infection can compromise the airway with significant swelling. Ludwig’s angina is a potentially life-threatening infection involving the submental, sublingual, and submandibular spaces. Infection can extend from these spaces to involve the parapharyngeal and retropharyngeal spaces and descend to the superior mediastinum. Even after surgical drainage and antibiotic therapy, severe infection may necessitate maintenance of an invasive airway pending regression of airway edema (22).

Facial trauma is also associated with marked swelling and its repair may require maxillomandibular fixation, further complicating the ability to relieve airway obstruction and re-intubate the trachea. It is imperative that patients in maxillomandibular fixation always have wire cutters available at the bedside should they experience vomiting or require emergent reintubation.

The consequences of swelling are also dependent on the location of the surgery (23). Surgery along the lateral aspect of the mandible, maxilla, or zygoma may lead to swelling, but the edema is unlikely to affect airway management, whereas surgery along the medial aspect of the mandible, submandibular region, or parapharyngeal space has a higher risk of causing swelling that may result in airway compromise (23).

Regardless of etiology, it is reasonable to consider extubation after swelling and risk for urgent re-operation have decreased (24,25). Previously, tracheostomy was widely used electively to secure the airways of high-risk patients, especially as intubation and reintubation in these patients can prove challenging (26,27). However, tracheostomy is not without complications, ranging from recurrent laryngeal nerve injury, esophageal damage, infection, pneumonia, hemorrhage, obstruction, difficulties with feeding and speech, tracheal stenosis, and increase in length of hospital stay, so there is increasing interest in delayed naso- or orotracheal extubation in the ICU postoperatively as an alternative to tracheostomy (21,26-30). A British study compared elective tracheostomy versus overnight intubation for patients who underwent intraoral cancer resection and subsequent reconstruction with a free flap (29). Compared to the tracheostomy group, the overnight intubation group had decreased time to feeding by mouth, decreased length of ICU stay, decreased length of hospital admission, and decreased rate of lower respiratory tract infections (29). Video-laryngoscopy and video-assisted flexible bronchoscopy have also helped mitigate the perceived need for tracheostomy placement (27,31).

Laryngeal and subglottic stenosis are common complications arising from prolonged intubation (32). Selecting the appropriately sized ETT for the patient at the time of intubation is crucial to minimizing risk. While intubated, employing protective ventilation strategies, including low tidal volume ventilation and avoidance of excessive ETT cuff pressures, can mitigate trauma to the airway mucosa. Use of humidification systems also helps to maintain mucosal integrity and reduces the likelihood of stenosis (28).

Difficult tracheal extubation

Difficult tracheal extubation refers to difficulties encountered with the airway, oxygenation, and ventilation after extubation. The Difficult Airway Society of the United Kingdom has published algorithms for the extubation of difficult airways that stratify patients as low- or at-risk (5). In the at-risk algorithm, patients deemed unsafe for extubation should have their extubation postponed or a surgical airway should be considered (Figure 2).

Figure 2 Difficult Airway Society extubation guidelines for the “at-risk” patient. Reproduced from (5), with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd. DAS, Difficult Airway Society; HDU, high-dependency unit; ICU, intensive care unit.

In the case of patients who have a delayed or potentially difficult tracheal extubation, consideration should be made as to whether the extubation should take place in the ICU or the operating room. An operating room setting can offer superior conditions compared to an ICU for emergent reintubation of a challenging airway due to availability of a wider range of airway equipment, fewer distractions, and proximity of clinicians—both anesthesiologists and surgeons—with advanced airway skills.

Of note, various equipment and techniques can be utilized to assist with a potentially difficult extubation, which will be discussed in a following section.

The medically frail patient

While significant emphasis has been placed on ensuring safety during intubation of critically ill patients, strategies to prevent potential failures during extubation are often neglected. In ICU patients, tracheal extubation has a 10% to 25% failure rate necessitating reintubation, which is a considerable source of morbidity and mortality (4,33).

To prepare for the potentially difficult or failed extubation, an extubation strategy should be built (34). According to a review by Joffe and Barnes, medically frail patients at risk for extubation failure should be approached with a pre-established plan encompassing the timing and method of extubation, along with considerations for reintubation (34). Another study by Tanaka et al. found that the use of the prediction of successful extubation (POSE) model among critically ill patients with successful spontaneous breathing trials (SBT) can be used to predict the outcome of extubation in medically frail patients (35). The POSE model considers the following eight variables as predictors: age, underlying or new heart failure, underlying respiratory disease or pneumonia, rapid shallow breathing index, fluid balance over the preceding 24 hours, PaO2/FiO2, Glasgow Coma Scale, and the count of endotracheal suctioning episodes within the preceding 24 hours (35,36).

To prevent adverse events, clinicians should establish a framework based on three essential elements for a safe extubation: ensuring appropriate respiratory mechanics, optimizing contributory comorbidities, and assessing the mechanical ability to safeguard the airway. Strategies for at-risk patients may involve transitioning to noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), or considering an airway exchange catheter (AEC) (37,38). A study by Thille et al. highlighted the benefits of utilizing a combination of NIV and HFNC following extubation in high-risk individuals; specifically, this approach proved advantageous for elderly patients and those with pre-existing chronic cardiac or respiratory conditions (39). Upon extubation, there should be vigilant monitoring for signs of impending respiratory failure such as increased respiratory rate, tachycardia, diaphoresis, worsening oxygenation, or persistent respiratory distress (e.g., intercostal or sternoclavicular retractions).

Patients who require prolonged postoperative intubation may develop laryngeal edema and post-extubation stridor. The cuff-leak test, where the presence of a leak around the ETT with the cuff deflated is interrogated, has been used as a barometer for upper airway obstruction upon extubation (40). While a negative test (presence of a leak) has been found to be a sensitive predictor of successful extubation and a positive test (absence of a leak) may identify patients at a higher risk of obstruction, presence of a leak does not definitively guarantee extubation success and absence of a leak does not preclude a patient from a successful extubation (41-43).

The pediatric patient

General good practice for the tracheal extubation of infants and children is not drastically different from that of adults, but there are some unique differences that are worth considering.

Whereas in adults, awake extubation is often marked by an ability to respond to verbal commands, this can be challenging to assess in pediatric patients. Templeton et al. studied factors that best predict readiness for and success of awake extubation in pediatric patients less than 7 years old (44). The most important factors were presence of facial grimace, eye opening, conjugate gaze, purposeful movement, and a tidal volume of greater than 5 mL/kg (44). None of the five factors were noted to be superior to the others, so a multifactorial approach should be undertaken, as presence of more of the five criteria led to a greater likelihood of extubation success (44).

With regards to emergence from anesthesia, children are susceptible to emergence agitation, which may lead to undesirable effects on hemodynamics or the surgical site (45). While mitigation of emergence agitation is beyond the scope of this review, it is worth noting that most pharmacologic strategies lead to a degree of sedation. As such, any administration of medications to ameliorate emergence agitation should be undertaken judiciously.

It is also important to recognize that the risk of laryngospasm associated with airway management is about double in children and triple in infants when compared to adults, and a pediatric tracheal extubation strategy should always include preparation to treat laryngospasm (46).

Shifting the focus to tracheal extubation in the pediatric ICU, as in the adult population, an SBT should be performed for these patients (47,48). A study by Eissa et al. showed that an extubation bundle incorporating a modified SBT demonstrated a sensitivity and positive predictive value of >90% for successful tracheal extubation in premature infants between 24 to 30 weeks gestational age (48). Quintard et al. note that there are limitations of the SBT and recommend exploring further risk factors, such as altered consciousness, ineffective cough, excessive airway secretions, and swallowing disorders prior to extubation (47). Additionally, NIV can be used to prevent reintubation, either prophylactically upon extubation or as a therapy for respiratory distress after extubation (47,49).

With regard to extubation of the known pediatric difficult airway, a single center study by Jagannathan and colleagues found a high rate of operating room extubation success without airway adjuncts but a 5% rate of extubation failure (50). Of the failed extubations, all but one had severe upper respiratory obstruction and weighed less than ten kilograms (50). This highlights a very important truth about the pediatric airway: the risk of obstruction due to edema is inversely related to the size of the airway lumen. As such, infants and children with suspected swelling along the respiratory tract should be treated with the utmost of caution.

Equipment and techniques


AEC can be used in patients who have undergone oral and maxillofacial surgery with potential difficult reintubation as a means for continuous airway access (51). AEC are long and thin with length markings on the exterior so depth of insertion can be easily measured. As they are hollow, they can be used to administer oxygen via anesthesia circuits or jet ventilators, though they are not effective conduits for ventilation. Prior to extubation, the AEC is inserted into the airway through the ETT, with the distal tip positioned in the mid-trachea. The ETT is removed, and the AEC should be secured to the patient’s forehead or cheek with tape, taking care to note the depth of the AEC relative to the patient’s nose, lips, or teeth (52). The AEC should be carefully labeled to distinguish it from other lines and drains (e.g., a nasogastric tube), and the patient should be taken to the appropriate recovery area with staff that are comfortable with managing an AEC. The patient should not take anything by mouth until the AEC is deemed safe to remove once the patient is no longer at risk of urgent reintubation. If the patient coughs from discomfort, the distal tip should be checked to ensure it is above the carina. If correctly positioned, intravenous lidocaine 1%, 1 mg/kg, can be injected via the AEC to help with patient tolerance (53). AECs have been tolerated for up to 72 hours (54).

If the patient requires reintubation, the AEC serves as a guide over which the ETT can be railroaded and the patient can be oxygenated temporarily prior to or during this process via the AEC, although this should be done with care due to the risk of barotrauma (5). If necessary to facilitate an adequate facemask seal and administer CPAP, the AEC can be moved to the corner of the mouth. While passing an ETT over the AEC, it is beneficial to use laryngoscopy to displace the tongue and epiglottis and directly visualize the reintubation. Studies have shown a high first-pass success rate at reintubation via an AEC (54,55).

Complications include barotrauma, perforation of the trachea, and dislodgement. While AECs have been used in children with known difficult airways for extubation trials, it is important to note that AEC are unlikely to be well-tolerated by children, the narrower caliber of pediatric AECs makes them relatively easy to dislodge from the airway during an attempted reintubation, and children’s relatively fragile tracheal mucosa may be more easily perforated (53).

Submental intubation

Submental intubation is also known as the transmylohyoid intubation (Figure 3). To perform this, a patient undergoes standard orotracheal intubation with a wire-reinforced ETT. The ETT is then passed through the floor of the mouth via surgical incision through the mylohyoid (56). It is advantageous particularly for management of facial fractures in oral and maxillofacial anesthesia, as an oral ETT can interfere with correction of midface fractures and a nasal ETT can impede stabilization of nasal fractures (57,58). Along with unimpeded access to the nasal and oral airways, it also allows for maxillomandibular fixation (59). This technique can also minimize the need for tracheostomy for patients who benefit from a surgical airway for an operation but do not require prolonged postoperative intubation and ventilatory support (31). To extubate, the ETT and the deflated pilot balloon are withdrawn through the mylohyoid and then removed out of the mouth (59).

Figure 3 Submental intubation with an ETT. Source: (56) (open access). ETT, endotracheal tube.

Front-of-neck access (FONA)

FONA, either as a tracheostomy or a cricothyroidotomy, is the final common pathway of most difficult airway algorithms. As such, it must always be considered as an option in the case of failed tracheal extubation; in patients at high risk of airway compromise with extubation or an anticipated need for prolonged airway intubation, it can be considered as an elective intermediate step.

Supraglottic airway-facilitated tracheal extubation

Replacement of an ETT with an LMA prior to emergence, or the Bailey maneuver, has been utilized to reduce the risk of airway obstruction and other respiratory complications (5,60). The LMA maintains patency of the supraglottic airway and protects it from secretions in the mouth but is far less stimulating than an ETT. This technique can be employed in cases where the hemodynamic responses to stimulation from the presence of an ETT are undesirable for either surgical or patient-specific reasons and can be beneficial in patients with hyperactive airways like asthmatics or smokers. This technique should not be used in patients at high risk of aspiration.

An intubating LMA that serves as a conduit for trans-LMA intubation can be utilized in patients with a suspected postoperative difficult airway; in this way, the LMA serves as a device through which an emergent reintubation can be performed if extubation fails (5,61). Of note, not all LMAs can serve as a conduit for intubation, so careful selection should be made if the need for expedient reintubation is anticipated.

Prediction factors for extubation outcomes

Despite the growing acknowledgment that extubation of a difficult airway poses a risk of severe complications, standards for ensuring safe extubation practices rely on limited consensus and evidence (62). Given that the incidence of extubation failure is higher in patients undergoing head, neck, and oral and maxillofacial surgeries, with reintubation rates estimated to be between 0.7% and 11.1%, studies have examined this population to determine factors that can be used to predict extubation outcomes (59,62,63). Risk factors for adverse airway extubation events include head and neck pathology, history of neck radiation, postradiation airway edema, and impairment of lymphatic drainage secondary to neck dissection (38,62-64). A retrospective study by Huang et al. found that two machine-learning models demonstrated potential to predict risk of extubation failure in patients receiving head, neck, and oral and maxillofacial surgeries (63). The two models included five variables: American Society of Anesthesiologists physical status classification, history of neck radiation, history of maxillofacial surgery, surgical blood loss, and anemia (63). Cameron et al. developed a scoring system to stratify at-risk patients to different postoperative airway management strategies after major head and neck surgery (65). Scores were assigned based on tumor location and whether mandibulectomy, neck dissection, or reconstruction were performed, and were used to assign patients to elective extubation in the operating room at the conclusion of the surgery, to remain intubated for the first postoperative day and night, or elective tracheostomy (65). It should be noted that prediction models can be useful aids in decision-making but should not replace clinical judgment.

Complications after extubation

Airway extubation in most patients is an uneventful procedure, but complications may arise that lead to serious morbidity and even death. Breath-holding, coughing, and bucking are common responses to the presence of an ETT as a patient emerges from anesthesia. Laryngospasm and bronchospasm can occur and lead to hypoxic cardiac arrest if not treated. There is increasing evidence that maintenance of total intravenous anesthesia with propofol may decrease the incidence of laryngospasm (5). Airway obstruction secondary to reduced muscle tone is particularly common in patients with obesity and sleep apnea and can be worsened by injudicious use of opioids or sedatives, as well as residual neuromuscular blockade (5). Aspiration can also occur in patients if there is insufficient return of upper airway reflexes.

Desaturation may occur due to exaggerated or reduced airway reflexes, or secondary to pulmonary compromise from hypoventilation, atelectasis, and reduced functional residual capacity. Complications in other physiologic systems like hemodynamic instability, electrolyte or metabolic derangements, and neurologic dysfunction can also contribute to hypoxia.

In oral and maxillofacial patients, several potential extubation complications should be given special attention. As described earlier, due to the location of the surgery itself, significant airway swelling can occur (23). Bleeding can occur during maxillofacial surgeries due to the rich blood supply in the head and neck region, and hematoma formation or hemorrhage can lead to postoperative airway compromise (66). Airway compromise secondary to iatrogenic complications such as airway swelling and compression from hematoma often do not present until after airway extubation.

Orthognathic surgery has a higher rate of postoperative nausea and vomiting—59.4% of patients experience nausea and 28.4% experience vomiting, compared to 30% of patients receiving general surgery—which can contribute to an increased risk of aspiration, especially if maxillomandibular fixation is in place (66,67). Throat packs placed by the surgeon to shield the airway from blood, saliva, and surgical debris must be accounted for carefully. Their removal must be confirmed prior to maxillomandibular fixation and extubation to prevent them from being left behind as a foreign body in the airway at the end of the surgery (66).

It should be noted that there are many human factors surrounding the period of extubation that can also contribute to complications. While induction of anesthesia is usually undertaken in a controlled and well-coordinated environment, the operating room environment is often not as favorable at the time of emergence and extubation, with personnel who may be fatigued and under production pressure, and with increased noise and distractions (68,69). All of these can contribute to worsening of airway complications after extubation.


Airway extubation is a key component in an anesthetic, but it should only be undertaken when conditions are optimized. Every patient should have an individualized plan for extubation that accounts for their unique characteristics, medical comorbidities, surgery, and potential changes to the airway secondary to the procedure; this is of heightened importance after oral and maxillofacial surgery. Together, these factors also provide an estimate of the risk of extubation and help determine if it requires special equipment or techniques or if the safest course of action is to delay extubation.


The authors would like to thank Annery Garcia-Marcinkiewicz, MD, Children’s Hospital of Philadelphia, and Eric Granquist, DMD, MD, Children’s Hospital of Philadelphia, for editorial assistance in preparing the manuscript.

Funding: None.


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doi: 10.21037/joma-24-3
Cite this article as: Li LT, Gjuzi K, He P, Daly Guris RJ. Airway extubation: a narrative review. J Oral Maxillofac Anesth 2024;3:10.

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