Extubation

What is extubation?

Extubation is a procedure where your healthcare provider removes an endotracheal tube (or ETT) from your throat and windpipe. An ETT is used to help you breathe when you can’t breathe on your own either due to surgery, injury or illness. Once your healthcare team determines you can once again safely breathe on your own, they remove the tube. This is extubation.

What is intubation?

Intubation is when your provider places a tube through your mouth and into your trachea (airway/windpipe). The tube keeps your trachea open so air can get through. The tube connects to a machine that delivers oxygen. Healthcare providers usually intubate people in a hospital during an emergency or before surgery.

When do people get extubated?

There are several reasons you may not be able to breathe on your own. Your healthcare team will need to intubate you so you can get the air you need. Extubation happens once your healthcare team is certain you can breathe on your own. This happens at a different point in time for everyone, depending on the reason for intubation and how stable you are.

Medications that help put you to sleep (general anesthesia) during surgery can affect your breathing. This is a common reason your surgeon places an endotracheal tube before a surgical procedure. Once surgery is over, you’re usually able to breathe on your own so the tube is taken out. In these cases, you may only have a breathing tube for an hour or so. In other cases, you may stay intubated while you recover in the hospital. Your provider takes certain precautions to make sure you transition well to breathing normally again. By the time you wake up in a recovery room, the entire process is finished.

If you’re injured or sick, extubation may go a little differently. For example, you could be awake when they remove the tube. Your healthcare providers perform a test called a spontaneous breathing test to ensure it’s safe to remove your breathing tube. They also check your gag reflexes to make sure you don’t choke or aspirate (breathe in) any food or debris. This is especially important if you were intubated quickly or in an emergency because you may still have food in your stomach. Some people transition from a ventilator to supplemental oxygen.

While it may sound straightforward, planning for extubation is a process that requires careful planning to ensure the best possible outcome. There can be risks involved no matter what the reason was for intubation.

What are the reasons for being intubated?

Extubation happens after intubation. Some reasons you may be intubated include:

• Airway obstruction (something is caught in your airway, blocking the flow of air).
• Cardiac arrest (sudden loss of heart function).
• Injury or trauma to your neck, abdomen or chest that affects your airway.
• Loss of consciousness or a low level of consciousness, which can make a person lose control of their airway.
• Need for surgery that will make you unable to breathe on your own.
• Respiratory failure or apnea (a temporary stop in breathing).
• Risk for aspiration (breathing in an object or substance such as food, vomit or blood).

What happens during extubation?

Once your healthcare provider decides it’s safe for you to breathe on your own, they remove the endotracheal tube from your trachea.

The steps they take to extubate include:

• Move the hospital bed to a sitting or upright position.
• Use a suction device to remove any debris in your mouth, the tube and your airway.
• Remove the tape or strap holding the tube in place.
• Disconnect the tube from the ventilator or whatever source is delivering air.
• Tell you to take a deep breath, then cough or exhale while they pull out the tube.

What is a spontaneous breathing test (SBT)?

A spontaneous breathing test (SBT) is what healthcare providers use to determine if a person can be extubated. It assesses your ability to breathe on your own with minimal or no support. It’s also called ventilation “weaning” or “liberation.” Healthcare providers have a set of parameters they use to decide if weaning a person from a ventilator or other device is safe. It may take a person several attempts to pass a breathing test. Failing a breathing test is also known as weaning failure.

Are you awake when they extubate?

Sometimes. You can be extubated while you’re still asleep or while you’re awake. It depends on why you were intubated and other factors. For example, if you were intubated for a surgical procedure, you may still be sedated under general anesthesia when they remove the tube. When you wake up, the tube will already be out. But in other cases, you’re awake while they remove the endotracheal tube.

What is the next step after extubation?

It depends on the reason you were intubated. If you’re in an intensive care unit (ICU) or emergency room due to an injury or illness, you typically require supplemental oxygen afterward. This could include a nasal cannula or an oxygen mask. If you were intubated for a surgical procedure, you may not need any supplemental oxygen.

Your healthcare team continues to monitor you after extubation. This involves checking your oxygen levels, heart rate and making sure your airway stays clear. Keeping your airways clear may mean coughing several times or getting additional airway suctioning.

What are the complications of extubation?

The most common complications are extubation failure and noisy breathing.

Other risks of removing the tube are:

• Damage to your larynx, vocal cords or other parts of your airway.
• Severe and forceful coughing that leads to laryngospasm or aspiration.
• Post-extubation hemodynamic shift (how your blood flows), mainly due to pressure in your lungs from coughing.

Extubation failure

Extubation failure is when the procedure doesn’t go as your healthcare provider plans and you need to be intubated again. This happens in up to about 14% of extubations. This is more common in people older than 65 and in people with heart disease or respiratory conditions.

Noisy breathing

Noisy breathing or post-extubation stridor occurs in less than 10% of people. Risk factors for noisy breathing include being intubated for more than two days and being older than 80.

How often does extubation fail?

Extubation failure happens in about 12% to 14% of all planned extubations. It’s more likely to fail if you’re older than 65 or have heart or lung disease.

What are the benefits of extubation?

Extubation doesn’t happen unless healthcare providers are sure you can get enough oxygen to breathe on your own. Being able to breathe without help means you’re closer to making a recovery.

Other benefits include being able to eat, drink and talk. When the ETT is in your throat, you can’t do these things.

Finally, prolonged intubation has risks. Extubation means you are avoiding the risks of intubation. Some of these include vocal cord paralysis, pneumonia and tracheomalacia (weak or collapsing windpipe).

Can you talk after extubation?

You might have a bit of trouble talking after extubation, as your throat might be sore for a few days.

What are the chances of survival after extubation?

The success rate of extubation after an outpatient surgical procedure is high. Your likelihood of complications following intubation due to surgery is low.

For more serious injuries or illnesses requiring intensive care, extubation is successful about 85% of the time. If a person needs to be re-intubated after extubation failure, their time in the intensive care unit (ICU) increases, as well as their chance of mortality. But just because you need to be intubated again doesn’t mean you won’t survive.

A note from Cleveland Clinic

Breathing is usually something we do without thinking about it. But if you’re injured, sick or need surgery, your healthcare providers take steps to ensure you’re able to get the oxygen you need. They may intubate you, and if they do, you’ll be extubated as soon as it’s safe. Let your provider know if you’re nervous or worried about this process, or if you’ve had trouble with intubation or extubation before.