All India Difficult Airway Association 2025 guidelines for extubation of the “at-risk” airway

Abstract

The All India Difficult Airway Association (AIDAA) guidelines for 2025 regarding the extubation of “at-risk airways” following anaesthesia emphasise the importance of recognising, preparing for, and executing a planned extubation procedure for these potentially vulnerable airways. AIDAA has reviewed its previous extubation guidelines and developed a new algorithm based on the latest evidence, a Delphi survey, and expert opinions to incorporate necessary changes for patients with “at-risk airways”, ultimately aiming to achieve successful extubation. This is articulated through a four-pronged strategy known as SAFE: S-Stratify Risk, A-Assemble and Anticipate, F-Facilitate Extubation, and E-Evaluate and Escalate. This stepwise approach is designed to enhance patient safety during the extubation process. The guidelines emphasise the significance of peri-extubation oxygen (PerEOx) supplementation. Furthermore, it is crucial to quantitatively assess recovery from neuromuscular blockade prior to extubation. A three-limb approach to extubation has been devised to address specific situations: Limb 1 focuses on suppressing the haemodynamic response during extubation in scenarios that require such control but do not pose a risk to the airway, Limb 2 involves a staged sequential extubation, and Limb 3 addresses the need for delayed extubation. Patients at higher risk of airway compromise, collapse, or dependence on the tube may benefit from a staged sequential extubation or delayed extubation strategy rather than a one-step extubation approach. The current guidelines also propose management plans for certain unusual situations, such as a stuck tracheal tube and unexpected extubation failure.

DISCLAIMER

These guidelines have been developed to help clinicians manage unanticipated difficult airways in patients using evidence-based recommendations or Delphi consensus opinions from airway experts, wherever evidence was lacking or weak. These guidelines do not represent the minimum standard of practice nor a substitute for good clinical judgement. The recommendations in the guidelines assume that the airway operator has adequate experience with the devices and techniques described and that these are applied within the scope of their practice. Recommendations regarding the use of specific resources (devices, medications, or workforce) apply where these resources are available. These recommendations should be viewed as aspirational; when this is not the case. While careful attention has been paid to providing accurate and updated information, the authors acknowledge that the literature on airway management is rapidly changing, altering our attitudes and clinical practice. It is important to note that the application of these recommendations in specific settings remains the clinician’s responsibility. Refer to the methodology document for the detailed disclaimer.[1]

INTRODUCTION

Tracheal extubation refers to the deliberate removal of the tracheal tube, transitioning from an established airway to the patient’s natural airway.[2] Extubation failure is defined as the inability of a patient to sustain a patent airway with effective spontaneous ventilation following the intentional removal of the tracheal tube (TT) within a specified timeframe.[2] The American Society of Anesthesiologists (ASA) Closed Claims Analysis[3] and the 4^th National Audit Project (UK)[4] have highlighted that airway mishaps continue to occur during extubation. Investigations of adverse respiratory events from the Closed Claims Project revealed that 16% of brain injuries and 4% of fatalities happened after extubation in either the operating room or the post-anaesthesia care unit. An “at-risk” extubation is characterised by a heightened likelihood of post-extubation complications, such as re-intubation, haemodynamic instability, or airway compromise. Unlike intubation, which may occasionally require urgent intervention, tracheal extubation is an elective procedure. Thus, employing a carefully crafted, systematic approach to extubation can help mitigate the failure rate and minimise complications associated with this process.

The All-India Difficult Airway Association (AIDAA)[2] emphasises the significance of peri-extubation oxygen supplementation. The three-limb format outlined in the 2016 extubation guidelines offers a structured approach to addressing group-specific conditions. Furthermore, after extubation, the selection of devices such as continuous positive airway pressure (CPAP), non-invasive ventilation (NIV), or high-flow nasal oxygen (HFNO) provides a continuum of airway support, aptly referred to as ‘bridging extubation to normalcy’.

The AIDAA 2025 extubation guidelines address challenges encountered during extubation and recovery, promoting a strategic, stepwise approach to this critical process. A four-pronged strategy is put forth to enhance patient safety across all types of extubation (SAFE: S – Stratify Risk, A – Assemble and Anticipate, F – Facilitate Extubation, E – Evaluate and Escalate). While the original three key components for “at-risk” extubation have been preserved,[2] specific techniques applicable at each stage have been redefined. The significance of oxygen supplementation before, during, and after extubation has been further emphasised. In post-operative patients requiring tracheal extubation in the operating room, a quantitative assessment of recovery from residual neuromuscular blockade provides reassurance that tracheal extubation is appropriate and the patient can be safely transferred to the post-anaesthesia care unit (PACU) only after regaining full motor function. It has also been recognised that not all patients can transition from “tube dependency” to normalcy through a single-step extubation plan. Thus, the guidelines now incorporate staged sequential extubation (SSE) and delayed extubation as strategies within the new algorithm. SSE is a structured, step-wise approach designed specifically for patients at high risk of airway compromise or collapse. This technique involves the intentional removal of the endotracheal tube while preserving airway access using a temporary conduit, such as an airway exchange catheter (AEC) or an extubation guidewire, thereby enhancing patient safety by ensuring a successful re-intubation if necessary.

METHODS

Based on the literature review and discussions among the Extubation Guideline Subcommittee members, nine PICO (Patient/Population, Intervention, Comparison, and Outcome) questions were formulated. A systematic literature search, data extraction, and evidence synthesis were conducted for each PICO question. The literature search was performed in PubMed and Scopus, covering the period from January 2000 to December 2024, using search strings tailored to each PICO question. A concept table, search strings, and PRISMA flowcharts outlining the search process for each PICO question are summarised in Appendix (1-9). All retrieved articles were imported into the Rayyan software (Rayyan Systems Inc., Cambridge, Massachusetts, USA; http://rayyan.qcri.org) for initial screening. Two reviewers independently screened the titles and abstracts of each article and selected the final list of full-text studies for inclusion. A table of the shortlisted articles was compiled.

The evidence was summarised, and recommendations were categorised according to the American Heart Association (AHA) Class of Recommendations and Level of Evidence for clinical strategies, interventions, treatments, or diagnostic testing in patient care.[5] Where evidence was absent or weak, the Steering Committee initiated a Delphi process to reach consensus (75% or above) among airway experts.[6] Statements were included in successive Delphi rounds until stability criteria were met. Expert consensus statements were then drafted based on survey items that reached consensus. Complete details of the guideline development process and methodology, including the Delphi process, are provided in the AIDAA Guideline Development Process and Methodology article.[1]

Universal strategy for safe extubation: SAFE [Figure 1]

Figure 1.

SAFE Extubation

Alongside the context-specific extubation plan employing the three-limb approach, the AIDAA Extubation Subcommittee introduces a systematic, step-wise method to improve patient safety during extubation. This approach is encapsulated in the mnemonic SAFE: S – Stratify Risk, A – Assemble and Anticipate, F – Facilitate Extubation, and E – Evaluate and Escalate, as outlined below.

S – Stratify risk

The process involves conducting a structured risk assessment for pre-existing, new, or reversible risk factors. It is advisable to utilise the “At-risk airway” framework, which encompasses the 3Ds: Distortion, Difficulty, Disease, and the 3Ss: Secretions, Swelling, Stenosis. Additionally, it is essential to recognise the necessity for smooth extubation in specific situations, whether in adult or paediatric cases.

A – Assemble and anticipate

Thorough preparation prior to extubation is critical and cannot be overstated. This preparation includes ensuring the presence of an airway expert, sufficient support staff, and clearly defined team roles to address any complications that may arise. All essential equipment, such as a difficult airway cart, should be readily accessible, and a bite block should be considered if an awake extubation is planned. Additionally, the environment must be optimised. “At-risk” extubation is best conducted in the operating room, ideally timed to allow for close post-extubation monitoring in the PACU, where rapid re-intubation or other airway interventions can be promptly executed if necessary. Patient readiness is another cornerstone of safe extubation, which involves a final airway inspection to rule out oedema, bleeding, or excessive secretions; adequate suctioning; complete recovery from neuromuscular blockade, confirmed by clinical signs and a train-of-four (TOF) ratio >0.9; complete emergence from anaesthesia; and ensuring the patient is alert, warm, comfortable, pain-free, and haemodynamically stable. Maintaining “Peri-Extubation Oxygenation” (PerEOx) by providing oxygen throughout the extubation process is also essential.

F – Facilitate extubation

Extubation should be conducted safely and systematically. Ensure PerEOx is maintained throughout the process. The choice between awake or deep extubation should be based on the patient’s clinical condition, utilising pharmacological agents, supraglottic airway (SGA) device exchange, or SSE as appropriate.

E – Evaluate and escalate

Post extubation, monitor the patient closely and be ready to intervene promptly if necessary. Continuous assessment of airway patency, oxygenation, and respiratory effort is essential. Early recognition and intervention are crucial for optimising outcomes. Maintain PerEOx during the transfer to the PACU. Provide a thorough handover that clearly outlines the re-intubation plan for patients with “At-risk” airways. Stay alert for potential complications such as laryngospasm, bronchospasm, stridor, airway obstruction, apnoea, negative pressure pulmonary oedema, aspiration, vomiting, and regurgitation, and act accordingly.

EXTUBATION ALGORITHM

Planned routine extubation

Adequate neuromuscular recovery should be ensured by neuromuscular monitoring (TOF ratio >0.9).[7,8,9] Pre-extubation oxygenation, achieved by filling the functional residual capacity with 100% oxygen, enhances protection against hypoxia in the event of airway compromise. It is essential to perform thorough oropharyngeal suctioning under direct visualisation before extubation. A difficult airway cart must always be readily available during the extubation process. Unless contraindicated, a lung recruitment manoeuvre may be considered to recruit collapsed alveoli before the patient resumes spontaneous respiration. PerEOx, which involves delivering oxygen before, during, and after extubation, ensures continuous oxygenation and helps maintain adequate oxygen saturation in the case of airway failure.

Extubation of the “At-Risk” airway [Figure 2]

Figure 2.

Algorithm for extubation in patients with “at-risk” airway

Conditions leading to extubation failure and complications following extubation are clubbed under three limbs. The acronyms 3 Ds (Limb 2) and 3 Ss (Limb 3) are used to recognise the conditions and proceed in a step-wise manner along the appropriate limbs [Figure 2]. In addition to the guidance provided above for routine extubation, the following specific precautions are outlined for “at-risk” extubation. All “at-risk” extubations should be performed in a controlled environment by experienced personnel.

Extubation limb 1

Suppression of the cardiovascular, cerebrovascular, and intraocular response to tracheal extubation must be ensured in specific clinical situations to prevent adverse events.[10] Pharmacological attenuation blunts stress and physiological responses when patients awaken with the tracheal tube in situ [Table 1].[11,12,13,14,15,16,17,18,19,20,21,22,23,24] A tracheal tube (TT) can be exchanged for an SGA device under a deep plane of anaesthesia (surgical plane of anaesthesia), which may provide better device tolerance upon awakening (Bailey’s manoeuvre).[25,26,27] Bailey’s manoeuvre is an advanced procedure requiring prior training.

Table 1.

Pharmacological agents used to attenuate the haemodynamic response to extubation

Agent (Route)	Dose	Timing of administration	Primary Effect
Agents that improve tracheal tube tolerance
Dexmedetomidine (Intravenous infusion)	0.5-1 μg/kg/hour	Infusion should begin 20 minutes before extubation, and infusion can be timed to cease during extubation.	Provides sedation and suppresses haemodynamic stress response[13,14]
Preservative-free 2% Lignocaine(Intravenous bolus)	1-1.5 mg/kg bolus	90 seconds before extubation	Reduces airway reactivity and suppresses extubation response[15]
2% Lignocaine (Intracuff instillation)	TT cuff sealing pressure (not to exceed 20-30 cm H2O)	Inflate the tracheal tube cuff after intubation	Improves tracheal tube tolerance and reduces cough reflex[15,16]
Propofol (Intravenous bolus)	0.5 mg/kg	30 seconds before extubation	Provides sedation and obtunds airway reflexes[15]
Remifentanil (Intravenous infusion)	0.2-0.4 μg/kg/min	Infusion during extubation	Potent opioid that suppresses airway reactivity[17,18]
Morphine (Intravenous bolus)	100-200 μg/kg	30 min before planned extubation	Provides antitussive effects, improving tracheal tube tolerance[20,21]
Agents that suppress the haemodynamic response to extubation
Esmolol (Intravenous bolus)	0.5-2 mg/kg	60 seconds before extubation	Short-acting beta-blocker that controls haemodynamic response[22,23]
Labetalol (Intravenous bolus)	0.1-0.2 mg/kg	3 minutes before extubation	Combined alpha- and beta-blockers that attenuate stress response[11,19]

The SGA device exchange necessitates a thorough understanding of supraglottic airway devices and careful evaluation of the patient’s condition as failure to execute it correctly may require immediate reintubation using a tracheal tube. It is crucial to employ neuromuscular monitoring to confirm an adequate neuromuscular block prior to attempting the SGA device exchange. The exchange of a tracheal tube with an SGA device can be accomplished through one of three commonly utilised methods [Figures 3-5]:

Figure 3.

Method 1. 1 = Tracheal tube; 2 = Supraglottic airway device

Figure 5.

Method 3. 1 = Tracheal tube; 2 = Supraglottic airway device; 3 = Epiglottis; 5 = Proseal™ with inflated cuff seen behind the tracheal tube; 6 = Catheter mount attached to the swivel connecter and breathing circuit; 7 = Airway exchange catheter

Method 1: Blind removal of the tracheal tube followed by SGA device insertion. The tracheal tube is withdrawn, and the SGA device is inserted [Figure 3].

Method 2: Insertion of the SGA device with the tracheal tube in situ. The SGA device is advanced posterior to the existing tracheal tube. The tracheal tube is subsequently removed after inflating the cuff of the SGA device, ensuring a seamless transition in airway management [Figure 4].

Figure 4.

Method 2. 1 = Tracheal tube; 2 = Supraglottic airway device; 3 = Epiglottis; 4 = Tracheal cuff deflated and tracheal tube ready for removal; 5 = Proseal™ with inflated cuff seen behind the tracheal tube; 6 = Catheter mount attached to the swivel connecter and breathing circuit

Method 3: Tracheal tube removal over an airway exchange catheter (AEC) with SGA device railroading. The tracheal tube is exchanged over an AEC, maintaining airway access. The SGA device is then railroaded over the AEC through the oropharyngeal pathway into position. This technique enhances safety during extubation, as well as in the “at-risk” airway (Limb 2 or 3), where mitigating respiratory and cardiovascular reflex responses is critical during the transition phase [Figure 5].

Extubation limb 2

Patients with anticipated and unanticipated difficult airway (DA) are likely to experience an airway that is rendered at risk following extubation. Difficult airway may be due to pre-existing disease, Delayed recovery, and predictors of difficult face mask ventilation (FMV), intubation, or reintubation (3Ds). Patients in whom DA management was planned pre-operatively or encountered during anaesthesia induction (unanticipated difficult airway) should undergo tracheal extubation when fully awake. The airway may be at risk after tracheal extubation in patients having conditions such as retrognathia, micrognathia, macroglossia, facial trauma, obesity, obstructive sleep apnoea, poor compliance of the submandibular space, ankylosing spondylitis, rheumatoid arthritis, and cervical spine injuries.[28]

Staged sequential extubation (SSE): SSE can be planned to extubate an anticipated or unanticipated difficult airway using an AEC or a wire guide. The SSE procedure is performed in the operating room under controlled conditions. An extubation wire or AEC is passed through the tracheal tube before removal and retained in the airway. The extubation wire or AEC provides a conduit to railroad the TT in the event of extubation failure. Topical anaesthesia of the trachea can be achieved by instilling or nebulising 2 mL of 4% lignocaine through the tracheal tube before placing the AEC or FOB, which improves patient comfort and tolerance to the guide[29] [Table 2].

Table 2.

Steps for use of AEC passed through the endotracheal tube

Steps	Procedure
Step 1	Length of the AEC to be inserted is measured: The tip to remain above the carina.
Step 2	Insert the AEC through the TT
Step 3	Confirm the AEC is inserted to the measured length.
Step 4	Withdraw the TT over the AEC and secure the AEC at the angle of the mouth.
Step 5	Oxygen supplementation can be continued through nasal prongs or a face mask while AEC is in situ.
Caution	Do not supplement oxygen or provide ventilation through the AEC.

AEC=Airway Exchange Catheter; TT=Tracheal Tube

The AEC can be maintained for 2 hours, and in extreme situations with a risk of airway collapse, it can be kept for up to 12 hours.[30] A commercially available SSE set [comprising a guide wire (a length of 145 cm, a diameter of 0.035 inches) and a guide catheter (14 French diameter and 83 cm length)] can be used to perform SSE.[31] If not used from the SSE kit, an alternative is to use a straight or J-tip wire guide (non-kinking, made of stainless steel or nitinol – a super elastic alloy, with a polytetrafluoroethylene or hydrophilic coating, with a diameter of 0.032 to 0.038 inches, and a length of more than 100 cm) for easy insertion of the AEC over the wire. The wire guide can be placed inside the trachea with the tip positioned at the mid-tracheal level prior to extubation. Care should be taken to ensure that the AEC or wire guide remains above the carina, using the same depth as the tracheal tube. The AEC or wire guide should be secured at the angle of the mouth and labelled. Oxygen supplementation or ventilation should be avoided through the AEC to prevent potential life-threatening complications.[32] Oxygenation may be continued with HFNO, NIV, or other oxygen delivery devices such as a non-rebreathing mask or nasal prongs.[33,34] NIV can be initiated with an AEC in situ using a specialised adapter to provide an adequate seal during NIV.[35] If the patient requires re-intubation, the guide catheter can be advanced over the wire guide, followed sequentially by TT.

Extubation limb 3

Delayed extubation (DE): Delayed extubation refers to the procedure of removing the tracheal tube after the patient has been transferred to the Intensive Care Unit (ICU) or High Dependency Unit (HDU). This approach is planned when concerns about potential airway collapse, airway oedema, or surgical factors may compromise airway integrity.

Airway compromise may arise from various conditions, including intra-luminal growths (such as recurrent laryngeal papillomatosis or granulomas), significant excisions of the mandible and other oral structures during oncological surgeries, extra-luminal obstructions (such as thyromegaly, thymomas, or lymphomas causing tracheal compression), or tracheomalacia and airway oedema. In certain patients who undergo extensive resection of airway structures, particularly following head and neck cancer surgeries, an upfront tracheostomy may be warranted. These patients are often unable to adequately protect their airway following extubation.[36]

Surgeries directly involving the airway, such as tracheal or laryngeal procedures, or extensive head and neck procedures, pose a higher risk of extubation failure, requiring meticulous planning and readiness for airway intervention. These patients may require delayed extubation[36] as well as SSE. Certain head and neck or thoracic surgeries can injure the recurrent laryngeal nerve that supplies the vocal cords and cause temporary or permanent recurrent laryngeal nerve palsy, which can be confirmed by ultrasound or nasal endoscopy and may need a surgical airway.[37,38] Bilateral recurrent laryngeal nerve injury may necessitate a tracheostomy. Infraglottic airway collapse, also known as tracheobronchomalacia, occurs when the walls of the trachea and bronchi are weak and collapse during breathing, leading to a compromised airway following extubation [Figure 6].

Figure 6.

Tracheomalacia and its causes. COPD = Chronic obstructive pulmonary disease; GERD = Gastro-oesophagal reflux disease

Postoperative extubation can be challenging, especially after surgeries such as thyroid or mediastinal tumour resection, as it may compromise airway stability after extubation[39,40] [Figure 6]. On suspicion of tracheomalacia (may also be identified on table by the surgeon by inspecting the trachea for evidence of deformation or by palpating for softened tracheal cartilages), a trial of extubation may be attempted. A flexible bronchoscope (FB) can be introduced via the tracheal tube, with its tip placed just distal to the bevel of the tracheal tube. Both the FB and tracheal tube are slowly withdrawn, and if approximation or collapse of the trachea is observed, the tracheal tube is pushed back into the trachea.[40,41] In patients having dynamic tracheal collapse secondary to tracheomalacia, keeping them intubated (with or without ventilation) post-operatively for 48–72 hours may help stabilise the condition, and a tracheostomy may be avoided.[42] These patients would require observation in the ICU/HDU and a planned delayed extubation using SSE. If an extubation failure occurs despite a planned delayed extubation in ICU/HDU, these patients with excessive dynamic airway collapse would require a planned SSE procedure under deep anaesthesia inside the operating room while preserving spontaneous ventilation. A deep anaesthetic plane helps to prevent adverse airway reflexes during emergence that may predispose to excessive dynamic airway collapse. Despite the above plan, tracheostomy will be the last option when extubation failure occurs.

If the attempts at re-intubation fail after extubation in a patient with a compromised airway, tracheostomy should be considered. A ventilating rigid bronchoscope should be kept ready as an airway rescue in the event of extubation failure in patients with tracheomalacia.[43,44]

Airway oedema can occur due to various factors, including hypersensitivity reactions, angioedema, airway instrumentation, airway manipulation during difficult intubation, airway trauma, infection, robotic surgery with a prolonged head-down position, pre-eclampsia, eclampsia, massive fluid infusion, and intentional ligation of veins that drain the upper airway. When airway oedema is suspected, a “cuff leak test” may be considered to predict post-extubation stridor. A quantitative cuff leak test is performed using the volume-controlled ventilation mode with the patient under the surgical plane of anaesthesia. The ventilator is set to deliver a tidal volume of 8 mL/kg of ideal body weight, and the exhaled tidal volume (V_TE) is noted first with the tracheal tube cuff inflated and then after the tracheal tube cuff is completely deflated. If the V_TE difference is <110–130 mL or <25%, then post-extubation stridor should be anticipated.[41,45] Alternatively, airway ultrasound can be used. Air column width difference is measured using a linear probe at the level of the vocal cords with the cuff inflated and after cuff deflation. An air column width of <9 mm should alert the anaesthesiologist to anticipate post-extubation stridor.[46,47,48] If upper airway oedema is anticipated, racemic adrenaline mixture can be nebulised (1 mg in 5 mL of 0.9% saline) by placing an appropriate-sized nasopharyngeal airway with an appropriate-sized tracheal tube connector or with a 6.5 mm ID tracheal tube placed in the oropharynx before extubation and nebulisation is continued 2^nd to 4^th hourly to prevent recurrence of airway oedema.[49,50] Dexamethasone can be administered at 0.1 mg/kg to treat airway oedema.[51] A difficult airway cart should be kept ready before attempting extubation of a patient with a compromised airway. In patients where the cuff leak test is negative, or the air column width is >9 mm, extubation should be performed in a fully awake state after ensuring adequate neuromuscular recovery (TOF ratio >0.9). NIV or HFNO may be considered after extubation to continue oxygenation and recruitment. Monitoring should be continued in all patients. If the cuff leak test is positive or the air column width is <9 mm, SSE can be planned after ensuring adequate neuromuscular recovery (TOF ratio >0.9), or delayed extubation can be planned in ICU/HDU. The tracheal tube is retained for 24 hours until the upper airway oedema resolves with steroid and adrenaline nebulisation via nasopharyngeal airway/TT. The patient is allowed to breathe spontaneously through the TT, and pressure support is added if indicated. A difficult airway cart, experienced help, and a tracheostomy set should be readily available before attempting extubation in a patient with a compromised airway (cuff leak test positive or an air column width of less than 9 mm).[46,48] Arrangements to continue oxygenation with NIV (positive pressure can act as a pneumatic splint to overcome the collapse of the airway) or HFNO should be made after extubation is accomplished. If a patient develops significant airway compromise after extubation, re-intubation is performed by railroading the TT over the AEC as a part of SSE.

STUCK TRACHEAL TUBE

A stuck tracheal tube during extubation can occur if the tracheal cuff fails to deflate due to cuff herniation, overinflation,[52,53] pilot balloon kinking, one-way valve malfunction, or improper fixation,[48] cuff deflation forming a folded sleeve,[54] or trapping of the tracheal tube at the glottis.[55] Other reasons can be laryngeal oedema, post-operative anatomical distortion, sutures, and entanglement with a feeding tube.[56] Several methods have been reported in the literature to overcome this difficulty. These include, but are not limited to, needle puncture of the inflated cuff,[57] cricothyroid puncture of the inflated cuff, ultrasound-guided needle puncture of the inflated cuff, deflating and reinflating the cuff with minimal air, cutting the inflation line of the cuff, and instillation of saline under direct vision over the glottis[58] and twisting and turning the tracheal tube.[55] There was no consensus among the experts for using any specific technique [Appendix 10]. Prevention involves tracheal tube integrity checks, cuff pressure monitoring, and atraumatic intubation.[57]

PAEDIATRIC EXTUBATION

The emergence and extubation of children from general anaesthesia are critical periods that are associated with a higher incidence of complications compared to other phases of the anaesthetic process. The APRICOT 11 study (Anaesthesia Practice In Children Observational Trial),[59] a prospective multi-centre observational study conducted across 261 hospitals in Europe, analysed over 31,000 anaesthetics in children and reported a greater occurrence of respiratory complications such as laryngospasm, bronchospasm, aspiration, and stridor during extubation.[59] The “SAFE” strategy previously described for adults applies to paediatric extubation. Additionally, PerEOx is crucial for ensuring children’s safety during this process. Post-extubation oxygenation in children may be attempted with nasal prongs, Hudson’s nebuliser mask, oxygen hood, or high-frequency nasal cannula, depending on the child’s need and discretion of the attending physician. Several unique factors pertaining to children have been identified to help mitigate extubation complications.[60]

Stratify risk

Children, particularly those of school age, often have hyper-reactive and sensitive airways due to recurrent respiratory infections. As a result, they are more susceptible to trauma, oedema, and increased airway resistance, which subsequently raises the work of breathing and heightens risks during extubation.

Assemble and anticipate

Preparing for extubation in children shares similar principles with adults, but it requires some essential paediatric adaptations. Whenever possible, ensure the presence of a paediatric airway expert, along with sufficient support staff. It is also crucial to consider appropriate restraints for younger children. All airway equipment must be tailored to the child’s age and weight, and a bite block should be contemplated for awake extubation. Extubation classified as “at-risk” should occur in the operating room (OR), allowing for a smooth transition to the PACU for close monitoring. Criteria for paediatric readiness include assessing for airway oedema or secretions, performing thorough suctioning, confirming complete neuromuscular reversal (TOF > 0.9), ensuring emergence from anaesthesia, and checking for indicators such as purposeful movements, SpO₂ levels above 95%, tidal volume exceeding 5 mL/kg, and age-appropriate respiratory effort.

Facilitate extubation

Children possess a limited apnoeic reserve, making pre-oxygenation with 100% oxygen before extubation essential. Both awake and deep extubation are safe options when selected appropriately.[61,62] Deep extubation may be preferred in specific cases, such as neurosurgery or ophthalmic procedures, if airway patency is confirmed before the patient leaves the operating room. In instances involving a known difficult airway, it is advisable to extubate the child while they are awake.

Evaluate and escalate

Post-extubation monitoring must be conducted with great diligence as children possess a narrower safety margin and can experience desaturation more rapidly. Oxygen therapy should be maintained during the transfer to the PACU. A thorough handover is essential, especially for children with an at-risk airway, and it is vital to have the appropriate re-intubation equipment readily available. Vigilance is required to detect potential complications such as laryngospasm, stridor, airway obstruction, and negative pressure pulmonary oedema. For airway oedema, nebulised adrenalin (0.5 mL, 1:1000) solution may be employed, although the effectiveness of steroids remains uncertain. Early identification of issues and prompt intervention are crucial for enhancing patient outcomes. For unanticipated extubation failure in paediatric patients, follow the unanticipated extubation failure algorithm described below.

UNANTICIPATED EXTUBATION FAILURE (WITHOUT RESCUE AEC IN SITU) [FIGURE 7]

Figure 7.

Unanticipated extubation failure algorithm (without rescue AEC in situ). SGA=Supraglottic airway, HFNO=High flow nasal oxygen, SSE=Staged sequential extubation

Unanticipated extubation failure following routine extubation can be a critical and challenging situation, particularly when the patient, team, and environment are unprepared. If the patient fails to maintain a patent airway and no conduit for re-intubation (e.g., airway exchange catheter) is in place, the immediate priority is to establish adequate oxygenation and initiate a plan for reintubation.

Call for help (Code D),[63] preferably from a qualified and experienced airway practitioner, should be made immediately, as re-intubation in this context may be difficult due to anatomical, physiological, or situational factors.

Oxygenation should be attempted using all available techniques, including conventional nasal oxygen, HFNO, face mask, or insertion of an SGA device, if feasible. Once effective oxygenation is restored, providing a reliable, safe apnoea period, further management should be guided by the suspected cause of extubation failure.

If the patient’s condition improves, ongoing oxygenation or ventilation should be maintained while evaluating the underlying issue. However, if the condition does not improve or deteriorates, re-intubation should be performed using the best available resources and expertise, anticipating a potentially difficult airway.

Re-oxygenation must be prioritised if re-intubation fails or is not immediately possible. When adequate ventilation cannot be achieved, an emergency surgical airway such as cricothyroidotomy or tracheostomy should be considered without delay, as per the AIDAA 2025 guideline for unanticipated difficult airway.[64,65]

POST-EXTUBATION PLAN

A strategy to reduce the post-extubation complication should start at intubation itself and should be continued before and after extubation.[11,12,13,14,15,16,17,18,19,20,21,22,23,24,66] As mentioned in our previous AIDAA extubation guidelines,[2] the administration of supplemental oxygen and continuous monitoring in a controlled setting, with the aim of early detection of any airway compromise, should be the primary post-extubation strategy. Adverse outcomes are quite common after extubation if not monitored adequately.[67] However, appropriate suctioning, head-up positioning, and bronchodilators should be continued as required.[28] In the case sheet and alert forms, the difficulties faced during extubation, the adverse events, and the strategies used to overcome the crisis should be documented. This would help in planning for any subsequent adverse events.

Research Questions (Summary of Recommendation/Best Practice Statement) [Table 3].

Table 3.

Summary of recommendations and best practice statements

Clinical Research Question	Recommendation/Best Practice Statement	Type of Guidance	Class (Strength) of Recommendation	Level (Quality) of Evidence
Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected ?	Quantitative cuff leak test may be considered before extubation when airway oedema is suspected	Best Practice Statement	Class 2b	C-LD
Should neuromuscular monitoring (NMM) be performed before extubation?	Quantitative neuromuscular monitoring (TOF ratio >0.9) is recommended before extubation when the equipment is available.	Recommendation	Class 1	A
Does tracheal cuff inflation with lignocaine in adults reduce the haemodynamic response during extubation?	Alkalinised lignocaine may be considered to reduce the haemodynamic response during extubation.	Best Practice Statement	Class 2b	B-R
Does tracheal cuff inflation with lignocaine in adults reduce cough and laryngopharyngeal symptoms after extubation?	Alkalinised lignocaine can be beneficial to reduce cough and laryngopharyngeal symptoms after extubation.	Best Practice Statement	Class 2a	B-R
Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients	Alkalinised lignocaine can be beneficial to attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients.	Best Practice Statement	Class 2a	B-R
Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients?	It is not well established whether extubation should be performed awake or in deeper planes of anaesthesia in paediatric patients.	Best Practice Statement	Class 2b	B-R
Should a lung recruitment manoeuvre be performed before extubation in adult patients?	Lung recruitment manoeuvres may be considered before extubation in adults.	Best Practice Statement	Class 2b	B-R
In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation?	The use of an AEC can be beneficial to facilitate reintubation in adult patients at risk of extubation failure.	Best Practice Statement	Class 2a	B-NR

Research Question 1: Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected? Appendix 1.[68,69,70,71,72,73]

Summary: A total of 120 abstract were reviewed by RG and AP, with 6 studies ultimately selected for detailed analysis and summary. These primarily focussed on post-operative extubation trials following surgery. One retrospective study analysed surgical ICU patients requiring extubation, including spine surgery patients positioned prone.[68]

The cuff leak test protocols varied significantly in thresholds and methodology, including absolute volume, percentage, and auscultation-based approaches. Failed cuff leak test thresholds ranged from 110 to 200 mL or percentages below 12% to 30%. The sensitivity of the cuff leak test ranged from 15.4% to 92.6%, while specificity varied between 48% and 96%. Positive predictive values (PPVs) were generally low (<50%). In contrast, negative predictive values (NPVs) were consistently high (>90%), indicating that the cuff leak test is more effective in ruling out post-extubation stridor than in predicting its occurrence. Additionally, air column width measurements (using laryngeal ultrasound) emerged as a significant predictor of post-extubation stridor before cuff deflation. Combined methods, such as cuff leak test with flexible bronchoscopy, demonstrated improved predictive capability for extubation outcomes.

Though the cuff leak test provides valuable insights, it should not replace a physician’s clinical judgment or additional diagnostic tools. Techniques such as laryngeal ultrasound for estimating air column width difference and refined threshold criteria show promise for enhancing the sensitivity and specificity of post-extubation stridor prediction.

Best Practice Statement: Quantitative cuff leak test may be considered before extubation when airway oedema is suspected (Class of Recommendation: 2b, Level of Evidence: C-LD).

Research Question 2: Should neuromuscular monitoring (NMM) be performed before extubation? Appendix 2.[74,75,76,77]

Summary: A total of 99 abstract were reviewed by AP and AS, with 4 studies ultimately selected for detailed analysis and summary. Quantitative NMM at extubation, particularly with TOF ratio measurement, is consistently associated with reduced risks of residual neuromuscular blockade, hypoxia, and post-operative respiratory complications. Thilen et al.[76] (Grade A) reported that quantitative NMM significantly decreases residual neuromuscular block risk compared to clinical and qualitative assessments, with a risk ratio (RR) of 0.18 (95% CI: 0.06, 0.50) against clinical methods and 0.24 (95% CI: 0.13, 0.43) against qualitative methods. Additionally, the risk of hypoxia was notably lower with quantitative monitoring (RR 0.15, 95% CI: 0.10, 0.22). Carvalho et al.[74] (Grade A) reported similar findings and demonstrated a reduced incidence of post-operative residual curarisation with quantitative monitoring (11.5%, 95% CI: 0.10, 0.22) compared to qualitative (30.6%) and no monitoring (33.1%). Huang et al.[77] (Grade B-R) supported the benefits of quantitative monitoring, showing that both diaphragm ultrasound and acceleromyography-based NMM effectively minimised residual neuromuscular block and hypoxaemia. Raval et al.[75] (Grade B-R) demonstrated that quantitative NMM had lower residual neuromuscular block incidence and fewer respiratory events, particularly when used with sugammadex. Collectively, these findings advocate using quantitative NMM at extubation to ensure safer patient outcomes when the necessary devices and expertise are available.

Recommendation: Quantitative neuromuscular monitoring (TOF ratio > 0.9) is recommended before extubation when the equipment is available. (Class of Recommendation: 1, Level of Evidence: A).

Research Question 3: Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected? Appendix 3.[78,79,80,81,82]

Summary: A total of 999 abstract were reviewed by JRD and AS, with 5 studies ultimately selected for detailed analysis and summary.

Muraro et al.[80] (Grade C-EO) recommends using inhaled adrenaline for managing anaphylaxis-related laryngeal oedema, emphasising its supplementary role to intramuscular (IM) administration due to minimal systemic absorption. Suri et al.[81] (2022) (Grade C-EO) nebulised adrenaline using a suspension laryngoscope and an 8 mm ID TT positioned near the larynx applied prior to extubation. Ambasta et al.[82] (Grade C-EO) describe using an 8-mm ID TT to nebulise adrenaline just above the glottis, providing an option for careful extubation under direct visualisation. Pluijms et al.[78] (Grade C-EO) review post-extubation laryngeal oedema, favouring a combined corticosteroid and nebulised adrenaline approach. However, a standardised treatment protocol is unavailable due to variable patient responses and limited data. Finally, MacDonnell et al.[79] (Grade C-EO) reported the use of racemic adrenaline nebulisation in four adult cases with emergency upper airway obstruction (not post-extubation). There was rapid symptom relief and minimal cardiovascular side effects in these patients.

The evidence remains low, mostly from case reports, guidelines, and reviews, showing potential benefits of nebulised adrenaline (1 mg in 5 mL of normal saline and repeated as necessary) in treating post-extubation laryngeal oedema but lacking high-quality evidence. Thus, expert consensus via a Delphi process was recommended to guide clinical decision-making. The Delphi survey achieved consensus in the second round and stability in the third round. Delphi survey results are as follows, with 96% agreeing on the intervention [Appendix 10]:

Expert consensus statement: Nebulisation with adrenaline may be considered to reduce post-extubation laryngeal oedema in adults [Table 4].

Table 4.

Expert consensus statements using Delphi methodology

Clinical Question	Expert Consensus Statement	Consensus (%)
Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected?	Nebulisation with adrenaline may be considered to reduce post-extubation laryngeal oedema in adults.	96%
Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected?	Nebulisation with adrenaline may be considered to reduce post-extubation laryngeal oedema in paediatric patients (1–12 years of age).	96%

Research Question 4: Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected? Appendix 4.[50,83,84,85]

Summary: A total of 93 abstract were reviewed by JRD and AS, with 4 studies ultimately selected for detailed analysis and summary. These high-quality RCTs provide insights into the effectiveness of nebulised adrenaline for managing post-extubation stridor and laryngeal oedema, findings that we cautiously extrapolate to post-operative airway management.

In a study by Cesar and Carvalho[84] (Grade B-R), the combination of dexamethasone and nebulised L-adrenaline (0.5 mg/kg) was evaluated in a double-blind RCT for treating post-extubation laryngeal oedema. This treatment did not significantly improve laryngeal oedema scores (P > 0.05), suggesting the limited utility of dexamethasone and nebulised L-adrenaline combination. Da Silva et al.[50] (Grade B-R) assessed three adrenaline doses (0.5, 2.5, and 5 mL of 1:1000 solution). Both doses (0.5 and 2.5 mL) were effective for stridor relief; however, the highest dose was associated with increased blood pressure, suggesting the importance of dose optimisation. Preutthipan et al.[85] (Grade B-R) compared 0.05 mL/kg and 0.5 mL/kg doses of adrenaline to manage post-extubation croup in children. Both doses were effective in reducing airway obstruction scores without side effects. Sinha et al.[83] (Grade B-R) compared aerosolised adrenaline with budesonide for post-extubation stridor. Both drugs provided immediate symptom relief, but adrenaline had significant, sustained effect at 2 hours post-nebulisation (P = 0.02), potentially offering greater protection in post-operative settings. Based on these studies, a nebulised adrenaline in a dose of 0.5 ml (1:1000) may be considered for effective stridor management with minimal adverse effects. Given the extrapolated nature of these PICU findings to post-operative care, we advise establishing expert consensus through a Delphi survey. The Delphi survey achieved consensus in the second round and stability in the third round. Delphi survey results are as follows, with 96% agree for intervention [Appendix 10].

Expert consensus statement: Nebulisation with adrenaline may be considered to reduce post-extubation laryngeal oedema in paediatric patients (1–12 years of age) [Table 4].

Research Question 5: Does tracheal cuff inflation with lignocaine in adults reduce the haemodynamic response, cough and laryngopharyngeal symptoms during and after extubation? Appendix 5.[86,87,88,89,90,91,92,93,94,95,96]

Summary: A total of 124 abstract were reviewed by SGM and SRS, with 11 studies finally selected for detailed analysis and summary. Zhan et al.[91] and Kulkarni et al.[86] (Grade B-R) reported decreased haemodynamic response to extubation after intra-cuff lignocaine or alkalinised lignocaine. However, the three meta-analyses do not support and have not assessed the haemodynamic effects of extubation while the endotracheal tube cuff is inflated with plain or alkalinised lignocaine.

Though there is Grade B-R evidence from individual RCTs to support the use of intra-cuff plain or alkalinised lignocaine to attenuate haemodynamic response to extubation, more RCTs and meta-analyses are required to make a strong recommendation for this outcome. For bucking/coughing during or after extubation, all three meta-analyses by Lam et al.,[88] Peng et al.,[89] and Chen et al.[94] (Grade B-R) recommend using lignocaine or alkalinised lignocaine in the cuff to reduce cough after extubation or prevent post-operative sore throat.

Intra-cuff plain or alkalinised lignocaine is suggested to reduce cough and post-operative laryngopharyngeal symptoms, including sore throat, based on multiple meta-analyses. The evidence is less consistent for attenuating haemodynamic responses during extubation, warranting cautious use until further high-quality studies confirm its efficacy.

Best Practice Statement: Alkalinised lignocaine may be considered to reduce haemodynamic response during extubation. (Class of Recommendation: 2b, Level of Evidence: B-R).

Best Practice Statement: Alkalinised lignocaine can be benefical to reduce cough and laryngopharyngeal symptoms after extubation. (Class of Recommendation: 2a, Level of Evidence: B-R).

Research Question 6: Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients? Appendix 6.[17,66,97,98,99,100,101]

Summary: A total of 120 abstract were reviewed by JRD and AS, with 7 studies ultimately selected for detailed analysis and summary. The findings consistently supported the use of intra-cuff alkalinised lignocaine. Oliveira MRE et al.[99] (Grade B-R) reported a significantly lower incidence of post-operative sore throat (POST) 24 hours after extubation in the intra-cuff alkalinised lignocaine + intravenous dexamethasone group (P = 0.01) compared to air and air + dexamethasone groups. Kavyashree MB et al.[100] (Grade B-R) observed that the incidence of post-extubation cough was significantly lower in the lignocaine-filled cuff group (13.3%) compared to the air-filled cuff group (28.3%), with a P value of 0.043. Additionally, a significant reduction in heart rate elevation was noted in the lignocaine group (P < 0.05). Assefa B et al.[17] (Grade B-NR) showed that the mean heart rate 5 minutes post-extubation was significantly lower in the alkalinised lignocaine group (107.29 ± 6.46 beats/min) than in the air group (122.04 ± 8.81 beats/min, P ≤ 0.001). Similarly, Soares SM et al.[101] (Grade B-R) demonstrated that the mean increase in heart rate post-extubation was lowest in the 1% alkalinised lignocaine group (4.1 ± 6.6 beats.min⁻¹) compared to the air group (14.2 ± 7.6 beats.min⁻¹, P < 0.001). Amucheazi AO et al.[66] (Grade B-R) observed a significant reduction in cough incidence in the alkalinised lignocaine group (30%) compared to the air group (60%, P < 0.05). Ahmady MS et al.[97] (Grade B-R) reported that intra-cuff alkalinised lignocaine reduced the incidence of cough (P = 0.005 and P = 0.014) and sore throat (P = 0.025 and P = 0.031) at extubation and in the post-anaesthesia care unit. In contrast, Behzadi M et al.[98] (Grade B-R) found no significant advantage of intra-cuff lignocaine over intravenous lignocaine following short surgeries.

Current evidence supports using intra-cuff alkalinised lignocaine, particularly at 1% concentration, to reduce post-operative sore throat, cough, and haemodynamic changes during extubation in paediatric patients. Combining intra-cuff lignocaine with intravenous dexamethasone further enhances these benefits, making it a reliable approach for improving post-extubation outcomes.

Best Practice Statement: Alkalinised lignocaine can be beneficial to attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients (age 1–12 years) (Class of Recommendation: 2a, Level of Evidence: B-R).

Research Question 7: Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients? Appendix 7.[59,60,102,103,104,105,106,107,108,109,110,111]

Summary: The decision to perform awake or deep extubation in paediatric patients hinges on individual patient characteristics, surgical conditions, and the risk of respiratory complications. A total of 518 abstract were reviewed by JRD and SRM, with 12 studies ultimately selected for detailed analysis and summary. A systematic review by Koo et al.[104] involving 17 RCTs (Grade A) did not find any significant difference in airway complications between the two techniques (OR 0.62, P = 0.17), indicating similar safety profiles. Von Ungern-Sternberg et al.[105] (Grade B-R) demonstrated that patients undergoing adenotonsillectomy had comparable respiratory outcomes. However, awake extubation was linked to more coughing (60% versus 35%, P = 0.028), while deep extubation had a higher rate of airway obstruction relieved by interventions (26% versus 8%, P = 0.03). Kaur et al.[106] (Grade B-R) reported that using propofol for deep extubation during adenotonsillectomy led to fewer complications and decreased haemodynamic variability.

Observational studies (Grade B-NR) by Baijal et al.[107] and Menda et al.[108] show these two extubation methods revealed no notable differences in respiratory outcomes or operating room turnover times. However, the APRICOT study by Habre et al.[59] (Grade B-NR) reported an increased risk of respiratory events following deep extubation (4.7% versus 3.9%, P = 0.049).

Retrospective studies (Grade B-NR) provided additional insights. Gautam et al.[109] demonstrated the safety of propofol-assisted deep extubation in cardiac procedures, while Zhang et al.[110] noted fewer emergence agitation events but more epistaxis in dental surgeries, emphasising the need to adapt extubation methods to specific surgical contexts. Tsui et al.’s[102] (Grade C-LD) “no-touch” awake extubation technique showed zero incidences of laryngospasm or severe coughing, and Vitale et al.[103] (Grade B-NR) stressed the importance of careful monitoring during deep extubation.

Awake and deep extubation techniques are safe when applied judiciously. Awake extubation may be preferred for children at higher risk of airway complications, while deep extubation can offer smoother recoveries when conducted in a well-prepared setting. When satisfactory recovery room resources are lacking, monitoring the child inside the operating room until fully awake should be considered.

Best Practice Statement: It is not well established whether extubation should be performed awake or in deeper planes of anaesthesia in paediatric patients. (Class of Recommendation: 2b, Level of Evidence: B-R).

Research Question 8: Should a lung recruitment manoeuvre be performed before extubation in adult patients? Appendix 8.[112,113,114]

Summary: A total of 96 abstract were reviewed by RG and AS, with 3 studies ultimately selected for detailed analysis and summary. Only three studies reported RM before extubation process.

RM protocols varied, with techniques such as pressure-controlled step-wise increases in PEEP up to 15 cm H₂O, inspiratory pressures up to 40 cm H₂O for 10 cycles, and low tidal volume ventilation (6 to 8 mL/kg). RMs combined with patient-customised PEEP were associated with fewer post-operative pulmonary complications [Koritarova[113] 2019, B-R]. RMs combined with individualised PEEP improve intra-operative oxygenation and compliance and reduce atelectasis and pulmonary complications. While these strategies show consistent short-term benefits, their impact on long-term clinical outcomes, such as hospital stay and mortality, remains variable, warranting further investigation. RMs should be done before the patient starts breathing spontaneously to achieve optimum benefit.

Best Practice Statement: Lung recruitment manoeuvres may be considered before extubation in adults. (Class of Recommendation: 2b, Level of Evidence: B-R)

Research Question 9: In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation? Appendix 9.[30,31,32,115,116,117,118,119,120,121]

Summary: A total of 113 abstract were reviewed by PK and AS, with 10 studies ultimately selected for detailed analysis and summary. Included studies were meta-analyses, prospective observational cohort studies, and reviews. In a review of 10 studies on the use of the Cook Staged Extubation Set^® (CSES) and Airway Exchange Catheter^® (AEC)[31] for managing difficult airways, various methodologies were explored. A key objective of these studies was to assess the efficacy of these devices in facilitating re-intubation, particularly in patients with difficult airways or those undergoing head and neck surgery.

CSES and AEC both play vital roles in reducing the risks associated with extubation failure. The studies reviewed consistently demonstrate high success rates in re-intubation when using these devices. The systematic review by Lu et al.[31] (Grade B-NR) reported a 93% clinical success rate for CSES, with low rates of complications (5%) and patient intolerance (9%).

Similarly, McManus et al.[116] (Grade B-NR) reported that 73% of ICU patients tolerated the guidewire of the CSES for 4 hours without significant adverse effects. McLean et al.[117] (Grade B-NR) observed a success rate of 86.2% in tube exchange with the AEC, with no instances of complete airway loss, while Mort TC[30] (Grade B-NR) reported 92% successful re-intubation rate over the AEC on 51 patients who had failed extubation. Notably, the incidence of hypoxaemia in patients with AEC during failed extubation was 8%, significantly lower than the 50% incidence in patients without AEC.

Roten et al.[115] (Grade B-NR) demonstrated in their prospective observational study that nasal AEC was better tolerated than oral AEC, with fewer retching episodes. In a literature review conducted by Duggan LV[32] (Grade C-LD) to investigate the efficacy and complications of using an AEC for oxygen insufflation or jet ventilation, they found that while oxygen insufflation through an AEC carries a lower risk of complications, jet ventilation poses significant dangers, including barotrauma, pneumothorax, pneumomediastinum, and cardiovascular collapse, with some cases resulting in death. The authors recommend that AECs be used cautiously for oxygen delivery, emphasising that reintubation should be prioritised when extubation fails. Loudermilk EP et al.[119] (Grade B-NR) evaluated using a paediatric AEC in a difficult airway. They found that 97% of patients tolerated the AEC well, and re-intubation was successfully achieved without desaturation in all cases. The AEC remained in place for an average of 9.4 hours, with the longest duration being 52 hours.

The use of AEC during extubation should be considered for patients with a difficult airway or with a high risk of re-intubation if an appropriate device and experience are available. Jet ventilation should be avoided due to the risk of barotrauma, and oxygen insufflation may be used cautiously, prioritising re-intubation if the patient decompensates.

Best Practice Statement: The use of an AEC can be beneficial to facilitate reintubation in adult patients at risk of extubation failure. (Class of Recommendation: 2a, Level of Evidence: B-NR).

FUTURE DIRECTION

Future research is needed to clarify several grey areas related to at-risk extubation, including, but not limited to, the use of nebulised adrenaline for suspected airway oedema, which lacks strong evidence in adults and children. Lung recruitment manoeuvres performed at the time of extubation after anaesthesia, which, although studied intra-operatively, require further evaluation for their role in improving post-extubation oxygenation. The optimal approach to awake versus deep extubation in paediatric patients remains uncertain, with limited outcome data. Lastly, the predictive value of the cuff leak test for identifying airway oedema and extubation failure is inconsistent and warrants the development of better-defined criteria.

SUMMARY

The AIDAA 2025 guidelines for extubation of “at-risk” airways provide a structured, evidence-informed framework to improve patient safety during this vulnerable phase of anaesthesia. Centered on the SAFE strategy—Stratify Risk, Assemble and Anticipate, Facilitate Extubation, and Evaluate and Escalate—the guidelines emphasise systematic preparation, careful execution, and ongoing evaluation. Key recommendations include routine peri-extubation oxygen supplementation and quantitative assessment of neuromuscular recovery prior to extubation. Recognising that not all patients can be safely managed with a single-step approach, the guidelines introduce staged sequential extubation and delayed extubation as alternatives for those at higher risk of airway compromise, collapse, or tube dependence. Additionally, practical solutions are provided for challenging scenarios such as stuck tracheal tubes and unexpected extubation failure. These updated guidelines integrate best available evidence, expert consensus, and a pragmatic algorithm to ensure safer and more predictable outcomes in extubation practice.

Study data availability

De-identified data related to the guidelines may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared upon request.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.

Declaration of use of permitted tools

The tables and figures are self-made and not copyrighted.

Authors contributions

RG, SMA, SNM, APS, VR, AP, SRS, JVD, JRD, PK – all authors conceptualised the idea for this manuscript. RG and SMA conducted the literature search and drafted the manuscript. All authors provided input, revised and approved the manuscript.

Supplementary material

This article has supplementary material and can be accessed at this link. Supplementary Material at http://links.lww.com/IJOA/A47.

Conflicts of interest

Dr Amit Shah- inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Dr Apeksh Patwa-inventor of Patwashahi video laryngoscope (non-commercial), designer of HFNO device HuFlo2. Dr Rakesh Garg, Dr Pankaj Kundra, Dr Sheila Nainan Myatra, Dr Syed Moied Ahmed, and Dr Jeson R Doctor, who are co-authors of this manuscript, are editors of this journal. They were not involved in the decision-making process, and an independent editor handled this manuscript. Other authors declare that they have no conflicts of interest.

APPENDICES

Appendix 1

Research Question: Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected ?

• Population: Adult patient undergoing extubation after general anaesthesia

• Intervention: Cuff leak test

• Comparator: Extubation without cuff leak test

• Outcome: Airway oedema, stridor, airway obstruction, re-intubation, extubation failure, post-operative pulmonary complications, hypoxia, oxygen supplementation, ventilation.

Supplementary Table 1a.

Concept table for Research Question: Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected ?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4
Key concepts	Cuff leak	Cuff leak test	Laryngeal oedema	Extubation
Free text terms/natural language terms	“cuff” “leak”	“cuff” “leak”	“larynx oedema” “larynx oedema”	“airway extubation” “extubation”
(synonyms, UK/US terminology, medical/ laymen's terms)		“research” “design” “research design” “test”	“laryngeal oedema” “laryngeal oedema”	“extubated” “extubations” “extubate” “extubating”
Controlled vocabulary terms/Subject terms (MeSH)		“research design”[MeSH Terms]	“laryngeal oedema” [MeSH Terms]	“airway extubation”[MeSH Terms]

Search String:

PubMed: 87 results

“cuff”[All Fields] AND “leak”[All Fields] AND (“research design”[MeSH Terms] OR (“research”[All Fields] AND “design”[All Fields]) OR “research design”[All Fields] OR “test”[All Fields]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields])

Scopus: 101 results

(TITLE-ABS-KEY (cuff) AND TITLE-ABS-KEY (leak)) AND (TITLE-ABS-KEY( “research design”) OR TITLE-ABS-KEY (research AND design) OR TITLE-ABS-KEY (test)) AND (TITLE-ABS-KEY(“airway extubation”) OR TITLE-ABS-KEY (extubated) OR TITLE-ABS-KEY (extubation) OR TITLE-ABS-KEY (extubations) OR TITLE-ABS-KEY (extubate) OR TITLE-ABS-KEY (extubating))

Supplementary Figure 1

PRISMA flow chart for Research Question: Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected ?

Supplementary Table 1b.

Summary table for included studies for Research Question: Does performing the cuff leak test prior to extubation reduce the chances of extubation failure when airway oedema is suspected ?

Author (Year)	Type of Study	Journal	Level of Evidence	Set-up	Intervention	Supports CLT
Dai Y (2017)[69]	Retrospective Analysis	Clin Respir	C-LD	Post operative	CLT + interventional	Yes
Fontes C (2020)[70]	Observational Study	J Rev Bras	C-LD	Post operative	flexible bronchoscopy CLT >200 mL	No clear
Bhargava M (2021)[71]	Observational Study	Ter Intensiva Indian J	C-LD	Post operative	ACWD via Ultrasound	conclusion Yes (for both
Beigmohammadi MT (2022)[72]	Observational Study	Anaesth Tanaffos	C-LD	Post operative	vs CLT GT vs Quantitative vs Qualitative CLT	ACWD and CLT) Yes for GT
Mohammad T (2023)[73]	Prospective Cohort	Egypt J	C-LD	Post operative	CLT and ACWD via	ACWD - Yes. CLT
Kallet RH (2023)[68]	Study Retrospective Analysis	Anaesth Respir Care	C-LD	Surgical ICU	ultrasound CLT < 110 mL	- Not significant Yes

CLT=Cuff leak test, GT=Gargle Test, ACWD=Air Column Width Difference

Appendix 2

Research Question 2: Should neuromuscular monitoring (NMM) be performed before extubation?

• Population: Adult patients undergoing extubation after general anaesthesia with relaxation Intervention: Neuromuscular monitoring

• Comparator: Without neuromuscular monitoring

Outcome: Extubation failure, re-intubation, residual paralysis, post-operative pulmonary complication, desaturation, hypoxia.

Supplementary Table 2a.

Concept table for Research Question: Should neuromuscular monitoring (NMM) be performed before extubation?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5
Key concepts	Adult patient	Extubation	Neuromuscular blockade	General Anaesthesia (GA)	Neuromuscular monitoring
Free text terms/natural language terms (synonyms, UK/US terminology, medical/ laymen's terms, acronyms/ abbreviations)	“adult patient” “adult” “adults” “adult s”	“extubation” “airway extubations” “extubation, airway” “extubations, airway” “tracheal extubation” “extubations, tracheal” “extubation, tracheal” “tracheal extubations” “endotracheal extubation” “endotracheal extubations” “extubation, endotracheal” “extubations, endotracheal” “extubation, intratracheal” “extubations, intratracheal” “intratracheal extubation” “intratracheal extubations”	“neuromuscular blockade” “blockade, neuromuscular” “neuromuscular block” “block, neuromuscular”	“anaesthesia, general” “anaesthesia” “anaesthesia, obstetrical” “anaesthesias, general” “general anaesthesia” “general anaesthesias”	“neuromuscular monitoring” “monitoring, neuromuscular” “neuromuscular blockade” “monitoring” “blockade” “monitoring, neuromuscular blockade” “train-of-four monitoring” “monitoring, train-of-four” “train of four monitoring”
Controlled vocabulary terms/ Subject terms (MeSH terms, Emtree terms) Consider: explode, major headings, subheadings	“Adult”[Mesh]	“Airway Extubation”[Mesh]	“Neuromuscular Blockade”[Mesh]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, Obstetrical”[Mesh]	“Neuromuscular Monitoring”[Mesh]

Search string

PubMed: 43 results

(“extubation” [All Fields] OR “extubation airway” [All Fields] OR “Tracheal Extubation” [All Fields] OR “extubation tracheal”[All Fields] OR “Tracheal Extubations”[All Fields] OR “Endotracheal Extubation”[All Fields] OR “Endotracheal Extubations”[All Fields] OR “extubation endotracheal”[All Fields] OR “Intratracheal Extubation”[All Fields] OR ‘Airway Extubation”[MeSH Terms]) AND 2000/01/01:2024/12/31[Date - Publication] AND ((“adult patient”[All Fields] OR ‘Adult”[All Fields] OR “adults”[All Fields] OR “adult s”[All Fields] OR ‘Adult”[MeSH Terms]) AND 1999/01/01:2025/12/31[Date - Publication]) AND ((“Neuromuscular Blockade”[MeSH Terms] OR (“neuromuscular”[All Fields] AND “blockade”[All Fields]) OR “Neuromuscular Blockade”[All Fields] OR “blockade neuromuscular”[All Fields] OR “Neuromuscular Block”[All Fields] OR “block neuromuscular”[All Fields] OR “Neuromuscular Blockade”[MeSH Terms]) AND 2000/01/01:2024/12/31[Date - Publication]) AND (((“neuromuscular”[All Fields] AND “monitoring”[All Fields]) OR “neuromuscular monitoring”[All Fields] OR “monitoring neuromuscular”[All Fields] OR “Neuromuscular Blockade Monitoring”[All Fields] OR “monitoring neuromuscular blockade”[All Fields] OR “train of four monitoring”[All Fields] OR “monitoring train of four”[All Fields] OR “train of four monitoring”[All Fields]) AND 2000/01/01:2024/12/31[Date - Publication]) AND ((“anesthesia general methods”[Title/Abstract] OR “anesthesia*”[Title/Abstract] OR “General Anesthesia”[Title/Abstract] OR “General Anesthesias”[Title/Abstract] OR “anesthetics, general”[MeSH Terms] OR ‘Anesthesia”[MeSH Terms]) AND 2000/01/01:2025/12/31[Date - Publication])

Scopus: 77 results

TITLE-ABS-KEY (“Preschool Child” OR “children preschool” OR “Preschool Children” OR “Children” OR “child preschool” OR “Child” OR “Pediatrics”) AND TITLE-ABS-KEY (“management airway” OR ‘Airway Control” OR “control airway” OR “Airway Obstructions” OR “obstruction airway” OR “obstructions airway” OR “Choking” OR “Intratracheal Intubation” OR “Intratracheal Intubations” OR “intubation endotracheal” OR “Endotracheal Intubation” OR “Endotracheal Intubations” OR “Airway Management” OR “Airway Obstruction” OR “intubation intratracheal”) AND TITLE-ABS-KEY (“transtracheal puncture” OR “needle cricothyrotomy” OR “cricothyrotomy” OR “cricothyrotomy cannula” OR “cannula cricothyroidotomy” OR “surgical cricothyroidotomy” OR “surgical cricothyrotomy” OR “Tracheostomy” OR “Surgical airway” OR “surgical airway access” OR “surgical airways” OR “emergency surgical airway” OR “emergency surgical airways” OR “emergency surgical airway procedures” OR “front of neck access” OR “front of neck airway” OR “front of neck airway access” OR “fona” OR “Tracheotomy” OR “Tracheostomy”) AND TITLE-ABS-KEY (“anesthesia general methods” OR “anesthesia” OR “General Anesthesia” OR “General Anesthesias” OR “anesthetics general” OR ‘Anesthesia”) AND PUBYEAR > 1999 AND PUBYEAR < 2026

Supplementary Figure 2

PRISMA flow chart for Research Question: Should neuromuscular monitoring (NMM) be performed before extubation?

Supplementary Table 2b.

Summary table for included studies for Research Question: Should neuromuscular monitoring (NMM) be performed before extubation?

Neuromuscular monitoring at extubation
Author and Year	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Supports Neuromuscular Monitoring (NMM) at Extubation
Thilen SR (2023)[76]	Anesthesiology	Guideline	A	Clinical signs vs qualitative NMM vs quantitative NMM	Yes (Quantitative)
Carvalho H (2020)[74]	Br J Anaesth	Meta-analysis	A	Quantitative vs qualitative vs no monitoring	Yes (Quantitative)
Huang S (2024)[77]	Med Sci Monit	Randomised Controlled Trial (RCT)	B-R	Ultrasound (diaphragmatic thickening) fraction) + NMM vs NMM vs no NMM	Yes (DTF, NMM)
Raval AD (2020)[75]	J Clin Anesth	Meta-analysis (observational studies)	B-R	Quantitative NMM vs qualitative NMM vs no NMM	Yes (Quantitative)

NMM=Neuromuscular Monitoring; RCT=Randomised Controlled Trial; LOE=Level of Evidence; DTF=Diaphragmatic Thickening Fraction

Appendix 3

Research Question 3: Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected?

• Population: Adult patients undergoing extubation after general anaesthesia

• Intervention: Epinephrine nebulisation

• Comparator: No nebulisation, Saline nebulisation

• Outcome: Stridor, airway oedema, airway obstruction, extubation failure, re-intubation, desaturation, hypoxia

Supplementary Table 3a.

Concept table for Research Question: Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5	Concept 6
Key concepts	Nebulisation	Epinephrine	Laryngeal oedema	GA	Extubation	Adult, patients
Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms)	“nebule” “nebules” “nebulisation” “nebulisations” “nebulise” “nebulised” “nebuliser	“epinephrine” “adrenalin” “adrenaline” ”epinephrine” “epinephrines”	“larynx oedema” “larynx oedema” “laryngeal oedema” “laryngeal oedema”	Anaesthesia, General/methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias	“airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	“adult” “adults” “adult's” “patients” “patient” “patient's” “patients's”
Controlled vocabulary terms/ Subject terms (MeSH)	“nebulizers and vaporizers”[MeSH Terms]	“epinephrine”[MeSH]	“laryngeal oedema” [MeSH Terms]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]	“airway extubation”[MeSH Terms]	“adult”[MeSH Terms] “patients”[MeSH Terms]

Search String

PubMed: 218 results

((“nebule”[All Fields] OR “nebules”[All Fields] OR “nebulisation”[All Fields] OR “nebulisations”[All Fields] OR “nebulise”[All Fields] OR “nebulised”[All Fields] OR “nebuliser”[All Fields] OR “nebulizers and vaporizers”[MeSH Terms] OR (“nebulizers”[All Fields] AND “vaporizers”[All Fields]) OR “nebulizers and vaporizers”[All Fields] OR “nebulizer”[All Fields] OR “nebulisers”[All Fields] OR “nebulising”[All Fields] OR “nebulization”[All Fields] OR “nebulizations”[All Fields] OR “nebulize”[All Fields] OR “nebulized”[All Fields] OR “nebulizer s”[All Fields] OR “nebulizers”[All Fields] OR “nebulizing”[All Fields]) AND (“epinephrine”[MeSH Terms] OR “epinephrine”[All Fields] OR “adrenalin”[All Fields] OR “adrenaline”[All Fields] OR “epinephrin”[All Fields] OR “epinephrines”[All Fields]) AND “after”[All Fields]) OR ((“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields]) AND (“laryngeal oedema”[All Fields] OR “laryngeal edema”[MeSH Terms] OR (“laryngeal”[All Fields] AND “edema”[All Fields]) OR “laryngeal edema”[All Fields]) AND (“adult”[MeSH Terms] OR “adult”[All Fields] OR “adults”[All Fields] OR “adult s”[All Fields]) AND (“general anaesthesia”[All Fields] OR “anesthesia, general”[MeSH Terms] OR (“anesthesia”[All Fields] AND “general”[All Fields]) OR “general anesthesia”[All Fields] OR (“general”[All Fields] AND “anesthesia”[All Fields])))

Scopus: 908 results

(TITLE-ABS-KEY (nebulization OR nebulisation OR nebuliser OR nebuliser) AND TITLE-ABS-KEY (epinephrine OR adrenalin OR adrenaline)) OR (TITLE-ABS-KEY (extubation) AND TITLE-ABS-KEY (“laryngeal oedema” OR “laryngeal oedema”) AND TITLE-ABS-KEY (adult) AND TITLE-ABS-KEY (“general anaesthesia” OR “general anaesthesia”))

Supplementary Figure 3

PRISMA flow chart for Research Question: Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected?

Supplementary Table 3b.

Summary table for included studies for Research Question: Should nebulisation with adrenaline be performed in adults during extubation when laryngeal oedema is suspected?

Epinephrine nebulisation in adult patients
Author and Year	Journal	Type of Study	Evidence Grade	Intervention	Supports the Nebulisation in adults
Muraro A (2022)[80]	Allergy	Guideline	C-EO	Inhaled epinephrine + IM epinephrine in anaphylaxis	Yes (Reduces oedema)
Suri A (2022)[81]	Indian Journal of Anaesthesia	Case report	C-EO	Epinephrine nebulised via suspension laryngoscope	Yes (Novel delivery technique)
Ambasta S (2016)[82]	Indian Journal of Anaesthesia	Letter to the Editor	C-EO	Epinephrine nebulisation via a videolaryngoscope	Yes (Novel delivery technique)
Pluijms WA (2015)[78]	Critical Care	Review article	C-EO	Nebulised epinephrine + corticosteroids post- extubation	Yes (Supports epinephrine use)
MacDonnell SP et al (1995)[79]	Anaesthesia	Case Reports	C-EO	Nebulised epinephrine (1 mg in 5 ml saline) for airway obstruction	Yes (Supports use in laryngeal oedema)

IM=Intramuscular

Appendix 4

Research Question: Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected?

• Population: Paediatric age group requiring tracheal extubation after surgery

• Intervention: Epinephrine/steroid/other drugs nebulisation at extubation

• Comparator: No nebulisation/Saline nebulisation

• Outcomes: Post-operative pulmonary complication (POPC), laryngospasm, stridor, negative pressure pulmonary oedema (NPPE), desaturation, re-intubation, continuous positive airway pressure (CPAP)/ non-invasive ventilation (NIV), use of drugs to aid the extubation

Supplementary Table 4a.

Concept table for Research Question: Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5
Key concepts	Nebulisation	Epinephrine/steroid/saline	Paediatric age group	GA	Extubation
Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms)	“nebule” “nebules” “nebulisation” “nebulisations” “nebulise” “nebulised” “nebuliser	“epinephrine” “adrenalin” “adrenaline” “epinephrin” “epinephrines” (“steroidal”[All Fields] “steroidals”[All Fields] “steroidic”[All Fields] “steroids” “steroid”[All Fields])] “saline solution” “saline” “salines”	Preschool Child Children, Preschool Preschool Children Children	Anaesthesia, General/methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias	“airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”
Controlled vocabulary terms/ Subject terms (MeSH)	“nebulizers and vaporizers”[MeSH Terms]	“epinephrine”[MeSH] “steroids”[MeSH Terms] “saline solution”[MeSH Terms	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]	“airway extubation”[MeSH Terms]

Search String

PubMed: 55 results

((“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND ((“epinephrine”[MeSH Terms] OR “epinephrine”[All Fields] OR “adrenalin”[All Fields] OR “adrenaline”[All Fields] OR “epinephrin”[All Fields] OR “epinephrines”[All Fields] OR (“steroidal”[All Fields] OR “steroidals”[All Fields] OR “steroidic”[All Fields] OR “steroids”[MeSH Terms] OR “steroids”[All Fields] OR “steroid”[All Fields]) OR (“saline solution”[MeSH Terms] OR (“saline”[All Fields] AND “solution”[All Fields]) OR “saline solution”[All Fields] OR “saline”[All Fields] OR “salines”[All Fields])) AND (“nebule”[All Fields] OR “nebules”[All Fields] OR “nebulisation”[All Fields] OR “nebulisations”[All Fields] OR “nebulise”[All Fields] OR “nebulised” [All Fields] OR “nebuliser”[All Fields] OR “nebulizers and vaporizers”[MeSHTerms] OR (“nebulizers” [All Fields] AND “vaporizers”[All Fields]) OR “nebulizers and vaporizers”[All Fields] OR “nebulizer”[All Fields] OR “nebulisers”[All Fields] OR “nebulising”[All Fields] OR “nebulization”[All Fields] OR “nebulizations”[All Fields] OR “nebulize”[All Fields] OR “nebulized”[All Fields] OR “nebulizer s”[All Fields] OR “nebulizers”[All Fields] OR “nebulizing”[All Fields]) AND (“humans”[MeSH Terms] AND 2000/01/01:2024/12/31[Date - Publication] AND “english”[Language])) AND (“intubate”[All Fields] OR “intubated”[All Fields] OR “intubates”[All Fields] OR “intubating” [All Fields] OR “intubation”[MeSH Terms] OR “intubation” [All Fields] OR “intubations” [All Fields] OR “intubator”[All Fields] OR “intubator s”[All Fields] OR “intubators”[All Fields] OR (“general anaesthesia”[All Fields] OR “anesthesia, general”[MeSH Terms] OR (“anesthesia”[All Fields] AND “general”[All Fields]) OR “general anesthesia”[All Fields] OR (“general”[All Fields] AND “anesthesia”[All Fields])) OR (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields]))) AND ((humans[Filter]) AND (2000:2024[pdat]) AND (english[Filter]))

Scopus: 53 results

(TITLE-ABS-KEY (“preschool child” OR “children preschool” OR “preschool children” OR “children” OR “child” OR “pediatrics”)) AND (TITLE-ABS-KEY (“epinephrine” OR “adrenaline” OR “steroids” OR “steroid” OR “saline solution” OR “saline”)) AND (TITLE-ABS-KEY (“nebule” OR “nebulisation” OR “nebuliser” OR “nebulizer” OR “nebulizing” OR “nebulized” OR “nebulization”)) AND (TITLE-ABS-KEY (“endotracheal tube” OR “general anesthesia” OR “general anaesthesia” OR “airway extubation” OR “extubation”)) AND PUBYEAR > 1999 AND PUBYEAR < 2025 AND (LIMIT-TO (LANGUAGE, “English”))

Supplementary Figure 4

PRISMA flow chart for Research Question: Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected?

Supplementary Table 4b.

Summary table for included studies for Research Question: Should nebulisation with adrenaline be performed in paediatrics during extubation when laryngeal oedema is suspected?

Epinephrine nebulisation during and after extubation to reduce laryngeal oedema in children
Author and Year	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Supports the Epinephrine nebulisation in paediatric patients
Cesar RG (2009)[84]	Int J Pediatr Otorhinolaryngol	Prospective double-blind RCT	B-R	Steroid + Nebulised epinephrine versus Saline	No
Da Silva (2012)[50]	Intensive Care Medicine	Prospective double-blind RCT	B-R	L-epinephrine nebulisation at different doses	Yes (0.5 and 2.5 ml)
Preutthipan A (2005)[85]	J Med Assoc Thailand	Prospective double-blind RCT	B-R	Nebulised L-epinephrine (0.05 or 0.5 ml/kg)	Yes
Sinha A (2010)[83]	Indian Pediatrics	Prospective double-blind RCT	B-R	Nebulised epinephrine versus Budesonide	Yes

RCT=Randomised control trial

Appendix 5

Research Question: Does tracheal cuff inflation with lignocaine in adults reduce the haemodynamic response, cough and laryngopharyngeal symptoms during and after extubation?

• Population: Adult patients undergoing general anaesthesia at extubation

• Intervention: Intra-cuff lignocaine

• Comparator- Intra-cuff saline/air

• Outcome: Haemodynamic response, hypertension, tachycardia, cough, sore throat

Supplementary Table 5a.

Concept table for Research Question: Does tracheal cuff inflation with lignocaine in adults reduce the haemodynamic response, cough and laryngopharyngeal symptoms during and after extubation?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5	Concept 6
Key concepts Free text terms/natural language terms (synonyms, UK/US terminology, medical/ laymen's terms)	Lignocaine “lidocain” “lidocaine” “lignocaine” “lidocaine's “ “lignocain”	Extubation “airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	Adult “adult” “adults” “adult's”	GA Anaesthesia, General/ methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias	Intracuff “cuff” “intracuff” “intra-cuff”	Endotracheal tube “endotracheal” “endotracheally” “tube”
Controlled vocabulary terms/Subject terms (MeSH)	“lidocaine”[MeSH Terms]	“airway extubation”[MeSH Terms]	“adult”[MeSH Terms]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]

Search string

PubMed: 49 results

((“Cuff”[All Fields] OR “Intracuff”[All Fields] OR “Intra-cuff”[All Fields] OR “Cuf”[All Fields]) AND (“lidocain”[All Fields] OR “lidocaine”[MeSH Terms] OR “lidocaine”[All Fields] OR “lignocaine”[All Fields] OR “lidocaine s”[All Fields] OR “lignocain”[All Fields]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields] OR ((“endotracheal”[All Fields] OR “endotracheally”[All Fields]) AND “tube”[All Fields])) AND (“adult”[MeSH Terms] OR “adult”[All Fields] OR “adults”[All Fields] OR “adult s”[All Fields] OR (“general anaesthesia”[All Fields] OR “anesthesia, general”[MeSH Terms] OR (“anesthesia”[All Fields] AND “general”[All Fields]) OR “general anesthesia”[All Fields] OR (“general”[All Fields] AND “anesthesia”[All Fields])))) AND ((humans[Filter]) AND (2000:2024[pdat]))

Scopus: 121 results

(TITLE-ABS-KEY (cuff OR intracuff OR “intra-cuff” OR cuf) AND TITLE-ABS-KEY (lidocaine OR lignocaine) AND TITLE-ABS-KEY (“airway extubation” OR (airway AND extubation) OR extubated OR extubation OR extubate OR extubating OR (endotracheal AND tube)) AND TITLE-ABS-KEY (adult OR adults OR “general anaesthesia” OR (anaesthesia AND general))) AND PUBYEAR > 1999 AND PUBYEAR < 2025 AND (LIMIT-TO (DOCTYPE, “ar”) OR LIMIT-TO (DOCTYPE, “med”))

Supplementary Figure 5

PRISMA flow chart for Research Question: Does tracheal cuff Inflation with lignocaine In adults reduce the haemodynamic response, cough and laryngopharyngeal symptoms during and after extubation?

Supplementary Table 5b.

Summary table for included studies for Research Question: Does tracheal cuff inflation with lignocaine in adults reduce the haemodynamic response, cough and laryngopharyngeal symptoms during and after extubation?

Intra-cuff lignocaine to prevent extubation response in adults
Author and Year	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Supports Intra-cuff Lignocaine
Lam F (2015)[88]	PLoS One	Meta-analysis	B-R	Lignocaine (alkalinised/non-alkalinised) versus saline/air, Primary objective: POST, Secondary: cough, agitation, hoarseness, dysphagia, dysphonia, desaturation	Yes (Lignocaine (alkalinised/non- alkalinised) reduces POST and other phenomena.
Peng F (2020)[89]	J Int Med Res	Meta-analysis	B-R	Lignocaine (alkalinised/non-alkalinised) versus saline/air. Primary outcome: cough, Secondary: hoarseness, agitation/ restlessness, and dysphonia	Yes (Intra-cuff alkalinised or non-alkalinised lignocaine significantly reduced coughing and other intubation-related complications)
Nath P (2018)[90]	Anesth Analg	Randomised Controlled Trial (RCT)	B-R	Lignocaine (alkalinised) versus saline Primary outcome- Cough	Yes (decrease cough at the emergency)
Zhan B (2020)[91]	J Craniofac Surg	Randomised Controlled Trial (RCT)	B-R	Lignocaine (alkalinised, non-alkalinised) versus saline/air Primary: POST Secondary: tube sequel and haemodynamics	Yes (alkalinised lignocaine reduces Cough + reduces Haemodynamic changes)
Souissi H (2016)[92]	Can J Anaesth	Randomised Controlled Trial (RCT)	B-R	Lignocaine (alkalinised) versus saline Primary: Cough Secondary: sore throat, hoarseness, nausea, vomiting	Yes (for cough)
Fagan C (2000)[93]	Anesth Analg	Randomised Controlled Trial (RCT)	B-R	Lignocaine (non-alkalinised) versus saline/ air Outcome: cough, hemodynamics	Yes (only for cough)
Chen ZX (2021)[94]	World J Clin Cases	Meta-analysis	B-R	Lignocaine (alkalinised/non-alkalinised) versus saline/air Primary: cough Secondary: hoarseness, POST	Yes (only for cough)
Zafar J (2023)[95]	Pak Armed Forces Med J	Quasi-experimental	C-LD	Lignocaine (non-alkalinised) versus air Outcome: Cough	Yes (only for cough)
Alkaissi A (2022)[96]	Palestinian Med Pharm J	Randomised Controlled Trial (RCT)	B-R	Lignocaine (non-alkalinised) vs saline/air/ dexamethasone	Yes (only for cough)
Kulkarni LM (2016)[86]	Anaesth Pain Intensive Care	Randomised Controlled Trial (RCT)	B-R	VGB Lubic gel plus Lignocaine 4% versus lubrication with saline+air Outcome: Post-extubation morbidities	Yes (gel+lignocaine)- (for cough, hoarseness, Sore throat, haemodynamics)
Vijayakumar R (2024)[87]	J Krishna Inst Med Sci Univ	Randomised Controlled Trial (RCT)	B-R	Lignocaine (alkalinised) versus air Outcome: POST, hoarseness, haemodynamics)	Yes (for cough, haemodynamic changes)

RCT=Randomised Controlled Trial; LOE=Level of Evidence: POST=postoperative throat; VGB=Vegetable Gum-Based gel

Appendix 6

Research Question: Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients?

• Population: Paediatric age group requiring tracheal extubation after surgery

• Intervention: Intra-cuff lignocaine

• Comparator: Intra-cuff air/saline

• Outcomes: Cough/Bronchospasm/Laryngospasm/Sore throat/Stridor/Use of drugs to aid the extubation

Supplementary Table 6a.

Concept table for Research Question: Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5	Concept 6
Key concepts	Lignocaine/Air/Saline	Extubation	Paediatric age group	GA	Intracuff	Endotracheal tube
Free text terms/ natural language terms (synonyms, UK/US terminology, medical/ laymen's terms)	“lidocain” “lidocaine” “lignocaine” “lidocaine's “ “lignocain” “air” “saline” “saline solution” “salines”	“airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	Preschool Child Children, Preschool Preschool Children Children	Anaesthesia, General/methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias	“cuff” “intracuff” “intra-cuff”	“endotracheal” “endotracheally” “tube”
Controlled vocabulary terms/Subject terms (MeSH)	“lidocaine”[MeSH Terms] “saline solution”[MeSH Terms]	“airway extubation”[MeSH Terms]	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]

Search String:

PubMed: 66 results

((“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms])) AND ((“Cuff”[All Fields] OR “Intracuff” [All Fields] OR “Intra-cuff” [All Fields]) AND (“lidocain”[All Fields] OR “lidocaine”[MeSH Terms] OR “lidocaine”[All Fields] OR “lignocaine”[All Fields] OR “lidocaine s”[All Fields] OR “lignocain”[All Fields] OR “air”[All Fields] OR (“saline solution”[MeSH Terms] OR (“saline”[All Fields] AND “solution”[All Fields]) OR “saline solution”[All Fields] OR “saline”[All Fields] OR “salines”[All Fields])) AND (“humans”[MeSH Terms] AND 2000/01/01:2024/12/31[Date - Publication] AND “english”[Language])) AND (“humans”[MeSH Terms] AND 2000/01/01:2024/12/31[Date - Publication] AND “english”[Language]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields] OR (“general anaesthesia”[All Fields] OR “anesthesia, general”[MeSH Terms] OR (“anesthesia”[All Fields] AND “general”[All Fields]) OR “general anesthesia”[All Fields] OR (“general”[All Fields] AND “anesthesia”[All Fields])) OR ((“endotracheal”[All Fields] OR “endotracheally”[All Fields]) AND “tube”[All Fields]))) AND ((humans[Filter]) AND (2000:2024[pdat]) AND (english[Filter]))

Scopus: 104 results

(TITLE-ABS-KEY (“preschool child” OR “children preschool” OR “preschool children” OR “children” OR “child” OR “pediatrics”)) AND (TITLE-ABS-KEY (“cuff” OR “intracuff” OR “intra-cuff”)) AND (TITLE-ABS-KEY (“lidocaine” OR “lignocaine” OR “lidocaine s” OR “lignocain” OR “air” OR “saline solution” OR “saline” OR “salines”)) AND (TITLE-ABS-KEY (“airway extubation” OR “extubation” OR “extubated” OR “extubate” OR “extubating” OR “general anesthesia” OR “general anaesthesia” OR “endotracheal tube”)) AND PUBYEAR > 1999 AND PUBYEAR < 2025 AND (LIMIT-TO (LANGUAGE, “English”))

Supplementary Figure 6

PRISMA flow chart for Research Question: Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients?

Supplementary Table 6b.

Summary table for included studies for Research Question: Does tracheal cuff inflation with lignocaine attenuate the haemodynamic response and reduce laryngopharyngeal symptoms after extubation in paediatric patients?

Intra-cuff lignocaine to prevent extubation response in children (1-12 years)
Author and Year	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Supports Intra-cuff Lignocaine
Oliveira MRE (2024)[99]	Braz J Anesthesiol	Randomised Controlled Trial (RCT)	B-R	Air versus alkalinised lignocaine	Yes
Kavyashree MB (2024)[100]	Indian J Anaesth	Randomised Controlled Trial (RCT)	B-R	Air versus lignocaine 2%	Yes
Assefa B (2022)[17]	BMC Anesthesiol	Prospective observational cohort	B-NR	Air versus alkalinised lignocaine	Yes
Amucheazi AO (2019)[66]	Trends Anaesth Crit Care	Randomised Controlled Trial (RCT)	B-R	Air versus alkalinised lignocaine 2%	Yes
Soares SM (2017)[101]	Anaesthesia	Randomised Controlled Trial (RCT)	B-R	Air versus alkalinised lignocaine 0.5%/1%	Yes
Ahmady MS (2013)[97]	Anaesth Pain Intensive Care	Randomised Controlled Trial (RCT)	B-R	Saline versus alkalinised lignocaine	Yes
Behzadi M (2010)[98]	Int J Pediatr Otorhinolaryngol	Randomised Controlled Trial (RCT)	B-R	Intra-cuff lignocaine versus intravenous lignocaine	Unsure

RCT=Randomised Controlled Trial; LOE=Level of Evidence

Appendix 7

Research Question: Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients?

• Population: Paediatric age group requiring tracheal extubation after surgery

• Intervention: Awake extubation/deep extubation

• Comparator: Deep extubation/awake extubation

• Outcomes: Post-operative airway complications

Supplementary Table 7a.

Concept table for Research Question: Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4
Key concepts	Deep extubation	Awake Extubation	Paediatric age group	Postoperative Airway Complications
Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms)	“deep”[All Fields] “airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	“awake”[AN Fields] “awakeness”[AN Fields] “awakes”[All Fields] “awaking”[All Fields]) “airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	Preschool Child Children, Preschool Preschool Children Children	“laryngospasm” “stridor” “desaturation” “airway obstruction” “coughing” “breath holding” “post-extubation complications” “airway complications”
Controlled vocabulary terms/ Subject terms (MeSH)	“airway extubation”[MeSH Terms]	“airway extubation”[MeSH Terms]	“Child, Preschool”[Mesh] “Child”[Mesh] “Pediatrics”[MeSH]	“Laryngospasm”[MeSH] “Airway Obstruction”[MeSH] “Hypoxia”[MeSH] “Cough”[MeSH] “Complications”[MeSH]

Search String:

Scopus: 457 results

(extubate OR extubating) AND PUBYEAR AFT 1999 AND PUBYEAR BEF 2025 AND (LIMIT-TO (LANGUAGE, “English”)))”extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields])) AND ((humans[Filter]) AND (2000:2024[pdat]) AND (english[Filter]))

PubMed: 105 results

((((“awake”[All Fields] OR “awakeness”[All Fields] OR “awakes”[All Fields] OR “awaking”[All Fields]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields]) AND (“humans”[MeSH Terms] AND 2000/01/01:2024/12/31[Date - Publication] AND “english”[Language])) OR (“deep”[All Fields] AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields]) AND (“humans”[MeSH Terms] AND 2000/01/01:2024/12/31[Date - Publication] AND “english”[Language]))) AND (“Preschool Child”[All Fields] OR “children preschool”[All Fields] OR “Preschool Children”[All Fields] OR “Children” [All Fields] OR (“child, preschool”[MeSH Terms] OR “Child”[MeSH Terms] OR “Pediatrics”[MeSH Terms]))) AND ((humans[Filter]) AND (2000:2024[pdat]) AND (english[Filter]))

Supplementary Figure 7

PRISMA flow chart for Research Question: Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients?

Supplementary Table 7b.

Summary table for included studies for Research Question: Should extubation be performed awake or in deeper planes of anaesthesia in paediatric patients?

Awake versus deep extubation in paediatric patients (1-12 years)
Author and Year	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Supports Awake or Deep Extubation
Koo CH (2018)[104]	J Clin Med	Systematic review and meta-analysis	A	Awake versus deep extubation	Comparable
von Ungern-Sternberg BS (2013)[105]	Eur J Anaesthesiol	Randomised Controlled Trial (RCT)	B-R	Awake versus deep extubation	Comparable
Kaur S (2006)[106]	J Anaesthesiol Clin Pharmacol	Randomised Controlled Trial (RCT)	B-R	Propofol versus no propofol	Deep
Veyckemans F (2020)[62]	Paediatr Anaesth	Review article	C-EO	None	Comparable
Baijal RG (2015)[107]	Paediatr Anaesth	Prospective observational study	B-NR	Awake versus deep extubation	Comparable
Templeton TW (2019)[111]	Anesthesiology	Prospective observational study	B-NR	Awake extubation	Awake
Zhang X (2024)[110]	BMC Anesthesiol	Prospective observational study	B-NR	Deep extubation	Deep
Vitale L (2022)[103]	BMC Anesthesiol	Retrospective observational study	B-NR	Deep extubation	Comparable
Gautam NK (2019)[109]	Semin Cardiothorac Vasc Anesth	Retrospective observational study	B-NR	Deep extubation	Deep
Tsui BCH (2004)[102]	Anesth Analg	Prospective observational study	C-LD	Awake extubation (no touch technique)	Awake
Menda SK (2012)[108]	Can J Anaesth	Retrospective observational study	B-NR	Awake versus deep extubation	Comparable
Habre W (2017)[59]	Lancet Respir Med	Prospective multi-center observational study	B-NR	Awake versus deep extubation	Awake

RCT=Randomised Controlled Trial; LOE=Level of Evidence

Appendix 8

Research Question: Should a lung recruitment manoeuvre be performed before extubation in adult patients?

• Population: Adult patient undergoing extubation after general anaesthesia

• Intervention: Lung recruitment manoeuvre

• Comparator: Extubation without lung recruitment manoeuvre

• Outcome: Hypoxia, oxygen desaturation, post-operative pulmonary complications, re-intubation, extubation failure, oxygen supplementation, and ventilation

Supplementary Table 8a.

Concept table for Research Question: Should a lung recruitment manoeuvre be performed before extubation in adult patients?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4
Key concepts	Lung recruitment manoeuvre	Extubation	Adults	GA
Free text terms/ natural language terms (synonyms, UK/US terminology, medical/ laymen's terms)	“lung” “recruit” “recruited” “recruiter” “recruiters” “recruiting” “recruitment” “recruitments” “recruits” “manoeuvre” “maneuvered” “manoeuvring” “manoeuvrings” “manoeuvres” “manoeuvrability” “manoeuvrable” “manoeuvre” “manoeuvred” “manoeuvres” “manoeuvring”	“airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	“adult” “adults” “adult's”	Anaesthesia, General/ methods* Anesthesia* Anaesthesias, General General Anesthesia General Anesthesias
Controlled vocabulary terms/Subject terms (MeSH)	“lung”[MeSH Terms]	“airway extubation”[MeSH Terms]	“adult”[MeSH Terms]	“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]

Search string:

PubMed: 72 results

(“lung”[MeSH Terms] OR “lung”[All Fields]) AND (“recruit”[All Fields] OR “recruited”[All Fields] OR “recruiter”[All Fields] OR “recruiters”[All Fields] OR “recruiting”[All Fields] OR “recruitment”[All Fields] OR “recruitments”[All Fields] OR “recruits”[All Fields]) AND (“maneuver”[All Fields] OR “maneuvered”[All Fields] OR “maneuvering”[All Fields] OR “maneuverings”[All Fields] OR “maneuvers” [All Fields] OR “manoeuvrability” [All Fields] OR “manoeuvrable” [All Fields] OR “manoeuvre” [All Fields] OR “manoeuvred” [All Fields] OR “manoeuvres” [All Fields] OR “manoeuvring”[All Fields]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation” [All Fields]) OR “airway extubation” [All Fields] OR “extubated”[All Fields] OR “extubation” [All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields])

Scopus: 54 results

(TITLE-ABS-KEY (lung) AND TITLE-ABS-KEY (recruit OR recruited OR recruiter OR recruiters OR recruiting OR recruitment OR recruitments OR recruits) AND TITLE-ABS-KEY (manoeuvre OR manoeuvred OR manoeuvring OR manoeuvres OR manoeuvrability OR manoeuvrable OR manoeuvre OR manoeuvred OR manoeuvres OR manoeuvring) AND TITLE-ABS-KEY (airway AND extubation OR extubated OR extubations OR extubate OR extubating))

Supplementary Figure 8

PRISMA flow chart for Research Question: Should a lung recruitment manoeuvre be performed before extubation In adult patients?

Supplementary Table 8b.

Summary table for included studies for Research Question: Should a lung recruitment manoeuvre be performed before extubation in adult patients?

Recruitment manoeuvre before or after extubation
Author (Year)	Journal	Type of Study	Level of Evidence (LOE)	Intervention	Recruitment at Extubation Supported
Koritarova L (2019)[113]	Eur J Anaesthesiol	Randomised Controlled Trial (RCT) in open gynaecological surgery	B-R	RM post-intubation and before extubation, and PEEP vs no RM, PEEP	Yes (Lower post­operative complications)
Bae J (2024)[114]	Perioper Med	Randomised Controlled Trial (RCT) in laparoscopic surgery	B-R	RM at 3 perioperative points, including pre-extubation vs no RM	No advantage in post­operative pulmonary complications
Kashyap L (2024)[112]	Ann Geriatric Med Res	Randomised Controlled Trial (RCT) in laparoscopic surgery in older adults	B-R	FiO2 1 vs RM followed by PEEP (5 cm H2O) with FiO2 1 vs RM followed by PEEP (5 cm H2O) with FiO2 0.4	Yes (RM + PEEP before extubation is beneficial with any FiO2)

RCT=Randomised Controlled Trial; LOE=Level of Evidence; PEEP=Positive End-Expiratory Pressure; RM=Recruitment Manoeuvre; FiO2 = Fraction of inspired oxygen

Appendix 9

Research Question: In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation?

• Population: Adult patients undergoing extubation after general anaesthesia

• Intervention: Airway exchange catheter, delayed extubation

• Comparator: Direct extubation/Conventional extubation

• Outcome: Re-intubation, extubation failure, post-operative pulmonary complication, desaturation, hypoxia

Supplementary Table 9a.

Concept table for Research Question: In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation?

Research Question	Concept 1	Concept 2	Concept 3	Concept 4	Concept 5
Key concepts Free text terms/ natural language terms (synonyms, UK/ US terminology, medical/laymen's terms)	Airway exchange catheter “airway” “airway s” “airways” “exchangeable” “exchange” “exchangeabilities” “exchangeability” “exchangeable” “exchanged” “exchanger” “exchanger s” “exchangers” “exchanges” “exchanging” “catheter s” “catheters” “catheters” “catheter”	Extubation “airway extubation” “extubation” “extubated” “extubations” “extubate” “extubating”	Endotracheal tube “endotracheal” “endotracheally” “tube”	GA Anaesthesia, General/ methods* Anesthesia* Anaesthesia, General General Anesthesia General Anesthesias	Adult “adult” “adults” “adults”
Controlled vocabulary terms/ Subject terms (MeSH)		“airway extubation”[MeSH Terms]		“Anaesthetics, General”[Mesh] “Anesthesia”[Mesh] “Anaesthesia, General”[Mesh]	“adult”[MeSH Terms]

Search string:

PubMed: 63 results

((“airway”[All Fields] OR “airway s”[All Fields] OR “airways”[All Fields]) AND (“exchangable”[All Fields] OR “exchange”[All Fields] OR “exchangeabilities”[All Fields] OR “exchangeability”[All Fields] OR “exchangeable”[All Fields] OR “exchanged”[All Fields] OR “exchanger”[All Fields] OR “exchanger s”[All Fields] OR “exchangers”[All Fields] OR “exchanges” [All Fields] OR “exchanging” [All Fields]) AND (“catheter s”[All Fields] OR “catheters”[MeSH Terms] OR “catheters”[All Fields] OR “catheter”[All Fields]) AND (“airway extubation”[MeSH Terms] OR (“airway”[All Fields] AND “extubation”[All Fields]) OR “airway extubation”[All Fields] OR “extubated”[All Fields] OR “extubation”[All Fields] OR “extubations”[All Fields] OR “extubate”[All Fields] OR “extubating”[All Fields] OR ((“endotracheal”[All Fields] OR “endotracheally”[All Fields]) AND “tube”[All Fields]) OR (“general anaesthesia”[All Fields] OR “anesthesia, general”[MeSH Terms] OR (“anesthesia”[All Fields] AND “general”[All Fields]) OR “general anesthesia”[All Fields] OR (“general”[All Fields] AND “anesthesia”[All Fields]))) AND (“adult”[MeSH Terms] OR “adult”[All Fields] OR “adults”[All Fields] OR “adult s”[All Fields])) AND (2000:2024[pdat])

Scopus: 91 results

(TITLE-ABS-KEY (airway OR airways) AND TITLE-ABS-KEY (exchange OR exchangeability OR exchangeable OR exchanged OR exchanger OR exchangers OR exchanges OR exchanging) AND TITLE-ABS-KEY (catheter OR catheters) AND TITLE-ABS-KEY(“airway extubation” OR (airway AND extubation) OR extubated OR extubation OR extubate OR extubating OR (endotracheal AND tube) OR “general anaesthesia”) AND TITLE-ABS-KEY (adult OR adults)) AND PUBYEAR > 1999 AND PUBYEAR < 2025

Supplementary Figure 9

PRISMA flow chart for Research Question: In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation?

Supplementary Table 9b.

Summary table for included studies for Research Question: In adult patients at risk of extubation failure, does the use of an AEC facilitate reintubation?

Airway exchange catheter (AEC)/CSES at extubation
Author and Year	Journal	Type	Level of Evidence (LOE)	Intervention	AEC/CSES Supported
Lu Y (2023)[31]	BMC Anesthesiol	Systematic review and meta-analysis	B-NR	CSES	Yes
Mort TC (2007)[30]	Anesth Analg	Observational	B-NR	AEC	Yes
Roten A (2019)[115]	BMC Anesthesiol	Prospective observational	B-NR	AEC	Yes
McManus D (2018)[116]	Anaesthesia	Prospective cohort	B-NR	CSES	Yes
Duggan LV (2011)[32]	Can J Anaesth	Review	C-LD	AEC	Yes
McLean DJ (2018)[117]	J Clin Anesth	Prospective observational	B-NR	AEC	Yes
Loudermilk EP(1997)[119]	Chest	Prospective	B-NR	Paediatric AEC	Yes
Furyk J (2017)[120]	Anaesth Intensive Care	Single-group observational	B-NR	CSES	Yes
Dosemeci L (2004)[121]	Crit Care	Prospective observational	B-NR	Paediatric AEC	Yes
Corso RM (2020)[118]	Minerva Anestesiol	Multicentric observational	B-NR	CSES	Unsure

AEC=Airway Exchange Catheter; CSES=Cook Staged Extubation Set; LOE=Level of Evidence

Appendix 10

Supplementary Table 10.

Consensus and Stability Analysis of the Clinical Statements from the Delphi Survey

Likert Scale Statements and Multiple-Choice Questions	Agree (%)	Neutral (%)	Disagree (%)	Median (IQR)	P
1. Nebulisation with adrenaline post extubation can reduce laryngeal oedema in adults	96	4	0	7(0)	0.47
2. Nebulisation with adrenaline post extubation can reduce laryngeal oedema in paediatric patients (1-12 years)	96	0	4	7(0)	0.63
3. If a difficult extubation is encountered due to failure of deflation of the tracheal tube cuff, the following interventions may be considered after ruling out other causes (laryngeal oedema by visual inspection, kinked inflation line, entangled endotracheal tube)?					0.52
• Needle puncture of the inflated cuff using a spinal needle under direct vision	31
• Cricothyroid puncture of inflated cuff after ascertaining the position using CT scan guidance	13
• Cutting the inflation line	65
• Deflating and re-inflating the cuff with minimal air	4
• Instillation of saline under direct vision over the glottis to add lubrication	0
• Twisting and turning the tube to disengage and pull out using minimal force	13
• Ultrasound guidance for the cuff puncture.	4

IQR=Interquartile range

Funding Statement

All expenses related to the development of the guidelines were entirely funded by the All India Difficult Airway Association (AIDAA).