Extubation is removing an endotracheal tube (ETT), which is the last step in liberating a patient from the mechanical ventilator. To discuss the actual procedure of extubation, one also needs to understand how to assess readiness for weaning and management before and after extubation.

Weaning is a gradual transition from full invasive ventilatory support to spontaneous ventilation with minimal support. Liberation, however, means the complete discontinuation of mechanical ventilation. The current trend is to use the term “liberation” as opposed to “weaning’” in intensive care unit (ICU) ventilator management because the goal is to liberate patients from the ventilator as soon as possible rather than weaning over several days to weeks. Weaning is more common in long-term, acute care settings.

If the patient has passed the spontaneous breathing trial (SBT) after weaning, they should undergo reassessment for the suitability of extubation. (See Figure 8^[1]) Many of these assessments may have been done at the start of the weaning trial or as a part of the daily assessment of the patient’s readiness to wean.

The most important part of this assessment is assessing the ability of the patient to protect and maintain a patent airway.

The patient should have an adequate level of consciousness – a Glascow Coma Scale (GCS) greater than 8 suggests a higher likelihood of successful extubation. The patient should have a strong cough. Most clinicians objectively determine the presence of a moderate to strong cough before extubation, although there are other objective measures like a MIP. The presence of a weak cough, or a MIP of more than -20 cm H2O, is a strong independent risk factor for extubation failure. Additionally, the patient should be assessed for the volume and thickness of respiratory secretions, and the cuff-leak test should be done to ensure airway patency. Clinicians must be familiar with the airway anatomy observed prior to intubation, recognize potential difficult airways, and understand the techniques used for intubation. In cases of a known difficult airway, it is essential to have all necessary equipment readily available. If extra personnel are needed, they should be informed beforehand and be available at very short notice^[2].

Withdrawing of Life Support for Death

One of the dilemmas that can occur when a patient is on mechanical ventilation relates to the cessation of medical interventions in patients. Sometimes these interventions range from minor, such as a non-life sustaining medication, to more complex, such as mechanical ventilation. The rationale for stopping these interventions is often based on the fact that the burdens are outweighing any benefits the patient may get from it. Sometimes life-sustaining therapies may prolong suffering at the cost of decreasing the patient’s quality of life. Patients and their family often decide to stop medical interventions based on some of these factors. One of the most heart-wrenching decisions that family members often have to make is about withdrawing life-sustaining treatments (life support) from patients. This is why advance directives are so important. Advance directives are documents that enable patients to make their decisions about medical care known to their family and health care providers, in the event that they are unable to make those decisions themselves. If a family member knows for sure that their loved one would not have wanted a particular medical intervention done, it may help to alleviate some of the burden they may feel about making the decision. It also helps prevent the initiation of some life-sustaining treatments beforehand, in which case no decision will be needed to withdraw that intervention. It also can help reduce overall costs of futile medical care^[4].