STEP I Screen

Passed SBT

SAT Done

Tracheal suction <q2h

Minimal oral secretions

Spontaneous cough

Cuff leak

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SBT=Spontaneous Breathing Trial; SAT=Spontaneous Awakening Trial

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If yes to any of the screening items, patient automatically classified as

High Risk - Delayed Failure.

If all criteria met, STOP - proceed to routine extubation.

Screen failure in any of the criteria place patient in categories above

Low Risk.

STEP II Assess

C-Spine Surgery (>3 levels + operative time > 5 hrs or blood loss >300 mL)

Restricted Airway Access

Cervical Immobility/Instability

History of Difficult Airway

BMI >40kg/m2

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Any Of The Following:

STEP II Assess

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>2 Of The Following:

Age >60 years

Male Gender

Coma (GCS <10)

Chronic Lung Disease

Positive Cardiac History

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End Stage Kidney Disease

Tracheal Suctioning >q2h

Frequent oral suctioning

Failed >3 previous SBTs

STEP III Prepare

Difficult Airway Cart: at bedside

Notify Anesthesia Airway Pager

Allow Continuous Airway Access

Hold Feeds: 2h pre- & 6h post-extubation

Insulin Treated Patients: initiate dextrose

Recommend: methylprednisolone 20mg IV q4h; 3 doses prior to extubation

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HIGH RISK: Immediate FailureImmediate post-extubation respiratory distress requiring reintubation w/in 2hrs of extubation.

STEP III Prepare

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HIGH RISK: Delayed FailurePost-extubation respiratory distress requiring reintubation up to 24-48 hrs after extubation

Backup Plan Notify ICU Team Consider ABG/VBG q12 h

Respiratory Therapist Assess 4h post-extubation Bronchial Hygiene Protocol (if indicated)

STEP III Prepare

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LOW RISK

Routine extubation

STEP III: PrepareClear communication among teams, observation & monitoring

Resume feeds after succesful intubation

If reintubation, prepare smaller size endotracheal tube

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STEP IV Extubate