The planned removal of an endotracheal tube is one of the most important milestones in both anesthesia and critical care. Although it is a straightforward process, its risks include airway obstruction, agitation, hemodynamic instability, and respiratory failure, all of which can all complicate the process. Medications play a central role in reducing these risks, smoothing the transition to spontaneous breathing and ensuring patient comfort. This pharmacologic approach typically spans three overlapping phases: preparation, the moment of extubation, and post-extubation care.
To begin the process of extubation, sedation is lightened so the team can assess wakefulness, reflexes, and respiratory drive. Agents that allow calm cooperation without suppressing breathing are preferred, and pain relief is balanced to prevent discomfort while avoiding over-sedating the patient. Nausea prevention reduces aspiration risk, especially in surgical patients. For patients exposed to prolonged sedation, medications may be adjusted in advance to support a smoother emergence 1,2.
Any residual neuromuscular blockade must be corrected in order to restore full muscle strength. In addition, depending on a patient’s prior drug use, either traditional reversal agents or newer targeted therapies can be used. In rare cases, the reversal of sedatives or opioids may be considered; however, this is done cautiously due to safety concerns. The overall aim is to ensure the patient is sufficiently awake, breathing effectively, and able to protect their airway 2–4.
The airway itself often requires targeted support. Prolonged intubation can lead to swelling or reactivity, increasing the eventual risk of stridor. Preventive measures, including steroids administered hours in advance, can help to reduce this risk. Local or systemic agents may blunt coughing and minimize the hemodynamic surges that accompany tube removal. In patients with asthma or COPD, optimizing bronchodilator therapy can ease airflow and reduce resistance. Attention to secretion clearance through suctioning, humidification, or mucolytics can further protect the airway 2,5,6.
At the time of extubation, small doses of sedative or analgesic medications may be used to reduce distress while preserving spontaneous breathing. For patients vulnerable to cardiovascular complications, short-acting drugs that blunt surges in blood pressure or heart rate can prevent ischemia, bleeding, or neurologic injury. In addition, in patients at a high risk of upper-airway obstruction, teams remain ready with medications for stridor as well as equipment for immediate airway rescue 7–9.
Following extubation, pharmacologic care focuses on preventing respiratory failure. Supplemental oxygen, sometimes through high-flow systems, can reduce the work of breathing. In hypercapnic patients, noninvasive ventilation combined with optimized bronchodilation may also help. If airway swelling emerges, steroids or nebulized therapies are administered promptly, though reintubation is considered if there are any signs of deterioration in the patient’s condition. In general, pain management tends to favor multimodal, opioid-sparing approaches to avoid respiratory depression. In addition, antiemetics can reduce aspiration risk, while delirium prevention strategies can help support patient recovery 10–12.
No single strategy fits every patient. Factors like age, organ function, comorbidities, and surgical details shape the clinical approach. In general, however, when combined with readiness assessments and vigilant monitoring, thoughtful use of medications makes extubation safer, smoother, and more comfortable for patients.
References
1. Management of tracheal extubation guidelines. Difficult Airway Society https://das.uk.com/guidelines/das-extubation-guidelines1/.
2. Saeed, F. & Lasrado, S. Extubation. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).
3. Benham-Hermetz, J. & Mitchell, V. Safe tracheal extubation after general anaesthesia. BJA Education 21, 446–454 (2021). DOI: 10.1016/j.bjae.2021.07.003
4. Zein, H., Baratloo, A., Negida, A. & Safari, S. Ventilator Weaning and Spontaneous Breathing Trials; an Educational Review. Emerg (Tehran) 4, 65–71 (2016).
5. Li, L. T., Gjuzi, K., He, P. & Guris, R. J. D. Airway extubation: a narrative review. Journal of Oral and Maxillofacial Anesthesia 3, (2024). DOI: 10.21037/joma-24-3
6. Parotto, M., Cooper, R. M. & Behringer, E. C. Extubation of the Challenging or Difficult Airway. Curr Anesthesiol Rep 10, 334–340 (2020). DOI: 10.1007/s40140-020-00416-3
7. Reddall, R. E. & Yeow, D. Extubation techniques in anaesthesia—a narrative review. Journal of Oral and Maxillofacial Anesthesia 2, (2023). DOI: 10.21037/joma-23-21
8. Tung, A. et al. Medications to reduce emergence coughing after general anaesthesia with tracheal intubation: a systematic review and network meta-analysis. Br J Anaesth 124, 480–495 (2020). DOI: 10.1016/j.bja.2019.12.041
9. Bruschettini, M. Improving rates of successful extubation: Medications. Seminars in Fetal and Neonatal Medicine 28, 101490 (2023). DOI: 10.1016/j.siny.2023.101490
10. Khemani, R. G., Randolph, A. & Markovitz, B. Corticosteroids for the prevention and treatment of post‐extubation stridor in neonates, children and adults. Cochrane Database Syst Rev 2009, CD001000 (2009). DOI: 10.1002/14651858.CD001000.pub3
11. Thille, A. W., Wairy, M., Pape, S. L. & Frat, J.-P. Oxygenation strategies after extubation of critically ill and postoperative patients. J Intensive Med 1, 65–70 (2021). DOI: 10.1016/j.jointm.2021.05.003
12. Boscolo, A. et al. Noninvasive respiratory support after extubation: a systematic review and network meta-analysis. European Respiratory Review 32, (2023). DOI: 10.1183/16000617.0196-2022