Extubation Complications: Causes, Risks and Clinical Management
Extubation complications are adverse events that occur during the removal of the endotracheal tube, such as laryngospasm, post-extubation stridor or negative pressure pulmonary oedema.
Complications associated with extubation:
Adverse medical events occurring during or immediately after the removal of the endotracheal tube, including laryngospasm, post-extubation stridor caused by laryngeal oedema, and life-threatening negative-pressure pulmonary oedema. According to a specialist publication, around one third of all serious airway incidents occur during this phase.
Table of Contents
Important note
This article is for information purposes only and is not a substitute for a medical diagnosis or advice. If you are unsure, or if you require a personalised treatment plan, it is essential that you consult a qualified specialist.
When an endotracheal tube – the breathing tube used to secure the airways during anaesthesia or in the intensive care unit – is removed, the body reacts to this procedure. In most cases, this process proceeds without complications. Sometimes, however, the larynx, bronchi or lungs can be affected to such an extent that rapid action is required. Anyone undergoing surgery should be aware of these risks and understand the financial implications that unexpected follow-up treatment may entail.
How do extubation complications arise?
Key points at a glance
- Extubation refers to the deliberate removal of the endotracheal tube following anaesthesia or ventilation.
- Complications arise when the larynx or airways react excessively to the removal of the tube.
- Around one third of all serious respiratory incidents occur during the weaning phase (source: Anaesthesiology & Intensive Care Medicine, Gottschlich 2017).
- High-risk patients are those with anatomical abnormalities of the airways, who are on long-term ventilator support, or who have pre-existing lung conditions.
- According to the AWMF S1 guideline on airway management 2023 (valid until 2028), a clinical algorithm should be available for high-risk patients.
When the endotracheal tube is removed, marking the end of invasive ventilation, the larynx and airways react to the mechanical stimulus. If they overreact, laryngospasm occurs (spasmodic laryngeal obstruction) or laryngeal oedema (swelling of the mucous membrane in the larynx). Both conditions can acutely obstruct the airways and require immediate intervention.
Another risk is negative pressure pulmonary oedema: if a patient breathes against a closed larynx, a strong negative pressure is created in the lungs, which draws fluid from the capillaries into the lung tissue. In addition, there is a risk of pulmonary aspiration – the accidental inhalation of gastric secretions – which can lead to ventilator-associated pneumonia (VAP).
Experience has shown that the most severe cases occur in patients who did not fully meet the extubation criteria or in whom the so-called Cuff leak test, a secondary ventilation test, in which the air around the vented tube is measured, was omitted. This test checks whether there is sufficient space around the tube, which is an indication of absent or minimal laryngeal oedema.
Extubation versus intubation: Why the extubation phase is often underestimated
Intubation, the insertion of an endotracheal tube, is regarded as a critical moment in anaesthesia and is the subject of numerous guidelines and training programmes. Extubation, on the other hand, is often treated as a routine procedure in clinical practice. According to the journal Anaesthetology & Intensive Care Medicine (2017), however, around one third of all serious airway incidents occur precisely during this extubation phase. The AWMF S1 Guideline on Airway Management 2023, issued by the German Society for Anaesthesiology and Intensive Care Medicine (DGAI), therefore stipulates that a specific clinical algorithm must be in place for patients in whom extubation failure is anticipated.
The key difference is that, during intubation, the anaesthesia team is prepared for complications. During extubation, there is a risk that emerging problems such as laryngospasm or aspiration may be detected too late, because the tube has already been removed and the immediate airway protection has been withdrawn.
The main types of complications in detail
Key points at a glance
- Laryngospasm: a reflexive spasm of the larynx, which can be life-threatening.
- Post-extubation stridor caused by laryngeal oedema: the most common unexpected complication of long-term ventilation.
- Negative pressure pulmonary oedema: the influx of fluid into the lungs caused by negative pressure resulting from airway obstruction.
- Pulmonary aspiration: inhalation of gastric contents; risk of ventilator-associated pneumonia.
- Bronchospasm: a spasm of the bronchial muscles, clinically similar to an asthma attack.
Laryngospasm: reflexive closure of the larynx
Laryngospasm refers to the spasmodic closure of the glottis caused by contraction of the laryngeal muscles. It occurs as an excessive protective reflex when secretions, blood or the endotracheal tube itself irritate the mucous membrane of the larynx. Typical triggers include a build-up of secretions above the larynx whilst the depth of anaesthesia is still insufficient, as well as mechanical irritation during tube removal.
Clinically, laryngospasm is characterised by a distinctive stridor, progressive cyanosis (a bluish discolouration of the lips due to a lack of oxygen) and visible signs of respiratory distress without effective ventilation. If left untreated, complete laryngospasm leads to critical hypoxia within minutes.
Emergency treatment follows a clear protocol: oxygen administration, the jaw thrust manoeuvre; if symptoms persist, a low dose of succinylcholine (a short-acting muscle relaxant); and, if necessary, reintubation. As a preventive measure, extubation whilst the patient is in a deep anaesthetic state or fully awake reduces the risk; so-called „awake extubation“ offers advantages in cases where the airway is known to be difficult.
Post-extubation stridor caused by laryngeal oedema
Post-extubation stridor is an inspiratory breath sound caused by laryngeal oedema – swelling of the laryngeal mucosa – following the removal of the endotracheal tube. Laryngeal oedema develops as a result of mechanical pressure exerted by the tube, whilst the patient is lying down, on the sensitive mucous membrane. It occurs particularly frequently following prolonged ventilation, when the tube diameter is too large, or when the tube has been removed whilst the patient is actively attempting to cough.
The cuff leak test is the most important predictive tool: after deflating the tube cuff (the inflatable sealing cuff), a measurement is taken to determine whether air is escaping around the tube. If no leak is detected, this indicates mucosal oedema and an increased risk of post-extubation stridor. In accordance with clinical guidelines, high-risk patients should be given corticosteroids prior to extubation to reduce mucosal oedema.
From a therapeutic perspective, adrenaline inhalations and systemic corticosteroids are available in the event of stridor. In severe cases, non-invasive ventilation (NIV) is an effective interim measure before reintubation becomes necessary.
Negative pressure pulmonary oedema: a rare but serious complication
Negative-pressure pulmonary oedema (also known as negative-pressure-induced pulmonary oedema, NPPE) occurs when a patient actively breathes against a closed or severely narrowed glottis. The resulting severe intrathoracic negative pressure draws fluid from the pulmonary vessels into the tissue. The result is acute pulmonary oedema without a cardiac cause.
Negative pressure pulmonary oedema occurs more frequently than is generally assumed; it is considered one of the most underestimated complications of extubation. Clinically, it typically presents within minutes to an hour after extubation, characterised by shortness of breath, tachycardia, frothy sputum and falling oxygen saturation. Risk factors include young, robust patients with high respiratory drive, known upper airway problems and obstructive complications during the extubation procedure.
Treatment comprises oxygen therapy, non-invasive ventilation with PEEP (positive end-expiratory pressure) and, where necessary, loop diuretics. In severe cases, reintubation is required.
Pulmonary aspiration and ventilator-associated pneumonia
Pulmonary aspiration refers to the accidental inhalation of gastric contents, secretions or blood into the airways. It occurs primarily when the gag reflex has not yet fully returned at the time of tube removal, or when gastric contents have flowed retrograde into the throat. The risk is particularly high in obese patients, following emergency surgery when the patient has not been fasting, and in cases of impaired consciousness.
Aspiration can lead to chemical pneumonitis (inflammation caused by gastric acid) or bacterial pneumonia. The KRINKO guidelines published by the Robert Koch Institute (RKI) list aspiration prevention as one of more than 25 measures for preventing ventilator-associated pneumonia (VAP). Specific measures include raising the upper body, oral care and correct timing of extubation following an adequate period of fasting.
Bronchospasm following extubation
Bronchospasm refers to the contraction of the smooth muscle in the bronchi, which narrows the airways and makes it difficult to breathe out. It occurs more frequently following extubation in patients with a history of bronchial asthma or chronic obstructive pulmonary disease (COPD), but may also occur for the first time as a result of irritation caused by secretions or the endotracheal tube.
Clinically, bronchospasm differs from laryngospasm in that it is characterised by expiratory wheezing and a prolonged exhalation phase. Treatment involves inhaled beta-2 sympathomimetics (e.g. salbutamol) and, in severe cases, systemic corticosteroids.
A comparison of laryngospasm, bronchospasm and post-extubation stridor
Three types of complications are frequently confused following extubation because they are all associated with respiratory distress, but require different immediate interventions. Rapid differentiation is clinically crucial:
| Complication | Cause | Key symptom | First step |
|---|---|---|---|
| Laryngospasm | Reflexive closure of the larynx caused by irritation of the mucous membrane | Inspiratory stridor, cyanosis, rocking breath | Jaw thrust, oxygen, and succinylcholine if necessary |
| Bronchospasm | Spasm of the bronchial muscles (common in asthma/COPD) | Expiratory wheezing, prolonged exhalation | Inhaled beta-2 agonist (salbutamol) |
| Post-extubation stridor | Laryngeal oedema caused by endotracheal tube pressure, particularly following prolonged ventilation | Inspiratory stridor, hoarseness, barking cough | Adrenaline inhalation, systemic corticosteroids |
Clinical note:
In cases where extubation is expected to fail, the DGAI recommends the use of an airway exchange catheter (AEC), a thin guide catheter that remains in the airway after the tube has been removed and enables rapid reintubation without the need for difficult re-access. The AEC makes it possible to insufflate oxygen and, if necessary, to reintubate immediately.
Risk factors for extubation failure: Who is particularly at risk?
Key points at a glance
- Anatomical changes to the airways (e.g. following surgery on the neck or a head and neck tumour).
- Long-term ventilation, particularly in cases of ARDS (Acute Respiratory Distress Syndrome).
- Pre-existing lung conditions such as COPD or bronchial asthma.
- A negative cuff leak test is indicative of laryngeal oedema.
- High tidal volume prior to extubation (indicating persistent respiratory weakness).
Extubation failure – that is, the failure to resume spontaneous breathing following tube removal, necessitating re-intubation – does not occur by chance. Gottschlich (2017) identifies three main risk groups for which a corresponding algorithm should be available in advance:
Anatomical and structural risk factors
- Known or anticipated airway difficulties (e.g. restricted mouth opening, short neck, macroglossia)
- Oedema or haematomas in the neck and face (e.g. following neck dissection or thyroid surgery)
- Pre-existing laryngeal or subglottic stenosis
- Positive cuff leak test (no air leakage when the cuff is unsealed)
Risk factors in respiratory and intensive care medicine
- Long-term ventilation (> 24 hours), particularly in cases of ARDS or sepsis
- A history of multiple or traumatic intubation attempts
- Failure to wean during previous attempts at extubation
- Residual neuromuscular block or inadequate protective reflexes
Pre-existing conditions and patient-specific risk factors
- Obstructive lung disease (COPD, bronchial asthma) currently poorly controlled
- Obesity (BMI > 35) with impaired respiratory mechanics
- Cardiac instability or decompensated heart failure
- Known swallowing disorder (dysphagia) or tendency to aspirate
An advanced extubation strategy is recommended:
Where two or more risk factors are present, the AWMF S1 guideline on airway management (2023) recommends an extended extubation strategy: having a tube-exchange catheter (AEC) ready, the presence of an experienced anaesthetist, and the immediate availability of re-intubation equipment.
Anatomical changes
Patients who have undergone head and neck surgery, those with a known difficult airway, or those with tumours near the airway. Post-operative swelling or bruising may further narrow the airway.
Long-term ventilation
Patients who have been on ventilator support for several days or weeks (e.g. due to ARDS or sepsis in the intensive care unit). Their respiratory muscles are weakened, their mucous membranes are irritated, and weaning – the gradual withdrawal from ventilator support – must be carried out in accordance with protocol.
Pre-existing lung conditions
Patients with COPD, asthma, pulmonary hypertension or neuromuscular disorders have reduced respiratory reserve. Even following successful extubation, respiratory failure can develop rapidly.
In addition to these three main groups, there are other risk factors: being female (narrower airways, higher incidence of laryngeal oedema), obesity, short stature in relation to tracheal diameter, and increased secretion production. The following applies to intensive care medicine: A weaning protocol, a standardised step-by-step plan for weaning from ventilation, involving daily attempts at spontaneous breathing, measurably reduces the rate of extubation failure.
Cuff leak test: The most important predictive tool
The cuff leak test (side-breathing test) is a simple, non-invasive procedure for assessing the risk of laryngeal oedema. In this test, the cuff (the sealing collar of the tube) is deflated, and a check is made to see whether air flows past the tube. If there is no leak at all, the space between the tube and the laryngeal mucosa is too narrow, which indicates swelling.
In quantitative terms, a leak volume of less than 110 ml per breath is considered a high-risk finding for post-extubation stridor. In this situation, clinical guidelines recommend administering corticosteroids prior to extubation and having an airway exchange catheter ready. The test is not an absolute predictor, but it significantly increases the reliability of the decision.
Prevention and clinical management of extubation complications
Key points at a glance
- Check that the defined extubation criteria have been met before removing the tube.
- Carry out a cuff leak test in cases of long-term ventilation and for high-risk patients.
- Use an Airway Exchange Catheter (AEC) if extubation is expected to fail.
- Administer corticosteroids prophylactically if the cuff leak test is negative.
- Consider non-invasive ventilation (NIV) at an early stage as a temporary measure.
- Consistently implement the weaning protocol for patients on long-term ventilation.
The AWMF S1 guideline on airway management 2023, published by the DGAI and valid until 2028, sets out binding minimum standards for airway management, including extubation. The guideline distinguishes between routine extubation and extubation in cases of anticipated failure, for which a separate algorithm must be in place.
Extubation criteria: When is the right time?
Extubation should only take place once the following criteria have been met:
- Adequate spontaneous breathing A stable tidal volume and a respiratory rate of less than 25 per minute.
- Stable haemodynamics Without critical doses of vasopressors.
- Sufficient awareness The patient follows simple instructions.
- Defence mechanisms Swallowing and coughing reflexes are present and strong enough.
- Acceptable gas exchange Oxygen saturation above 90 % at an FiO₂ below 0.4 and a maximum PEEP of 5 cmH₂O.
If even one of these criteria is not met, the risk of extubation failure increases significantly. Extubation that is carried out too early is just as problematic as extubation that is carried out too late: prolonged intubation itself increases the risk of laryngeal oedema, mucosal damage and ventilator-associated pneumonia.
Non-invasive ventilation (NIV) as a temporary measure
Non-invasive ventilation (NIV) refers to mechanical respiratory support delivered via a face mask or nasal mask, without inserting a tube into the airways. It has become established as an effective measure following extubation in high-risk patients: in patients with COPD, hypercapnoic respiratory failure or heart failure, prophylactic NIV following extubation measurably reduces the reintubation rate. According to Springer Medizin (Windisch/Karagiannidis), specialised weaning centres recommend NIV as a standard component of follow-up care for patients requiring ventilation.
Important caveat:
NIV is not a substitute for reintubation in the event of complete airway obstruction. In the event of laryngospasm or complete laryngeal oedema, the airway must be secured by reintubation or supraglottic airway support (e.g. a laryngeal mask). NIV can only be used as a temporary measure whilst partial ventilation is maintained.
A comparison of four common complications following extubation: location, cause, main symptom and initial management, in accordance with the AWMF S1 guideline on airway management 2023.
Frequently asked questions about extubation complications
Extubation failure (also known as „difficult extubation“) refers to the condition in which, following the removal of the endotracheal tube, adequate spontaneous breathing fails to occur or serious complications such as airway obstruction or respiratory failure arise, necessitating reintubation. Patients with anatomical abnormalities of the airways, those who have undergone prolonged mechanical ventilation, and those with pre-existing lung conditions such as COPD or bronchial asthma are particularly at risk.
According to an analysis published in the specialist journal Anaesthetology & Intensive Care Medicine (Gottschlich, 2017) states that around one third of all serious airway incidents occur during the weaning phase, when extubation takes place. This makes this moment clinically just as high-risk as the intubation itself, yet it is addressed far less frequently in guidelines and training programmes. In 2017, 219,874 intubations were documented under OPS code 8-701 in Germany alone (Federal Statistical Office), which illustrates the scale of the problem.
The cuff leak test is a simple procedure for predicting the risk of post-extubation stridor. It involves deflating the endotracheal tube’s cuff and checking whether air is escaping around the tube. If there is no leak, or if it is very slight (less than 110 ml per breath), laryngeal oedema is suspected. In this case, corticosteroids should be administered as a precaution and an airway exchange catheter should be kept ready.
The following factors increase the risk of extubation complications: anatomical abnormalities in the head and neck region (tumours, previous surgery, haematomas), long-term ventilation, particularly in cases of ARDS or sepsis; pre-existing lung conditions (COPD, bronchial asthma); a negative cuff leak test (indicating laryngeal oedema); insufficient depth of anaesthesia at the time of tube removal; obesity and female gender (narrower airways).
If complications arise during extubation following a cosmetic procedure – such as aspiration, pneumonia or emergency reintubation – this results in subsequent medical costs which, as a rule, are not covered by either statutory or private health insurance. Particularly in the case of elective cosmetic procedures, the patient is left to bear these costs. A Consequential Costs Insurance covers such unexpected medical expenses up to 300,000 euros.
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