When the indications that prompted endotracheal intubation no longer exist, extubation should be executed carefully. Three major concerns in the removal of a tube are avoiding laryngospasm, maintaining airway patency, and ensuring adequate ventilatory function.

The tube should be removed when the patient has adequate reflex control. Therefore, paralyzing agents, sedatives, and narcotics must be discontinued or weaned before extubation is performed.

Laryngospasm occurs when the patient is in a state of semialert-semiasleep consciousness and droplets of secretions fall on the vocal cords, which in turn approximate and occlude the airway. Although this situation may be short-lived, it is potentially fatal, so extubation should be conducted as if the patient were to require intubation at the same time, which implies having the equipment and medications immediately available.

Laryngospasm is better prevented than treated. The treatment includes administering oxygen under pressure using a reservoir bag and mask and perhaps paralyzing the patient completely. Laryngospasm is prevented best by keeping the patient as alert as possible and by providing attention to the aspiration of secretions. Before the tube is removed, the lungs should be inflated with 100 percent oxygen for 1 to 3 minutes; after removal of the tube, the patient should be given oxygen.

In infants and small children, the administration of racemic epinephrine has been shown to be helpful in the control of postintubation subglottic edema. After the endotracheal tube has been removed, a chest radiograph should be obtained to check for postintubation atelectasis.