All India Difficult Airway Association 2025 guidelines for extubation of the “at-risk” airway

The All India Difficult Airway Association (AIDAA) guidelines for 2025 regarding the extubation of "at-risk airways" following anaesthesia emphasise the importance of recognising, preparing for, and executing a planned extubation procedure for these potentially vulnerable airways. AIDAA has reviewed its previous extubation guidelines and developed a new algorithm based on the latest evidence, a Delphi survey, and expert opinions to incorporate necessary changes for patients with "at-risk airways", ultimately aiming to achieve successful extubation. This is articulated through a four-pronged strategy known as <b>SAFE:</b> S-Stratify Risk, A-Assemble and Anticipate, F-Facilitate Extubation, and E-Evaluate and Escalate. This stepwise approach is designed to enhance patient safety during the extubation process. The guidelines emphasise the significance of peri-extubation oxygen (PerEOx) supplementation. Furthermore, it is crucial to quantitatively assess recovery from neuromuscular blockade prior to extubation. A three-limb approach to extubation has been devised to address specific situations: Limb 1 focuses on suppressing the haemodynamic response during extubation in scenarios that require such control but do not pose a risk to the airway, Limb 2 involves a <i>staged sequential extubation</i>, and Limb 3 addresses the need for <i>delayed extubation</i>. Patients at higher risk of airway compromise, collapse, or dependence on the tube may benefit from a staged sequential extubation or delayed extubation strategy rather than a one-step extubation approach. The current guidelines also propose management plans for certain unusual situations, such as a stuck tracheal tube and unexpected extubation failure.