Challenge of tracheal extubation and tube exchange of a difficult airway: a narrative review.

Tracheal extubation is an integral part of airway management. Even though available data indicated that the incidence of complications immediately after tracheal extubation may be higher than during tracheal intubation, it is significantly underexplored in the scientific literature in comparison with tracheal intubation. Failure to re-secure the airway during or immediately after tracheal extubation may have fatal consequences. Closed claims analyses have highlighted the seriousness of adverse events occurring postextubation. Consequently, a well-planned strategy for tracheal extubation is as important as for the intubation and is correctly regarded as a logical extension of an intubation strategy. This narrative review focusses on the challenges of tracheal extubation and complications of routine and 'at-risk' extubation in adults. It provides the reader with a risk stratification before extubation. Guidelines for tracheal extubation including advanced techniques for tracheal extubation of patients 'at-risk' are followed by a detailed step-by-step approach for video-assisted tracheal tube exchange in patients with a difficult airway.