Summary of "Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how?"

The literature on extubation strategies among pediatric patients with difficult airways is scarce and limited to unsuccessful extubations in the PICU. In this educational review, the authors discuss the causes and management of problematic paediatric tracheal extubations. As an alternative to the Difficult Airway Society (DAS) guidelines, the authors have suggested the ‘Risk, Ready, Do and Discharge’ (R2D2) strategy. This strategy includes 1) the identification of all potential risk factors (e.g. pre-existing, reversible, etc.), 2) preparation of the appropriate equipment, 3) the creation of a reintubation plan, nd 4) a post procedure observation period. For example, a component of an extubation plan may include extubating the child before midday to increase the likelihood that if reintubation is required, it will be done during normal business hours, when staffing and support are optimal. In conclusion, institutional protocols for difficult intubation and extubation scenarios should be in place and future peri-extubation research and multicentral airway registries are recommended.