Rapid and reliable: the PUMA 2026 extubation guidelines compared with DAS 2012

September 28, 2026 · Read 14 min

Extubation accounts for approximately one-third of the major airway complications documented in the UK 4th National Audit Project (NAP4) [1]. Its outcomes have not kept pace with the improvement in intubation over the past 25 years [1]. The Project for Universal Management of Airways (PUMA) extubation guidelines, published in 2026, attribute much of the problem to strategies that are not matched to the identified risk. Their answer is a single criterion for every extubation: each airway lifeline must be rapid and reliable, and the one that is not defines the strategy.

1. Decision architecture: from two strata to four questions

Both guidelines treat planned extubation as an elective procedure, with the same assessment, preparation, monitoring, and observation as intubation [1, 2]. DAS 2012 stratified it into two groups and, in the second, resolved the strategy with a single question (Table 1) [2]. PUMA links assessment to strategy through four questions: whether it is appropriate to consider extubation, whether it is at risk, whether deferral decreases that risk, and how to secure a margin against hypoxaemia [1].

Preconditions before considering extubation

The first question is answered with the preconditions in Table 1, which should be satisfied before entering the algorithm [1]. The resources and trajectory domains are the least familiar in a theatre checklist, and two deserve detail. The surgical domain rules out extubation when early re-intubation is anticipated in a difficult context, such as a return to theatre, imaging, or transfer, or when a major body cavity remains open. The trajectory domain rules it out when deterioration is anticipated over the following day, such as evolving sepsis [1].

”Rapid and reliable” for each airway lifeline

For PUMA, rapid means that the time to ventilation approaches that of an expert operator under routine conditions, and reliable means that the operator expects to succeed with a single attempt [1]. The judgement is made for the facemask, the supraglottic airway, and the tracheal tube, and any lifeline that falls short is at risk, together with the extubation. A complex lifeline may be rapid and reliable if the team, the device, and the preparation are in place: the criterion depends on the patient and also on the team and the situation [1].

Any lifeline that was difficult at intubation is at risk by default, unless explicitly justified, and prior difficulty is not simply attributed to another operator’s skill [1]. Laryngoscopy with the tube in situ gives false reassurance, as DAS 2012 already warned [2]. PUMA adds that glottic oedema may progress after extubation and worsen access [1]. The reading of the cuff leak test has changed: DAS 2012 took a large leak as reassuring [2]; PUMA considers it insufficient to justify extubation if other factors indicate risk [1].

The assessment of each lifeline during intubation, which feeds this judgement, is developed in the article on the difficult airway according to the DAS 2025 guidelines.

Deferral, tracheostomy, and the three options for proceeding

The re-intubation questions assign each case to one of three rows, and in each row the algorithm asks whether both facemask and supraglottic airway are at risk (Table 1) [1]. Only the route with rapid and reliable re-intubation and both lifelines not at risk goes directly to discretionary management, where the operator chooses the technique [1]. Every other route first asks whether deferring extubation will decrease risk, and deferral decreases it only when it improves patient, team, or situation factors; otherwise, it transfers the difficulty to another operator who knows the case less well [1]. Extubation is therefore scheduled away from shift changes, and after each deferral the preconditions and the algorithm are reviewed before extubation is reconsidered [1].

The options for proceeding replace the DAS 2012 list of advanced techniques and are graded by the margin against hypoxaemia [1, 2]. A “trial of extubation” in the patient who fails to progress in weaning, accepting a probable re-intubation to avoid tracheostomy, is restricted to intensive care and ruled out if re-intubation is expected to be difficult [1]. The scope also widens relative to DAS 2012 (row “Use” in Table 1) [1, 2].

The guidelines pair the algorithm with a checklist that, when difficulty is anticipated, is read as a team in a challenge-response format, and with an interactive version in the PUMA app [1].

2. Preparation: neuromuscular block, oxygen, position, and level of consciousness

Quantitative monitoring and reversal

PUMA makes quantitative neuromuscular monitoring a key recommendation to confirm return of baseline neuromuscular function when neuromuscular blocking drugs have been used [1]. The order also changes: suction, gastric decompression, the bite block, and positioning are completed while the patient is still deeply sedated and fully blocked, and reversal follows, still under sedation [1]. Stimulating manoeuvres thus do not coincide with emergence.

Sugammadex is associated with more anaphylaxis than neostigmine, and that reaction often appears around extubation, so observation continues after the tube is removed [1]. In its favour is a rapid and reliable reversal that allows deep block to be maintained until the end [1]. It is also associated with less extubation failure and fewer unplanned ICU admissions [1]. When the monitor shows recovery sufficient for neostigmine, the choice of antagonist is individualised [1].

ETO2 and vital capacity

PUMA recommends re-oxygenating the functional residual capacity before extubation and continuing supplemental oxygen afterwards, even when saturation is normal [1]. The 2021 review of DAS 2012 proposed shortening that exposure because of atelectasis (Table 2); PUMA prioritises the reservoir, because it buys time if rescue becomes complicated [1].

Sustained inflation to near vital capacity is delivered just before the cuff is deflated, and positive pressure is maintained while the tube is removed. Passive exhalation carries out material pooled above the cuff and reduces the excitability of the laryngeal adductors, two effects that lower the risk of laryngospasm [1]. Suctioning through the tube lumen during removal is discouraged, because it promotes atelectasis and empties the reservoir; suction with a catheter before removal, followed by ventilation with oxygen, remains acceptable [1].

Position

The extubation position is part of the strategy and is declared [1]. A moderate head-up tilt or the supine position gives the best access for re-intubation, and any other position requires staff available to reposition quickly. In obesity, more elevation is preferable. With aspiration risk, the supine position is avoided, and the lateral position protects the non-dependent lung [1]. Head-up positioning reduces passive regurgitation and increases aspiration of vomitus; Trendelenburg does the reverse [1]. The position is chosen by the risk that weighs most in each case, without losing access to the airway [1].

Awake or deep

Awake, for PUMA, means obeying specific commands, such as squeezing a hand; eye opening to command may be a non-specific response, and purposeful movements, such as reaching for the tube, do not indicate wakefulness [1]. Once sedatives are stopped, emergence proceeds without stimulation: slow passive movement of large joints may hasten it, and abrupt stimuli precipitate coughing, biting, regurgitation, and hypertension [1].

Deep extubation remains an advanced technique, with the conditions in Table 2 [1, 2]. The rule on level of consciousness in Table 2 still applies [1, 2]. Its practical test is the response to cuff deflation: if an adult responds with coughing or a change in breathing pattern, removal is deferred and sedation is deepened [1]. In the child, a transient pause in ventilation on cuff deflation is acceptable if there is no abdominal rigidity and breathing resumes promptly [1].

3. Pulmonary aspiration and airway stimulation: two axes outside the algorithm

Pulmonary aspiration and harm from airway stimulation are planned separately from the algorithm, with their own tools, and are layered onto the approach it suggests [1].

Protective sequence extubation

Protective sequence extubation is the extubation counterpart of rapid sequence induction for the patient at risk of aspiration [1]. That patient should always undergo awake extubation, because it best ensures the return of protective reflexes [1]. Deliberate stimulation to hasten emergence is counterproductive, since consciousness may decline after removal once stimulation ceases [1]. The sequence orders the elements of section 2 and adds two: a wide-bore sucker available for gastric and pharyngeal suction, and a bed able to rapidly adopt Trendelenburg inclination [1]. The wide-bore sucker, the gastric tube, and the bite block are listed as optional; the bed and sustained inflation, as suggested [1].

Techniques against airway stimulation

Deep extubation and exchange of the tracheal tube for a supraglottic airway under deep anaesthesia reduce sympathetic stimulation, coughing, and bronchospasm at the cost of more upper airway obstruction [1]. The exchange is the Bailey manoeuvre, already described in DAS 2012 [2]. In the child, removal of the device at a deep plane is usual practice, unless contraindicated, because reactivity and its complications increase with awake removal [1]. In the adult, the supraglottic airway is removed awake, unless there is a specific problem [1]. Neither technique applies with aspiration risk or when the algorithm suggests anything other than discretionary management [1].

For stimulation, PUMA proposes topical, intracuff, or intravenous lidocaine, antihypertensives such as beta blockers, clonidine, and magnesium, and fewer stimulating interventions [1]. Opioids and dexmedetomidine join that group with caution when the suggested approach is awake extubation [1]. Remifentanil, which DAS 2012 presented as an advanced technique for the at-risk patient [2], no longer holds a place of its own in the decision to extubate.

4. Airway exchange catheter

When the algorithm calls for the greatest margin against hypoxaemia without deferral, the approach is awake extubation over an airway exchange catheter [1]. The catheter does not make an extubation suitable if it should be deferred or managed with tracheostomy [1]. In the small child, the short trachea favours endobronchial or supraglottic displacement and published experience is limited, so feasibility is assessed case by case [1].

The sharpest contrast with DAS 2012 lies in oxygen via the catheter (Table 3): PUMA proscribes insufflating it because of the risk of barotrauma [1, 2]. If saturation falls with the catheter in situ and simple measures do not correct it, the next step is re-intubation [1]. The catheter is labelled as an airway device so that it is not mistaken for a gastric tube, and its prolonged use is off-label for many models [1].

To change a tube, PUMA prefers airway conversion, which maintains ventilation or leaves a guide in the airway, over airway replacement, which interrupts it [1]. It uses the catheter rather than the bougie, because of its greater length [1]. Deep block is maintained during conversion, unless spontaneous breathing is needed [1].

5. Complications and post-extubation care

Biting and negative-pressure pulmonary oedema

The young, healthy adult tends to bite hard on emergence; if the tube or supraglottic airway is occluded, inspiratory effort against the obstruction produces negative-pressure pulmonary oedema [1]. Deflating the cuff allows breathing around the device and avoids the oedema; when this is contraindicated by aspiration risk or does not work, sedation is deepened and, if needed, a rapid-onset neuromuscular blocking drug is given [1].

Once oedema is established, fluid is cleared with positive pressure and not with suction, which increases losses and interrupts oxygenation; suction is justified only to see the glottis for intubation [1]. Diuretics are not beneficial and may worsen hypovolaemia [1].

Laryngospasm

PUMA stages the treatment of laryngospasm into initial management and refractory management, the latter when laryngospasm persists or desaturation or bradycardia occurs (Table 4) [1]. Before treating, mimics are considered: foreign body, clot, regurgitation, pharyngeal collapse, and bronchospasm [1]. Airway obstruction that does not resolve with an intubating dose of neuromuscular blocking drug is not due to laryngospasm, and rescue continues through the upper airway and, if needed, the front of the neck [1]. Bradycardia secondary to hypoxaemia is managed by resolving the hypoxaemia [1].

Regurgitation

With regurgitation, the patient is moved to the lateral or head-down position, and wide-bore suction is preferred to a standard cannula when material is copious, thick, or semi-solid [1]. Stimulating the gag reflex, which triggers or worsens vomiting, is avoided, and if there was significant pulmonary aspiration, bronchoscopy is considered [1].

Post-extubation monitoring

The risk of re-intubation lasts a variable time that is estimated case by case, and during that period observation takes place where there are staff, equipment, and monitoring to recognise deterioration and re-intubate [1]. Patients remain nil by mouth until that period ends [1]. Verbal and written handover of the high-risk patient, with the re-intubation plan, warning signs, and the contact of the responsible clinician, is inherited from DAS 2012 [1, 2].

Agitation counts as a marker of hypoxaemia, and the signs of progressive obstruction are voice change, drooling, stridor, paradoxical chest movement, tracheal and intercostal retraction, and, finally, silence [1]. After surgery near the airway, swelling, bleeding, flap perfusion, and drain losses are also monitored [1].

A nasopharyngeal or oropharyngeal airway placed before the device is removed may limit obstruction in vulnerable cases [1]. High-flow nasal oxygen, CPAP, or non-invasive ventilation reduce desaturation in selected cases [1]. Routine prophylactic high-flow nasal oxygen after cardiac surgery was not shown to reduce respiratory complications in susceptible patients [1].