Extubation criteria — TOF + awake + breathing

Pre-extubation checklist

Mnemonic device

TOF · Tidal · Tone · Trachea

Mapping

TOF

Train-of-four ratio ≥0.9 (clinical: sustained head lift 5 sec, hand grip, sustained tetany)

Tidal

Tidal volume ≥5-6 mL/kg, RR <30, RSBI <100 (rapid shallow breathing index = RR/TV)

Tone

Awake, following commands, gag reflex returning, no stridor on cuff leak test (esp after long intubation, head/neck surgery, prone)

Trachea

Suction, verify no excessive secretions, oxygenating well on minimum FiO2 (0.4) with PEEP 5, reasonable acid-base

Clinical note: Failed extubation 5-10x worse outcome than delayed extubation. Cuff leak <110 mL or audible whisper without leak = consider re-intubation risk; defer + treat with steroids 4-12h. Have airway equipment + capnography ready.