Tracheal tube introducers or bougies and airway exchange catheters (AECs) are widely used airway adjuncts for facilitating airway management in difficult circumstances. They are easy to use, relatively inexpensive and have success rates of ≥ 90% in most settings. Both are included in many modern airway management algorithms. The use of bougies has expanded over the years, and they are now used to aid insertion of supraglottic airways (SGAs), videolaryngoscope-guided intubation and as adjuncts to emergency front of neck airway procedures. Stylets are rigid or semi-rigid airway adjuncts that are inserted into the tracheal tube before intubation. They maintain the tracheal tube in a particular shape and may therefore assist during intubation. AECs are semi-rigid hollow tubes designed to aid airway device (SGA, and single- or double-lumen tracheal tube) exchange or to manage ‘at-risk’ extubation. The risk of serious airway trauma associated with the use of bougies and airway exchange catheters, and the risk of barotrauma with the latter, invites cautious and educated use of these devices.

Extubation and emergence are high-risk phases of anaesthesia which accounted for 28% of the anaesthesia cases reported to the Fourth National Audit Project of the Difficult Airway Society and the Royal College of Anaesthetists. Problems generally relate to the patient’s anatomy, physiology or to the context in which extubation is carried out. Minor issues such as coughing and breath-holding are common, more serious complications such as aspiration, laryngospasm, post-obstructive pulmonary oedema and hypoxic brain injury are often preventable with proper planning. In this chapter we discuss how to formulate an extubation strategy including risk stratification, planning, awake and deep extubation and modifications aimed at reducing the risk of complications. An awake extubation is suitable for most patients but special techniques such as supraglottic airway exchange, remifentanil infusion or the use of an airway exchange catheter may be helpful in high-risk situations. Post-operative care does not end when the tracheal tube has been removed, handover and documentation are essential components of the extubation plan.