Multiple factors mandate that this neonate remain intubated or have a tracheostomy placed at the end of the case. This surgery involves an extensive dissection of the patient's neck and upper thorax that will result in a tremendous amount of upper airway and neck edema. Consequently, this would make extubation life threatening. High-dose opioids and neuromuscular blocking agents have been used, which also hamper safe extubation. The neonate should continue to remain well narcotized and paralyzed to facilitate effective mechanical ventilation. Artificial ventilation and oxygen supplementation should be titrated to serial arterial blood gases. In addition, the prostaglandin drip must be continued to ensure ductal patency. Generous opioid supplementation will ensure that the pulmonary vascular resistance stays low. At 24 hours postoperatively, a leak test can be performed to assess residual vocal cord and airway edema. Fiberoptic visualization of the laryngeal inlet can provide useful information about the state of the laryngeal inlet in anticipation of extubation.

Anatomic airway factors aside, the IAA and associated HF will make extubation more challenging. Assuming all other factors are under control, the following ventilatory parameters should be met prior to extubation: normal arterial blood gases with satisfactory oxygenation on 28% oxygen, spontaneous tidal volume greater than 5 mL/kg, and an inspiratory force greater than 12 cm H₂O. One needs to be vigilant for early signs of airway obstruction and be ready to reintubate or perform an emergent tracheostomy if airway obstruction and desaturation occur.