Early tracheal extubation has been safely performed after large operative procedures, questioning the need for routine postoperative ventilation. Because immediate postoperative tracheal extubation of liver transplantation patients has not been previously reported, we performed preliminary studies at two institutions to evaluate potential risk and cost benefit. At the University of Colorado (UC), extubation criteria were derived from the retrospective analysis of patients who were ventilated less than 8 h and experienced an intensive care unit stay less than 48 h in 1994. Preoperative criteria for age, severity of illness, and absence of encephalopathy and coexistent disease were used in a subsequent prospective study in 1995. Donor graft function, blood use, hemodynamic stability, and alveolar-arterial oxygen gradient served as intraoperative criteria. Cost of intensive care services was compared for the 1994 ventilated patients and the 1995 patients whose tracheas were extubated immediately postoperatively. At the second institution, University of California at San Francisco (UCSF), patients were tracheally extubated immediately postoperatively, based on clinical judgment by the anesthesiologist. A retrospective analysis was then completed. Sixteen of 67 patients at UC and 25 of 106 patients at UCSF were tracheally extubated. There were no reintubations at UC, while 2 of 25 patients at UCSF required reintubation. Prior encephalopathy, poor donor liver function, and an increased alveolar-arterial oxygen gradient were present in the patients who suffered perioperative respiratory failure. Seventeen of 25 patients at UCSF did not have all criteria used at UC but did not require reintubation. Wider limits on age and severity of illness did not preclude successful extubation. Cost analysis at UC showed a significant reduction in intensive care unit services and associated cost for extubated patients. We conclude that immediate postoperative tracheal extubation of selected liver transplantation patients is safe and cost effective.