Prolonged mechanical ventilation after Cardiac Surgery (CS) is associated with longer hospitalization, higher morbidity, mortality, and increased costs. Prolonged intubation is associated with both ventilator-associated pneumonia and significant dysphagia. Early extubation, within 6 hours of ICU arrival, can be achieved with time-directed extubation protocols and low-dose opioid anesthesia. This is safe (even in patients at high risk) and associated with decreased ICU time, length of stay, and costs. A meta-analysis demonstrated that ICU times and length of stay were reduced; however, no difference in morbidity and mortality occurred, likely because of disparate study design and statistical underpowering. Thus, studies have shown early extubation to be safe, but efficacy in reducing complications has not been conclusively demonstrated. Based on this evidence, we recommend strategies to ensure extubation within 6 hours of surgery (class IIa, level B-NR).