Incidence of airway complications associated with deep extubation in adults

Abstract

Background: Endotracheal extubation is the most crucial step during emergence from general anesthesia and is usually carried out when patients are awake with return of airway reflexes. Alternatively, extubations can also be accomplished while patients are deeply anesthetized, a technique known as "deep extubation", in order to provide a "smooth" emergence from anesthesia. Deep extubation is seldomly performed in adults, even in appropriate circumstances, likely due to concerns for potential respiratory complications and limited research supporting its safety. It is in this context that we designed our prospective study to understand the factors that contribute to the success or failure of deep extubation in adults.

Methods: In this prospective observational study, 300 patients, age ≥ 18, American Society of Anesthesiologists Physical Status (ASA PS) Classification I - III, who underwent head-and-neck and ocular surgeries. Patients' demographic, comorbidity, airway assessment, O2 saturation, end tidal CO2 levels, time to exit OR, time to eye opening, and respiratory complications after deep extubation in the OR were analyzed.

Results: Forty (13%) out of 300 patients had at least one complication in the OR, as defined by persistent coughing, desaturation SpO2 < 90% for longer than 10s, laryngospasm, stridor, bronchospasm and reintubation. When comparing the complication group to the no complication group, the patients in the complication group had significantly higher BMI (30 vs 26), lower O2 saturation pre and post extubation, and longer time from end of surgery to out of OR (p < 0.05).

Conclusions: The complication rate during deep extubation in adults was relatively low compared to published reports in the literature and all easily reversible. BMI is possibly an important determinant in the success of deep extubation.

Keywords: Adult; Airway; Ambulatory surgery; Anesthesia; Complications; Deep extubation; Emergence; Tracheal extubation; Volatile anesthetics.

Conflict of interest statement

The authors do not have any competing interests.

Figures

Fig. 1

Number of patients with at least one complication* in the OR after deep extubation (a) and comparison of patient demographics between complications and no complications group by (b) Age, (c) BMI, and (d) Sex. *Complications include desaturation SpO2 < 90% for longer than 10s, persistent cough, laryngospasm, stridor, bronchospasm, and reintubation

Fig. 2

Comparison of patients and intraoperative characteristics between complications versus no complications groups by a ASA PS Classification, b Surgery Class, c Respiratory Pathology, d Mallampati (MP) Score, e Cormack-Lehane Grade

Fig. 3

Comparison of emergence conditions between complications versus no complications groups by a MAC, b end-tidal CO2 (etCO2), (C) O2 Saturation (Sat) before and (D) O2 Sat after extubation

Fig. 4

Comparison of emergence times between complications versus no complications groups from end of surgery to a time out of OR and from extubation to b time to eye opening