Anesthesia Incident Reporting System (AIRS) Case 2024-10: Airway Complications After Deep Extubation

A 4-year-old male undergoing a procedure with an endotracheal tube who experienced a bronchospasm during induction is nonetheless planned for deep extubation at the end of the procedure in light of a reassuring airway and otherwise stable course.

After extubation, the patient coughed and appeared to bronchospasm with suctioning despite what appeared to be an adequate depth of anesthesia (3% sevoflurane with additional propofol and dexmedetomidine boluses just before extubation). The patient then became bradycardic, requiring CPR.

The patient recovered after two minutes of CPR and one dose of epinephrine, but had persistently low oxygen saturation for which the patient was reintubated. On auscultation, the patient had diminished bilateral breath sounds with expiratory wheezing.

The decision was made to keep the patient intubated and transport to the intensive care unit.

“Deep extubation” refers to the removal of the endotracheal tube while the patient is under general anesthesia with no response to stimuli and the absence of protective airway reflexes (Miller’s Anesthesia. 8^th ed, 2015). This contrasts with awake extubation, which is performed when the patient has recovered their airway reflexes and responds appropriately to verbal and physical stimuli. In practice, the definition and technique of deep extubation can vary widely.

The benefits of deep extubation are thought to include less straining, airway stimulation, hemodynamic changes, and patient movement on emergence, which can reduce tension on the surgical repair. Although no one surgery is an absolute indication for deep extubation, procedures such as open globe repair, intracranial surgery, head and neck surgery, and vascular surgeries may benefit from deep extubation.

Deep extubation can result in upper-airway obstruction, hypoventilation, laryngospasm, and aspiration. Contraindications to deep extubation include difficult mask ventilation, difficult intubation, high aspiration risk, and blood in the oropharynx (Anesthesiology Resident Manual of Procedures. 2021).

Although it is ideal for the patient to spontaneously breathe with adequate tidal volumes before extubation, this is not strictly necessary. The anesthesia practitioner may elect to extubate the patient deep and provide ventilatory support by mask until the patient’s respiratory drive returns.

Before deep extubation, care should be taken to ensure that the patient is at an adequate depth of anesthesia, which can be achieved with volatile and/or intravenous agents. Typically, a volatile MAC of 1.3 to 1.5 is targeted, although this may be lower depending on the presence of other intravenous agents such as opioids, propofol, or dexmedetomidine. A mixed volatile/intravenous anesthetic or total intravenous anesthetic are options as well. A small propofol bolus may temporarily deepen the patient to a safe level for deep extubation. Intravenous lidocaine may be given to further blunt airway reflexes.

There is an element of judgment when determining if the patient’s anesthetic depth is adequate for deep extubation. Sometimes, an extubation is claimed to be “deep” when, in fact, the patient is reactive to stimuli. For instance, one thought process is that the patient’s anesthetic depth needs to be lightened to restore spontaneous breathing, and that the endotracheal tube can always be removed safely without further assessment whenever spontaneous breathing resumes, even with a volatile MAC of 0.7 or lower. Although it is true that the volatile MAC value does not fully reflect a patient’s true depth of anesthesia, we urge caution in assuming that a patient who is just beginning to breathe spontaneously remains in a deep plane of anesthesia.

Deep extubation requires close supervision afterward, as the patient will not have a protected airway during stage 2 of anesthesia when airway irritability is at its peak. Irregular breathing, breath holding, and laryngospasm may occur. An anesthesia professional or a PACU nurse familiar with emergence should monitor the patient closely until they fully emerge from anesthesia. Although deep extubation is often believed to save time and improve OR throughput, increased efficiency alone should not be a reason for pursuing deep extubation.

In the case report above, the patient appeared to have a reactive airway on induction of anesthesia. Some would argue that this is grounds for an awake extubation. If the patient bronchospasms again or has another adverse event during emergence without a secure airway, it may be necessary to reintubate the patient. The lack of a secure airway may cause unnecessary respiratory complications.

On the other hand, deep extubation may help to reduce overall airway reactivity by removing an irritating foreign body from the trachea prior to emergence (You’re Wrong, I’m Right. 2016). Depending on the surgery, the severe coughing, straining, and hemodynamic changes during emergence with an endotracheal tube in place could lead to other complications. However, due to the patient’s known reactive airway, the practitioner should exercise particular caution in ensuring optimum conditions before deep extubation and should monitor the patient closely during emergence without a secure airway.

To the authors’ knowledge, there is no definitive evidence that deep extubation is superior to awake extubation, or vice versa. Each anesthesia practitioner should consider the individual patient and procedure, the provider’s experience and comfort level with deep-versus-awake extubation, and if there are adequate post-extubation resources available to monitor the patient.

Deep extubation is a useful technique and has its place in low-risk patients, particularly those undergoing certain procedures. However, anesthesia professionals should carefully weigh each scenario’s individual risks and the benefits of deep versus awake extubation.