A “deep” extubation refers to removing an endotracheal tube (ETT) or laryngeal mask airway (LMA) while the patient is still under anesthesia and his/her airway reflexes (ie, gag) have not returned. Although there are no absolute indications for deep extubation, it’s often performed in pediatric anesthesia as well as adult neurosurgery and ENT cases where coughing can lead to sudden increases in intracranial pressure, disruption of delicate suture lines, etc.

When I do cases solo or with more experienced residents, I tend to prefer extubating deep and early. By doing this, I find emergence from general anesthesia is smoother since patients aren’t “bucking” or gagging on the ETT. By the time we’re in the recovery area, patients are often fully awake and conversing. I don’t perform deep extubation on patients who received a rapid sequence induction (RSI) for any reason. Their risk of aspiration will only be compounded by an insecure airway and lack of protective airway reflexes after emergence. I also avoid it in patients with difficult airways and/or two-handed bag masks at induction.

So what’s my process?

  • Get the patient breathing ~80% oxygen spontaneously on the ventilator for a few minutes after reversing any residual paralysis.
  • Gather airway equipment (laryngoscope, ETT, oral airway).
  • Suction the mouth and stomach.
  • Ensure the patient is actually deep under anesthesia! I do this with short acting intravenous agents like propofol and turn off any halogenated volatile agent at this time.
  • I’ll deflate and reinflate the ETT’s pilot balloon to see if the stimulus elicits any reaction. If not, I’ll extubateresuction the oropharynx, place an oral airway, and hold a mask with 100% O2 and end-tidal CO2 monitoring.
  • Apnea may result from the propofol bolus or “breath holding.” I maintain airway patency with a jaw thrust maneuver and wait patiently. After ~30 seconds, I may assist with mask ventilation, but patients almost always regain their spontaneous breathing pattern before that.