From the Guidelines
Deep extubation in anesthesia refers to the removal of an endotracheal tube while a patient is still under general anesthesia, before they regain consciousness, and is typically reserved for spontaneously breathing patients with uncomplicated airways and only performed by clinicians familiar with the technique. This technique is used to avoid the coughing, bucking, and hemodynamic responses that often occur during awake extubation. For deep extubation to be performed safely, the patient must have spontaneous respiration, adequate oxygenation, and a patent airway, as outlined in the Difficult Airway Society guidelines for the management of tracheal extubation 1.
The sequence for deep extubation involves several key steps, including:
- Ensuring no further surgical stimulation
- Balancing adequate analgesia against inhibition of respiratory drive
- Delivering 100% oxygen through the breathing system
- Ensuring adequate depth of anesthesia with volatile agent or total intravenous anesthesia (TIVA) as appropriate
- Positioning the patient appropriately
- Removing oropharyngeal secretions using a suction device
- Deflating the tracheal tube cuff and applying positive pressure via the breathing circuit to remove the tracheal tube
- Reconfirming airway patency and adequacy of breathing, and maintaining airway patency with simple airway maneuvers or oro-/nasopharyngeal airway until the patient is fully awake, as described in the guidelines 1.
Deep extubation is particularly useful in patients where avoiding coughing is beneficial, such as those with increased intracranial pressure, open eye procedures, or after airway surgeries. However, it requires careful patient selection and monitoring as it carries risks of airway obstruction, laryngospasm, and aspiration until protective reflexes fully return, highlighting the importance of meticulous attention to detail and adequate depth of anesthesia to avoid complications 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Definition of Deep Extubation
Deep extubation refers to the removal of an endotracheal tube from a patient while they are still under deep anesthesia, rather than waiting for them to fully awaken. This technique is used to minimize the risk of complications such as coughing, laryngospasm, and desaturation that can occur during emergence from anesthesia.
Benefits of Deep Extubation
- Reduces the risk of overall airway complications, including cough and desaturation 2
- May be recommended in pediatric patients to minimize overall airway complications, except airway obstruction 2
- Can reduce the hemodynamic response, choking, and irritability observed at the end of anesthesia upon removing the endotracheal tube 3
Comparison with Awake Extubation
- Deep extubation reduces the risk of overall airway complications, cough, and desaturation compared to awake extubation 2
- However, deep extubation may increase the risk of airway obstruction compared to awake extubation 2
- The choice of extubation method depends on the individual patient's risk of airway complications 2
Anesthetic Agents Used for Deep Extubation
- Remifentanil: can be used to maintain a deep level of anesthesia during extubation, reducing the risk of coughing and hemodynamic response 4, 3
- Propofol: can be used for induction and maintenance of anesthesia, but may not be as effective as remifentanil in reducing coughing and hemodynamic response during extubation 4, 5
- Dexmedetomidine: may be used as an alternative to propofol and remifentanil, with potential benefits in reducing NIV failure, mortality, and ICU LOS 6