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 extubate, resuction 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.

Drop me a comment with your thoughts! 🙂

12 Comments

  1. I’ve been extubating deep for the past 35 yrs of practice for several physiological reasons and haven’t had any airway issues. First and foremost is the presence of a foreign body(the tube) in an awake persons airway. This is perceived as a threat to life resulting in massive sympathetic discharge increasing all vascular pressures and heart rate, a triggering of G.I. activity, secretions and gaging. Not the way to emerge from g.a. I place a smaller e.t. Tube (Less irritating 6.5-7) with lido jelly and no use of stylet and a smaller oral airway after induction. At the end of the procedure (including double lumen chest cases) I use a small suction catheter to evacuate secretions, deflate the cuff (strong stimulus to airway) and help patient to develop symmetrical CO2 wave forms while still at 2% sevo. As the last few skin sutures go in the tube comes out nasal cannula in place agents off and flushed out and mask applied. Assistance rarely needed patient wake in time for transfer to stretcher. P.S. I never use LMA’s why? The act of vomiting is volitive for a reason. To expel toxic gastric contents past the airway and out of the body. An LMA takes that protection away. Deep extubation allows a comfortable emergence with a GI tract that is still “asleep”.

  2. Chris Link MD Reply

    When I was first in practice, I stopped in to say something to one of the long-experienced MDAs. I was startled to see that his patient’s ETT had been dislodged and pointed it out. He replied that, whenever possible, he got the patient breathing spontaneously and pulled the ET back just above the vocal cords. Even with the cuff down one can almost always get a seal up to around 10 cm pressure in order to assist their respiration if needed. I very, very rarely can smell any volatile agent and don’t recall ever getting a laryngospasm or having to reintubate one of these patients.

    • Thanks for sharing your insight! Interesting to see how much practices vary in our field! 🙂

  3. Sina Ghaffari Reply

    No reason for giving apnea in deep extubation, Patient must maintain spontaneous ventilation before and after deep extubation.

    • Although I agree, I do find some patients will “breath hold” during the transition.

  4. Are you using BIS monitors to confirm the patient is actually deep? The patient may be breathing spontaneously but be light under GA when inhaled anesthetic is turned off. Have you had issues with laryngospasm extubating deep? How much propofol, in general, do you inject with an adult patient prior to extubation?

    • I use anywhere from 50 – 100 mg of propofol, push it, then turn the gas off, and extubate (assuming everything is stable). On the rare occasion that I have mild laryngospasm, it has always broken with positive pressure.

    • Placing a BIS on a cucumber will elicit 40. BIS is junk science, and should not be used as a reliant measure. The maneuvers that RK.MD uses, certainly is enough to determine if patient is deep enough for extubation.

      • I agree! The whole point is assessing if airway reflexes have returned. A bit of jaw thrust, stimulating the pilot balloon, looking for swallowing, etc. should be enough to determine this.

  5. Teresa Marrero Reply

    I do not agree with suctioning the stomach because it is too stimulating and rarely is there content…..unless there are reasons you think the stomach is full in which case probably shouldn’t extubate deep anyway.
    Totally agree with peds, but you HAVE to have a PACU that know how to handle deep extubations which includes having lots of one on one nursing.

    • I don’t do this in patients who had a reason for an RSI (ie, “full stomach”) in the first place. That’s a hard stop. Second, sometimes I’ve already passed an OG tube, so might as well suction the stomach before removing it. I completely agree that the PACU has to know how to handle deep extubations, but I extubate early enough that by the time we finish, close records, waste meds and transport the patient, patients have had a considerable amount of time to “come out of anesthesia” before arriving to the step down unit, PACU, etc.

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