A “deep” extubation refers to removing an endotracheal tube (ETT) or laryngeal mask airway (LMA) while the patient is still under anesthesia and their 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 or remifentanil 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, suction 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! 🙂
This blog stole your words:
I’ve been following you for some time now. I suppose you may have taken it from them but I doubt it : )
I certainly didn’t take it from them. They actually gave me credit… although it’d be nice if they didn’t repost the entire thing word-for-word, lol.
Oh, good call. I totally missed that bit. At least they gave you credit.
I have had equivocal results with “deep” extubation in both peds/neuroENT cases or maybe I am not doing it right. If the latter, perhaps I could benefit from some suggestions. I find deep extubation does not work ideally unless the pharynx is VERY dry (glycopyrrolate +/- aggressive suctioning, both of which may be undesirable in some of these cases). I would rather extubate deeply solely on sevoflurane (without administering propofol to avoid its respiratory depressant effect). For those that do that about what MAC multiple do you like having the pt expire before extubating?
I have been in practice for 35 years and have been extubating deep 98% of the time. In fact I find it smooth the airway is never an issue. Early in residency I realized a foreign body (ET TUbe compounded with inflated cuff) was physiologically interpreted as a threat to life, more so than an incision! And rightfully so.
I approach the reversal the same single lumen or double. As the procedure is winding down I already have an undersized oral airway in place, suction oral pharynx and deflate the tube (strongest stimuli to bucking). I administer reversal agents and help the patient develop a symmetrical CO2 wave form 100%O2 1.5-2% Sevo.
I place a nasal cannula give 60-70 mg Lido, allow 5min time for final surgical steps and extubate.
Patient leaves the OR awake any discomfort gets Fentanyl. Without contraindications I administer dilaudid (case/patent dependent) versed/Fent lido, deca,zofran early on. There is zero bucking no sore throats (4% lido jelly) and no pain (encourage surgical use of esperill )
Thanks so much for outlining your technique, Joseph!
P.S. NEVER FEAR AN AIRWAY!
This has been my practice for 25 years. It hits all the points made by the author, and also improves OR efficiency.
I feel as though the practice should be more wide spread.
Thanks so much, Daniel! I think it lends credence to the fact that there are so many ways to emerge patients!
Thanks for Sharing this nice topic. I find myself more confident to perform fully awake extubations in ENT cases, specially in peds tonsillectomies. I use TIVA with propofol/remifentanyl after the placement of an iv line under inhalational induction and complete induction phase with 1ug/kg of clonidine, 0,1 mg/kg morphine and 1mg/kg of lidocaine prior to intubation. Excellent intubation conditions with no muscle relaxation. By the end of the case and after a careful aspiration of pharynx, I switch off tiva and give 0,5mg/kg of lidocaine. Mean extubation time 10 minutes. Pts fully awake with intact airway reflexes, no cough and remain sedated and comfortable with clonidine and morphine combination. Antiemetics dexa and ondansetron. Oral acetaminophen prior to procedure. I perform around 20 cases a month with this protocol and luckily have no respiratory complications.
Thanks again you are great and have an outstanding year 2020 from Argentina!!!!
Thank you so much for sharing your insight, Diego! Best wishes to you in 2020!
I will extubate deep in ENT cases. Get them breathing spontaneously and go to two MAC make sure the stomach is empty and then gently slip out the tube. Then turn off the gas apply the mask with jaw trust and a oral airway and let the breath off the gas at high O2 flow.
Thanks for sharing your technique!
With the use of Remifentanil infusion/intermittent bolus while blowing off the volatile at the end, I find that one can achieve the same endpoint. Interesting how traditionally one is taught that deep extubation is perceived as an “act of treason” to the profession, yet there are several “pockets” of practice where it remains alive and well (and without adverse outcome)- goes to show there are many ways to “skin the cat”!
Absolutely! And that’s the beauty of our field. 🙂
Agreed. Clearly, there are many ways to achieve a good outcome.
Thanks for sharing,
I use Sevo (I find additional Prop. rarely nec.). Oral airway already in place; deflate/inflate cuff rapidly to assess depth. Suction before extubation with soft catheter (can go deeper than Yankauer).
Excellent point about the limitations of Yankauer! Appreciate the comment!
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”.
Thank you so much for sharing your insight and experience!
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! 🙂
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.
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.
I agree with DK. The BIS is not reliable measure.
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.