The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago. Here are time-tested steps:

Allow the patient to resume breathing spontaneously, making sure that muscle relaxation is completely reversed and anti-emetic medication has been given. Deep extubation is most easily done with inhalation anesthesia and minimal narcotic use. Do not reduce the amount of inhaled anesthetic toward the end of the case.

Make sure that tidal volume is adequate, and that the respiratory rate is less than 25. If the patient is breathing rapidly, titrate small amounts of a long-acting IV opioid (hydromorphone, morphine) until the respiratory rate settles down.

Insert an appropriately sized oral airway, and use a suction catheter to suction down the center of the airway and beside it on each side. Secretions are the enemy.

If the patient reacts at all to suctioning, he or she is not deeply enough asleep. Titrate small amounts of IV opioid or propofol, and/or give 1 mg/kg IV lidocaine. Suction again; confirm that the level of anesthesia is deep and that the patient does not react but is still breathing well.

Deflate the cuff and remove the tube. Discontinue the inhaled anesthetic. My preference is to have the patient breathe supplemental oxygen via a transport face mask rather than to use the anesthesia circuit and mask, because there is no need for further inhaled anesthesia.

Turn the patient’s face slightly to one side and gently lift the chin and/or mandible. Make sure that the patient is exchanging air well. It is not uncommon for the patient to hold his/her breath momentarily just after extubation, but breathing will resume, I promise. There is no need to intervene. Continue to support the chin or mandible until the patient is able to maintain a patent airway without assistance. Remove the oral airway as soon as the patient begins to react to it, to avoid biting or gagging.

Frequently asked questions

Is deep extubation dangerous?

With improper patient selection, it certainly could be. This is not the technique for the patient with a full stomach, ileus, GI obstruction, achalasia, a BMI of 70, or a reason why you might choose to intubate awake. It is appropriate for most patients who walk into the hospital breathing room air, are scheduled for elective surgery, have fasted, are not morbidly obese, and are not chronic CO2 retainers. If your plan is to induce anesthesia and mask ventilate prior to intubation, it is likely that deep extubation will be safe and feasible.

What if the patient goes into “Stage 2” on the way from the OR to PACU?

This question reflects a misunderstanding of the definition of “Stage 2” anesthesia. The stages of mask induction with diethyl ether anesthesia were described by Dr. Arthur Guedel in a 1920 article, and later in a 1937 textbook. He characterized “Stage 2” as the “delirium” stage, with rapid eyeball activity, swallowing, and possible vomiting.

We no longer use diethyl ether, and modern balanced anesthesia utilizes multiple different anesthetic medications for hypnosis, analgesia, and anti-emesis. There really is no “Stage 2” anesthesia, either on induction or emergence. Today “Stage 2”, in my opinion, has become a tale handed down by attending anesthesiologists from generation to generation to frighten the children and justify the unpleasantness of awake extubation.

Occasionally patients may exhibit signs of excitement on emergence. This occurs more often with younger patients, but may happen at any age. If the patient should move unpredictably, and isn’t awake enough yet to cooperate, a small dose of IV propofol will calm the patient and this phase will pass. For this reason, the prudent anesthesiologist will always have propofol in his/her pocket during any patient transport.

Emergence delirium and postoperative cognitive dysfunction are genuine medical problems, but are not related to the timing of extubation.

What about the risk of laryngospasm?

This is one of the old wives’ tales of anesthesiology. A patient may experience laryngospasm for multiple reasons, not solely as a response to extubation during “Stage 2”. Laryngospasm can happen in awake patients due to GE reflux or reactive airways disease, or upon induction of anesthesia in adults or children. It has occurred in the PACU. I was called into an operating room one day to assist in the care of a patient who had gone into laryngospasm at the end of her procedure, sitting bolt upright on the gurney, desperately trying to breathe but as blue as a Smurf. Awake extubation is no guarantee of immunity from laryngospasm.

There is a tendency to confuse inspiratory stridor with true laryngospasm. Inspiratory stridor may occur briefly after extubation, and may be relieved by elevating the mandible and opening the airway. Administration of 0.5-1 mg IV lidocaine may help as well. As the patient continues to emerge from anesthesia, inspiratory stridor will resolve on its own.

True laryngospasm is characterized by the complete absence of air movement or sound despite vigorous attempts to breathe. Obstruction of the airway occurs at the level of the true vocal cords, the false cords, and the redundant supraglottic tissue. This creates a ball-valve obstruction, controlled by the intrinsic and extrinsic laryngeal muscles.

Here is the most important point:

Applying positive pressure will not relieve true laryngospasm, and may worsen it, because it will press the aryepiglottic folds more firmly against each other and reinforce the closure.

This phenomenon was described elegantly by Dr. Bernard Fink in his classic article published in Anesthesiology in 1956, “The Etiology and Treatment of Laryngeal Spasm”, and reiterated more recently in a letter to the editor. The persistence of many anesthesiologists in believing after more than 50 years that positive pressure will “break” complete laryngospasm confirms my impression that the principles of “evidence-based medicine” are applied or ignored selectively if they challenge entrenched belief systems.

How should complete laryngospasm be managed?

If a patient at any stage of care is in true laryngospasm, characterized by attempts to breathe with no sound, no air movement, no chest rise, and a visible tracheal tug, positive pressure ventilation will be useless.

The first step is to elevate the mandible and apply firm upward pressure just behind and above the angle of the jaw — the so-called “laryngospasm notch“. (Click here to watch a NEJM video of this technique, known as the Larson maneuver.) Watch to see if air movement resumes.

If this maneuver does not work within a breath or two, however, the next step is to make the patient apneic. If the patient continues to try to breathe against a closed glottis, there is a risk that the patient will develop negative pressure pulmonary edema. This will cause no end of problems, including an extremely expensive cardiac work-up, extended hospitalization, and potential lawsuit.

Apnea may be achieved with enough propofol, or with a small amount of any muscle relaxant. Succinylcholine is the classic treatment; even 10 mg IV will suffice, but make sure the patient is asleep first. Assure adequate oxygenation with mask ventilation, suction any secretions, and then permit the patient to resume spontaneous ventilation and wake up. It isn’t always necessary to reintubate.

Laryngospasm should be neither life-threatening to the patient, nor terrifying to the anesthesiologist, if the pathophysiology and treatment are clearly understood and the right plan of care is promptly initiated.

Why bother with deep extubation when awake is easier?

There are many surgical situations where deep extubation is desirable: hernia repair, thyroidectomy, plastic surgery procedures, any major abdominal procedure where coughing will strain the repair, ophthalmology procedures, cervical spine surgery — the list goes on. With today’s modern insoluble anesthetics, emergence from anesthesia is rapid and outpatient discharge need not be delayed. Deep extubation is a useful technique for any anesthesiologist to master, and it is a key part of the art as well as the science of anesthesiology.

3 COMMENTS

Typing one handed here so please forgive typos. Deep extubation is a favourite discussion point as it often comes up as a solution to oral exam questions. What is interesting is that in the 9 years I've been discussing it, I've never had a single trainee who had either seen a deep extubation or was capable of defining it (I'm excluding paediatric extubations on TIVA which is a different beast). The historic literature dating from an era when it was a far more commonly used ...Read More

Oren Bernstein

Couldn't agree more on the elegance of deep extubation. Thank you for eloquently dispensing with the dogma that surrounds this issue.

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I wish I knew who coined the term “DRexit” so I could send flowers or a bottle of whiskey as a thank-you gift. There couldn’t be a more perfect term to describe the growing exodus of physicians from our beloved profession, which is turning into a morass of computer data entry and meaningless regulations thought up by people who never touch a patient.

The one bright note on the horizon for me is that physicians are starting to wake up to the trap of MOC, or mandatory maintenance of certification. It’s surprising that the Federal Trade Commission hasn’t recognized already that this is quite a racket, forcing physicians to do CME activities dictated by monopolistic certification boards which profit handsomely.

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3 COMMENTS

Dr. Phil (#thereal)

Wow! Great! I mentioned revising the way we do MOCA or board certification to another Sullivan (Dr. Erin Sullivan - u of Pitt/in the ASA/brilliant dr) a few years back. The next thing I know they (the ABA) changed the way the 10 year recertification was done going from the archaic one time test every 10 years test that cost $2100 to just take. It didn't factor in cost to prepare, time, travel, etc. If you pass ur ok, but if u didn't ...Read More
Burnout and DRexit occur when the insurance, pharma, med mal, hospital, EHR and professional medical boards prevent physicians from optimizing value=outcomes/costs with their patients. https://www.linkedin.com/pulse/american-physicians-putzes-howard-green-md

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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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11 COMMENTS

pam price

Your coverage regarding "eyes wide open" anesthesia brings up issues that never crossed my mind, however some curious patients might find their viewing these procedures terrific cocktail chatter. Personally, it could come down to a personal choice at some point, with all of the cost cutting in medical care one of the prevailing issues. Recovering from an operation/anesthesia whether the patient observes the process or not? Personally, I wouldn't want to observe any of it, I would ...Read More

Joyce Wahr

I also am an anesthesiologist in practice since 1982, so have seen a good many things change and develop. While I agree with most of what Carol writes, I have seen and heard about many anesthesiologists who ARE paternalistic and insulting to patients and their desire and wishes. I am a semi-expert on mast cell activation syndrome and often am asked to develop a preop and intraop plan for patients having surgery. On several occasions I have seen the patients after surgery where my own ...Read More

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In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

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10 COMMENTS

willy miller

HYPOCRITS! that's what the members of the AMA, ACGME, Specialty Colleges and academics are. TOOLS, interested in their income, stature and professional advancement. Boards are a joke, useless and serve no purpose. But US medical system has become the most corrupt business in the US due to these tools. FIGHT BACK. SUE. Inform the media to investigate these organizations.

Alieta Eck, MD

I have a certification in Internal Medicine that is not time limited. I will never participate in MOC. My husband was Board Certified in Family Medicine which expects repeated testing, but he brushed it off. One hospital suddenly decided this was a big deal and told him he needed to take the test in order to retain privileges. The Board wanted him to pay for all the tests he missed before they would allow him to sit for the current test. He refused, and after 25 ...Read More

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Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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4 COMMENTS

Alan Schneider M.D.

The real shocking statistic is that there are not more deaths if Dentists, along with their assistants, are allowed to provide sedation to children. Because one thing for sure it will not be moderate sedation in a child. I am amazed they are even able to get the IV started I trained decades ago as a pediatric anesthesiologist, although supervise mostly adults now, but even my adrenaline would be pumping if I provided sedation to a child in an office setting
Unnecessary dental sedation deaths persist. The practice of single-operator anaesthetist should have been stopped many many years ago. Thank you for an excellent article.

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