Intubation and extubation (Endotracheal tube (ETT) removal) represent a critically important phase of anesthesia care where multiple potentially catastrophic complications can occur. Therefore modern practice has focused on limiting adverse events during these stages. Intubation is accompanied with an algorithm designed to help providers navigate challenging airways. While extubation generally carries guidelines and practical measure to help guide extubation readiness, deep vs awake ETT removal is often left to provider discretion.

In general, patients are extubated when either under general anesthesia (GA) (deep) or awake and following commands, and not between these two states. Most adults are extubated awake while healthy pediatric patients are commonly extubated deep.

A few general exclusions that should preclude a deep extubation: difficult airway (mask or intubation), full stomach, severe OSA, or other pathology that limits adequate spontaneous ventilation.

Classic routine awake extubation is considered when patients are well oxygenated with adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry and end-tidal carbon dioxide (CO2). In addition the awake extubation is performed after the patient demonstrates the ability to follow commands such as sustained head lift, tongue protrusion, hand grip and release, etc.

Deep extubation is defined as ETT removal while under full general anesthesia (no response to surgical stimulus). If on volatile anesthesia, 1.0 MAC or higher is typically required. Patient should have full paralytic reversal and adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry, SaO2, and end-tidal carbon dioxide (CO2). Deep oropharyngeal suction to both remove any secretions and also identify breath holding or response to stimulus. If no grimace or breath holding, the patient is considered "deep" and extubation can proceed. Following ETT removal, supplemental O2 via face mask is applied and ventilation should be closely monitored to identify obstruction, spasm, or poor effort. Oral/nasal airways, jaw thrust, or other maneuvers may be required to overcome obstruction.

Benefits include:

  • Decrease coughing, gagging, bucking on the ETT
  • Potentially more calm and smooth emergence

Risks include:

  • Potentially unprotected airway in an anesthetized patient
  • Theoretical risk of laryngospasm
  • Increased risk of airway obstruction

A meta analysis in 2018 with 17 randomized trials and a total of 1881 pediatric patients had several interesting findings:[1]

Deep vs awake extubation Result Odds ratio
Overall complications No difference OR 0.5, 95% CI 0.23–1.11, p = 0.09
Airway obstruction Favors awake OR 2.67, 95% CI 1.03–6.94, p = 0.04
Cough Favors deep OR 0.25, 95% CI 0.10–0.60, p = 0.002
Desaturation (<96%) No difference OR 0.43, 95% CI 0.17–1.09, p = 0.08
Laryngospasm No difference OR 1.12, 95% CI 0.57-2.17, p = 0.75
Breath holding No difference OR 0.77, 95% CI 0.27–2.18, p = 0.62
  1. Koo CH, Lee SY, Chung SH, Ryu JH. Deep vs. Awake Extubation and LMA Removal in Terms of Airway Complications in Pediatric Patients Undergoing Anesthesia: A Systemic Review and Meta-Analysis. J Clin Med. 2018;7(10):353. Published 2018 Oct 14. doi:10.3390/jcm7100353