A comparison of deep versus awake tracheal extubation in adults: a randomized controlled trial

Awake extubation is deemed a generally safe option for tracheal extubation in low-risk patients, while anesthetized, or"deep" extubation is often considered best suited to seasoned providers due to its perceived hazards. However, inadequate data exists about the relative safety of deep and awake extubations in the adult population.

Adult patients (n=220) with favorable airways undergoing elective surgeries under general tracheal anesthesia were enrolled prospectively. Following a standardized volatile anesthetic regimen, patients were randomized to undergo deep or awake tracheal extubation. The primary outcome was the occurrence of at least one airway or respiratory complication. Secondary outcomes included airway interventions, hemodynamic parameters, severe emergence agitation, and sore throat severity.

Pre-extubation, awake extubations exhibited an increased rate of any airway and respiratory complications (risk ratio [RR] - 5.1; 95% confidence interval [CI] - 2.8-9.5; p<.001), attributable to greater incidences of cough (RR - 6.8; 95% CI - 3.2-14.3, p>.001) and hypoxemia (RR - 3.6; 95% CI - 1.3-10.6, p=.010). After extubation, a significantly decreased rate of one or more complications occurred in the awake extubation group (RR - 0.7; 95% CI - 0.6-1.0; p=.028). Awake extubations were associated with fewer incidences of airway obstruction (RR - 0.2; 95% CI - 0.1-0.4, p<.001) and apnea (RR - 0.3; 95% CI - 0.1-0.9; p=.025), but higher rates of any severity cough (RR - 2.9; 95% CI - 1.6-5.2; p<.001). Awake extubations required significantly fewer airway interventions after extubation (RR - 0.2; 95% CI - 0.1-0.6; p<.001). No serious adverse events occurred.

Deep and awake extubations produce distinct airway and respiratory complication profiles, without either being conclusively safer. The risks posed by each technique during emergence and after extubation should be considered by anesthesia providers when formulating an extubation strategy.

This study was retrospectively registered at clinicaltrials.gov (NCT05361850) on April 23, 2022.