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Randomized Controlled Trial
. 2025 Jul 31;25(1):387.
doi: 10.1186/s12871-025-03224-6.

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

Michael A Lee  1 , Peter W Schenke  2 , Matthew R Faller  2 , Henry R DeYoung  2 , Ashley R Adams  3
Affiliations
Randomized Controlled Trial

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

Michael A Lee et al. BMC Anesthesiol. .

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

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

Keywords: Adult anesthesia; Airway complications; Awake extubation; Deep extubation; General endotracheal anesthesia; Randomized controlled trials.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study protocol was approved by the Naval Medical Center Portsmouth’s Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects. Informed consent was obtained from all research subjects. Our study adhered to the World Medical Association Declaration of Helsinki, with the exception of trial registration before recruitment of the first subject, which was accomplished retrospectively before trial conclusion. Ignorance of the primary investigator, research personnel turnover during the COVID-19 pandemic, and administrative oversight were the root causes of this error. The only significant protocol change made after IRB approval and study initiation was formalizing the anesthesia provider’s discretion to forgo randomization and select an extubation method based on clinically compelling intraoperative events. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of participant enrolment into both the AE and DE arms
Fig. 2
Fig. 2
Survival curves of complications after extubation to PACU Transfer; analysis with Log-Rank test. A Any Cough (p <.001) B Severe Cough, Modified Minogue Score of 3 or 4 (p =.006) C Obstruction (p <.001) D Apnea (p =.026) E Any Hypoxemia, < 94% (p =.080) F Severe Hypoxemia, < 85% (p =.315) G Laryngospasm (p =.043) H Severe Agitation (p =.014). I Overall Complications (p <.001). J Overall Complications, excluding Modified Minogue Score of 2 (p <.001). There were no cases of Bronchospasm
Fig. 3
Fig. 3
Hypothesized relative indications for extubation method in adults
See this image and copyright information in PMC

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