BJA Education, 22(2): 75e81 (2022)

doi: 10.1016/j.bjae.2021.10.003
Advance Access Publication Date: 22 December 2021

Matrix codes: 1C02,

2D02, 3I00

Extubation of children in the operating theatre

C. Egbuta1,2,* and F. Evans1,2
1
Boston Children’s Hospital, Boston, MA, USA and 2Harvard Medical School, Boston, MA, USA
*Corresponding author: chinyere.egbuta@childrens.harvard.edu

Keywords: anaesthesia; general; paediatrics; tracheal extubation

Learning objectives Key points

By reading this article, you should be able to:
 Describe the characteristics unique to paediatric
patients that can make tracheal extubation
challenging.
 Identify commonly used criteria for awake and
deep extubation in children.
 Explain the steps for both awake and deep
extubation.
 Detail the characteristics of low, intermediate
and high-risk extubation.
 Anticipate and manage common complications
after extubation in children.
Emergence from general anaesthesia, the transition from
unconsciousness to complete wakefulness and recovery, is a
critical period of anaesthetic care. When compared with
other stages, audits performed in both the UK and USA have
reported emergence from anaesthesia and extubation to be a
period of particular high risk.1e3 Despite these findings,
there are currently few evidence-based guidelines for man-
aging perioperative extubation in children.4e7 The Difficult
Chinyere Egbuta MD is a paediatric anaesthetist and paediatric
critical care physician with a passion for clinical teaching and
medical education. She is the airway management team lead for the
MSICU at Boston Children’s Hospital and the co-director of the Pe-
diatric Difficult Airway Management Course at Harvard Medical
School.
 Emergence and extubation of children from gen-
eral anaesthesia are critical periods associated
with more complications than other phases.
Despite this, there are no clear published
evidence-based protocols to guide management.
 It is highly recommended that anaesthetists
formulate a plan for extubation and subsequent
airway management.
 Laryngospasm is the most common cause of up-
per airway obstruction after extubation and can
be life threatening.
 Continued intubation and ventilation in the im-
mediate postoperative period may be needed in
children at high risk of failed extubation or diffi-
cult reintubation
Airway Society (DAS) has published detailed evidence-based
guidelines for the management of tracheal extubation in
adults. Although children are not anatomically and physio-
logically the same as adults, many of the key principles
discussed are applicable to children.8 This article summa-
rises the unique challenges faced when extubating the tra-
chea of a child, commonly used criteria for awake and deep
extubation, and some of the risks and complications asso-
ciated with extubation of the paediatric patient in order to
highlight and target safety gaps that may exist between
actual and ideal practice. Weaning and extubation of chil-
dren in intensive care will be described in a forthcoming
article in this journal.9

Faye Evans MD is a paediatric anaesthetist with a passionate in- The challenge of extubation in children
terest in paediatric anaesthesia education to improve surgical care
There are attributes unique to the care of children that make
for children both in the USA and in low- and middle-income coun-
emergence from anaesthesia and extubation challenging. In
tries. She helped develop the Safer Anaesthesia from Education
contrast to adults, there is wide variance in baseline neuro-
(SAFE) paediatrics course, is the paediatric anaesthesia subsection
development with or without complex comorbidities. This
editor for Anaesthesia tutorial of the week, and is the current chair of
makes it difficult to develop a ‘one-size-fits-all’ approach for
education for the World Federation of Societies of Anaesthesiologists.

Accepted: 11 October 2021

© 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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75

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Extubation of children in the operating theatre
determining optimal anaesthetic depth for a successful
extubation. Tracheal extubation in adults has been covered
recently in this journal.10
The removal of airway devices in children is performed in
one of two ways: when the patient is conscious with pur-
poseful movements (awake extubation) or when the patient is
in a deeply anaesthetised state (deep extubation). Success is
usually defined as extubation without the need for prompt
intervention or reintubation.11 The decision to extubate and
the timing of extubation, whether deep or awake, after gen-
eral anaesthesia in young children is a complex decision that
is typically guided by the practitioner’s experience and insti-
tutional culture. The clinician takes into account a myriad of
factors including surgery performed and overall clinical sta-
bility to help determine the patient’s readiness for extubation.
There are only a few studies that have evaluated predictors of
successful extubation in children in the immediate perioper-
ative period. Consequently, routine practices surrounding
tracheal extubation in children are often institutionally based
and not well documented.6
Eight features have been found to be associated with suc-
cessful awake extubation in children: eye opening, facial
grimace, movement of the patient other than coughing, con-
jugate gaze, purposeful movement, low end-tidal anaesthetic
concentration (<0.2% for sevoflurane, <0.15% for isoflurane
and <1% for desflurane), SpO2 > 97%, tidal volume 5 ml kg 1
and a positive laryngeal stimulation test.6 A laryngeal stimu-
lation test involves gentle manipulation of the tracheal tube
up and down in a spontaneously breathing patient to deter-
mine whether there is a cough followed by a respiratory pause
of <5 s (pass), or a cough followed by a respiratory pause of >5
s (fail). A failed laryngeal stimulation test suggests a patient
has not completely passed through stage 2 of anaesthesia and
Table 1 Risk stratification for tracheal estuation.
Risk of extubation
Low
e Low risk of extubation failure AND low risk of difficult reintubation
Intermediate
e Some risk of extubation failure BUT low risk of difficult reintubation
High
e Some or high risk of extubation failure AND high risk of difficult
reintubation
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is at high risk of laryngospasm, breath-holding and apnoeic
spells if extubated.5,6 Patients with cyanotic congenital heart
disease may not achieve an SpO2 up to or greater than 97%.
Their preoperative (baseline) SpO2 should be used as a target to
help guide the decision to extubate. An increasing number of
these eight features ensures a higher likelihood of a successful
awake extubation.6
The authors recommend (based on literature cited, insti-
tutional practice and personal experience) that awake extu-
bation be considered in the following scenarios: difficult mask
ventilation; difficult tracheal intubation or high risk of difficult
reintubation; cases of high risk of aspiration; and patients at
risk for inadequate ventilation once extubated (infants espe-
cially those with prematurity or small size (<2 kg), obese pa-
tients and patients with sleep-disordered breathing).
Awake or deep extubation in children
Both awake and deep extubation are commonly used prac-
tices for extubation in children.6,12e14 Figure 1 lists the au-
thors’ recommended steps for each of these approaches.
There are proponents and opponents for each approach. The
European multicentre observational trial (Anaesthesia PRac-
tice in Children Observational Trial [APRICOT]) of children
from birth to 15 yrs of age found that awake extubation was
used more often. APRICOT also reported that the risk of
perioperative respiratory adverse events such as lar-
yngospasm and bronchospasm are much higher during
emergence and extubation than on induction.15
Although awake extubation may seem like the safer op-
tion, it is not necessarily appropriate in all situations and in-
creases the risk of adverse reflexes such as coughing.
Depending on the underlying pathology and surgical
Associated factors or conditions
e ASA 1 and 2 patients
e Uncomplicated surgery
Associated clinical conditions:
e Underlying lung pathology (chronic lung disease,
pneumonia, inflammatory lung disease, acute
chest syndrome in sickle cell disease and cystic
fibrosis)
e Congenital heart disease
e Pulmonary hypertension
e Central sleep apnoea
e Pre-existing neuromuscular disease
e Altered mental status or evolving intracranial
pathology
Associated clinical conditions:
e Known difficult airway
e Vocal cord injury
e Recurrent laryngeal nerve injury
e Laryngeal oedema or airway swelling
e Extrinsic airway compression
e Tracheo- or bronchomalacia
e Severe obstructive sleep apnoea
e Cervical instability or cervical immobility
e Intermaxillary fixation
e Airway injury (thermal or inhalational injury)
e Airway haematoma or infection
e Neck haematoma or infection
e Pre-existing neuromuscular disease (end stage)

procedure performed, the resulting transient increase in
airway pressure can lead to spikes in intracranial and intra-
ocular pressures and increased risk of bleeding and injury to
friable surgical sites. This can be especially problematic in
patients undergoing neurosurgical, ENT (ear, nose and throat),
and plastic surgery procedures. If an awake extubation is
planned, adjunctive use of dexmedetomidine, fentanyl,
remifentanil, and lidocaine i.v. have been shown to reduce
moderate and severe coughing when compared with placebo
or no medication; dexmedetomidine (0.5e1 mg kg 1 i.v.) was
ranked the most effective.16
Deep extubation is commonly used to try and prevent the
coughing or bucking often seen with awake extubation. It is
also helpful in patients with reactive airways from acute up-
per respiratory infection, history of asthma, or both, as it can
help to decrease the risk of bronchospasm on extubation.12
Deep extubation is also used to try and prevent emergence
agitation; however, the incidence of emergence agitation with
deep extubation has actually been shown to be quite similar to
that of awake extubation.17
Opponents of deep extubation suggest that this technique
is associated with a higher risk of adverse events. There have
been several studies suggesting this concern is not warranted.
von Ungern-Sternberg and colleagues prospectively evaluated
the occurrence of perioperative respiratory adverse events in
children undergoing elective adenotonsillectomy extubated
under deep anaesthesia or when fully awake.13 They found no
difference in the occurrence of laryngospasm or broncho-
spasm between the two groups.13 Templeton and colleagues
also found no difference in the incidence of perioperative
complications between awake and deep extubation when
deep extubation was used more often in children with upper
respiratory tract illness.6
Both awake and deep extubation techniques are safe when
properly performed by experienced anaesthetists who chose
the appropriate technique based on patient profile and sur-
gical procedure performed. In cases of low risk extubation,
where the risk of extubation failure is low and the risk of
difficult reintubation is also low, there seem to be no major
advantages or disadvantages to extubating awake vs
deep.8,13,14 The authors do recommend avoiding extubation in
the phase between fully anaesthetised and awake, which is
the stage where the risk of complications from triggered
airway reflexes is highest. Figure 1 depicts the authors’ steps
to perform successful awake and deep extubation in a pae-
diatric patient.
Location for extubation
Whether it is best to extubate a child in the operating theatre
or the PACU is still debated. Proponents for extubation in the
PACU argue operating theatre turnover time is decreased.
However, studies have shown little to no improvement in
turnover times.14,18 In the UK and the USA, extubation most
commonly takes place in the operating theatre.12,19 Regardless
of approach, all cases of difficult intubation should be extu-
bated in the operating theatre because of proximity to
necessary equipment used to manage a difficult reintubation
should the patient fail extubation.8,12
The immediate post-extubation period is a critical time in
which paediatric patients are at high risk for perioperative
airway complications. These complications include hypo-
ventilation, upper or lower airway obstruction, laryngospasm
and aspiration, all of which may lead to hypoxia and
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Extubation of children in the operating theatre
subsequent bradycardia and cardiac arrest. The practice of
extubation in the PACU by non-anaesthesia practitioners
(typically PACU nurses) depends on local or institutional
practice. It has been shown to be safe when strict protocols
were in place, emergency airway equipment was immediately
available, there was appropriate selection of patients, the
PACU nurses received appropriate airway training, and an
anaesthetist was available immediately. Other recommen-
dations for safe extubation of children in the PACU include a
short distance between the operating theatre and the PACU to
decrease the chance of a child awakening and bucking on the
tracheal tube, or self-extubating during transport.20
Intermediate- and high-risk extubation
Extubation can be classified as ‘intermediate risk’ when a
patient has an underlying condition that increases the risk
that there will be a compromised airway or impaired respi-
ratory effort after extubation; however, bag-mask ventilation
or re-establishment of an advanced airway is not expected to
be difficult. In contrast, an extubation is considered ‘high-risk’
when re-establishing the airway after a failed extubation
could be very challenging or impossible.21 Table 1 stratifies
extubation practices into low, intermediate and high risk, and
lists factors and clinical conditions associated with each
category.
Reintubation risk for both intermediate- and high-risk
extubation is different from the risks of initial intubation.
Reintubation is more likely to be urgent or emergent, and the
patient is more likely to be deteriorating clinically or has
already deteriorated.21 To mitigate this situation, it is important
to try to anticipate a difficult or impossible reintubation
whenever possible. An infant or child who is deemed to have a
high risk of extubation failure and a high likelihood of difficult
reintubation should not be extubated in the immediate peri-
operative period. Such a patient should be taken to the paedi-
atric ICU (PICU) for convalescence and resolution of the
condition that is conferring the higher risk of extubation fail-
ure, and if possible, resolution of the difficult reintubation risk.
When deciding about timing and location of high risk
extubation, the availability of appropriately trained personnel
(e.g. ENT) and the necessary airway equipment (e.g. rigid
bronchoscope) must be considered. Their immediate avail-
ability will depend on foresight and thoughtful planning.
The DAS extubation guidelines and the ASA task force on
management of the difficult airway recommend a preformu-
lated strategy for extubation and subsequent airway manage-
ment that takes three important factors into consideration: (i)
the relative merits of awake extubation compared with extu-
bation before the return of consciousness; (ii) general clinical
factors that may produce an adverse impact on ventilation af-
ter the patient has been extubated; and (iii) an airway man-
agement plan that can be implemented if the patient is not able
to maintain adequate ventilation after extubation.8,22
Wise-Faberowski and Nargozian evaluated the utility of the
Cook airway exchange catheter (CAEC) for extubation or rein-
tubation in paediatric patients with known difficult airway.
They extubated 20 children aged 18 yrs with a known difficult
airway by inserting a CAEC into the trachea before tracheal
extubation.23 They found that the patients tolerated the CAEC
quite well without requiring sedation and that the ability to
provide supplemental oxygen through the CAEC in the trachea
during reintubation diminished the potential for hypoxia and
maintained the ability to reintubate the trachea using the CAEC
BJA Education - Volume 22, Number 2, 2022 77
Extubation of children in the operating theatre

Awake extubation Deep extubation

Assess for haemodynamic and clinical stability. Assess for haemodynamic and clinical stability.

Reverse neuromuscular block (if applicable) and ensure Reverse neuromuscular block (if applicable) and ensure
recovery (train-of-four ratio > 0.9). recovery (train-of-four ratio > 0.9).

Increase F2 to 100%.

Ensure the patient is sufficiently anaesthetised* (at least 1 MAC of

volatile agent).
Discontinue the inhaled or i.v. anaesthetics.

Pharyngeal suction to clear the airway of secretions.

Pharyngeal suction to clear the airway of secretions before *There should be no response to suctioning of the oropharynx.
stimulating the patient.

Check for return of spontaneous ventilation and assess the for the
Insert a bite block to prevent tracheal tube occlusion should the following:
patient bite down during emergence.

• Spo2 >95% and tidal volume >5 ml kg–1 without ventilator

support
Check for return of spontaneous ventilation and assess the for the • appropriate ventilatory frequency for patient age
following:

• Spo2 >95% and tidal volume >5 ml kg–1

• eye opening Increase F2 to 100%.
• conjugate gaze
• facial grimacing
• purposeful movement
• passed laryngeal stimulus test Insert an airway adjunct while tracheal tube still in place or right
• appropriate ventilatory frequency for patient age after it is removed (oral or nasopharyngeal airway).

Deflate the tracheal tube cuff and extubate.

Perform a pre-extubation lung recruitment maneuver – by giving
a single breath with 100% oxygen. Appropriately anaesthetised patients may still breath-hold immediately
after deep extubation; wait at least 15–30 s for spontaneous
respiration to resume while providing 100% oxygen (5 s or less for
infants and small children)
Deflate the tracheal tube cuff and extubate at the end of
inspiration.

Discontinue anaesthetic agents (inhaled or i.v.) and deliver high-

flow oxygen.
Apply face mask oxygen; assess adequacy of tidal volume and
appropriate oxygen saturation.

Assess for signs of airway obstruction (supraclavicular tugging,

*Infants may breath-hold on extubation and may require a brief post-
see-saw breathing pattern, stridor on auscultation; apply airway
extubation recruitment manoeuvre.
maneuvers (jaw thrust, chin lift) as needed.

Transfer the patient out of the theatre only when airway

manoeuvres are no longer required to maintain airway patency.

Fig 1 How to perform awake and deep extubation in children. MAC, minimum alveolar concentration.

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as a guidewire to pass a tracheal tube. Five of the 20 children
(25%) ended up requiring reintubation in the PICU with the
assistance of the CAEC. This case series was too small to
determine the likelihood of potential complications of the
CAEC technique such as dislodgement, airway trauma, cough,
and laryngospasm, which can lead to respiratory distress
requiring reintubation.23 Although the DAS extubation guide-
lines and the ASA task force on management of the difficult
airway recommend assessing the relative clinical merits and
feasibility of the short-term use of an airway exchange catheter
that can serve as a guide for expedited reintubation in adults,
the ASA difficult airway task force recommends minimising the
use of such catheters with paediatric patients.8,22
Elective surgical tracheostomy in the immediate post-
operative period is rare in paediatrics (0e2.5% incidence).
However, there are several high-risk extubation scenarios
where it may be the safer option.24 Examples include cases
where there is bleeding in or around the airway or neck and
partial or complete airway obstruction.
Early complications
Laryngospasm
Laryngospasm is partial or complete closure of the glottis
caused by reflex constriction of the laryngeal muscles. It oc-
curs more commonly in paediatric patients. Older children (3
monthse9 yrs) have twice the incidence of laryngospasm and
younger children/infants (0e3 months) have three times the
incidence as adults.25 Laryngospasm is more common in
children with obstructive lung disease and those with acute
upper respiratory tract infections (URTIs). The risk associated
with acute URTI can last up to 6 weeks after infection.26 Pas-
sive smoking exposure increases the risk of perioperative
Fig 2 Larson’s manoeuvre.
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Extubation of children in the operating theatre
respiratory adverse events in children, especially lar-
yngospasm (up to 10-fold).13,27
Laryngospasm should be recognised quickly and managed
immediately (in less than 1 min) to prevent hypoxia and
subsequent bradycardia and cardiac arrest.12 Most cases of
partial laryngospasm in children (denoted by the presence of
stridor, supraclavicular retractions and auscultation of air
entry) can be managed with the application of CPAP of as high
as 30e40 cmH2O via face mask. If laryngospasm is complete
(denoted by no upper airway sounds and no chest rise despite
inspiratory effort), then Larson’s manoeuvre (Fig. 2) should be
performed by applying bilateral firm digital pressure on the
styloid process behind the posterior ramus of the mandible
while pulling the mandible forward e this manoeuvre causes
a painful stimulus and stretches the geniohyoid muscle to
move the paraglottis forward.18 Rapid bag-mask ventilation
through a now partially open larynx will break most cases of
laryngospasm. If these interventions do not break the lar-
yngospasm, then propofol (0.5e0.8 mg kg 1 i.v.) should be
given. Suxamethonium (1e2 mg kg 1 i.v.) with atropine (0.02
mg kg 1 i.v.), if there is bradycardia, should be given next if
propofol does not break the laryngospasm.28
Bronchospasm
Patients with pre-existing reactive airway disease, recent URI,
or pneumonia (acute infectious or chronic aspiration) are at
increased risk of intraoperative bronchospasm. The risk of
bronchospasm increases on emergence when the tracheal
tube is in place and the depth of anaesthesia is reduced.
Clinically significant bronchospasm (wheezing associated
with compromised ventilation, desaturation and/or haemo-
dynamic instability) can be treated with inhaled beta-agonists
BJA Education - Volume 22, Number 2, 2022 79
Extubation of children in the operating theatre
and if severe, adrenaline (epinephrine; 1 mg kg 1
i.v.) with or
without systemic steroids.
Post-extubation stridor
In paediatric patients, stridor after extubation most
commonly occurs as a result of upper airway obstruction from
upper airway oedema. It can also occur as a result of vocal
cord dysfunction or paralysis and laryngospasm. The inci-
dence of post-extubation stridor in paediatric patients is
about 1%.29 Children aged <4 yrs are most susceptible and
typically present with inspiratory stridor and associated
supraclavicular retractions. Risk factors associated with
laryngeal oedema include traumatic intubation or extubation,
intubation lasting longer than 1 h, a tight-fitting tracheal tube,
and coughing on the tube or frequent manipulation of head
and neck position during surgery.19 Management includes
using warm humidified oxygen. If stridor is present at rest,
associated with hypoxia, or both, and/or signs of increased
work of breathing, then nebulised racemic adrenaline, i.v.
steroids, or both should be given.
Negative pressure pulmonary oedema
Negative pressure pulmonary oedema results when a child
attempts to make a deep inspiratory effort against a closed
glottis. This can occur when a child bites down and occludes
their orotracheal tube or can occur with laryngospasm. Oc-
clusion of the tube can be prevented by placement of a bite
block before emergence. The hallmark of negative pressure
(post-obstructive) pulmonary oedema is bilateral pulmonary
oedema on chest X-ray with associated clinical symptoms e
respiratory distress and excessive airway secretions, which
may be pink and frothy. Often clinical and radiological fea-
tures resolve within 24 h with minimal or no sequelae; how-
ever, if not recognised quickly and treated appropriately
significant morbidity can occur.16 Management involves
removing the obstruction, oxygen supplementation and close
observation; CPAP, a dose of diuretic, or both may help
expedite resolution of symptoms.30
Special consideration: patients with
COVID-19
Airway management of paediatric patients with coronavirus
disease 2019 (COVID-19) places anaesthetists at high risk of
exposure to infection. Both tracheal intubation and extuba-
tion are potentially aerosol-generating procedures and
require close proximity of the anaesthetist to the patient.31
Extubation may be even of higher risk, as it is commonly
associated with coughing and mobilisation of airway secre-
tions. Early anaesthesia studies report that tracheal extuba-
tion carries a 0.2e6% risk of contact between the patient’s
sputum and the eye, nose or mouth region of the healthcare
provider performing extubation.32 Sputum and airway secre-
tions carry the highest viral load of severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2), the virus that causes
COVID-19.
Using a surgical face mask has been shown to reduce res-
piratory virus shedding in respiratory droplets and aerosols of
symptomatic individuals infected with human coronaviruses
and influenza viruses.33 To minimise exposure of the health-
care provider when extubating a COVID-19 patient, Kristensen
and colleagues recommend several steps.34 These include:
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confirming the patient has adequate spontaneous ventilation
before extubation to decrease the need for bag-mask ventila-
tion and re-intubation; the mouth, pharynx, and trachea
should be suctioned while the patient is still deeply anaes-
thetised to avoid coughing; nasal oxygen cannula should be
applied before extubation; a surgical mask should be placed on
the patient’s face before removing the tracheal tube with the
filter still in place; the tube should be covered with a drape as it
is withdrawn and both discarded together. A surgical mask
should be left on the patient after extubation, during transport,
in the post-anaesthesia recovery room and on the ward.
Healthcare providers involved should be wearing personal
protective equipment compliant with local regulations. This
method is simple, does not require a second operator and
minimises the risk of droplets and virus from the airway
reaching the anaesthetist during and after tracheal extuba-
tion.34 As mentioned previously, dexmedetomidine given
around the time of extubation is quite effective in reducing
emergence cough; this could be useful in the case of extu-
bating a patient with COVID-19 and preventing mobilisation
of airway secretions.16
Conclusions
Emergence from anaesthesia and extubation are associated
with increased risk of complications. Despite these risks,
there are few evidence-based guidelines on managing peri-
operative extubation in children. It is important to recognise
the key characteristics that help classify a paediatric patient
as low, intermediate or high risk, and to create a plan that is
suitable to the unique challenges of each case.
Declaration of interests
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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