Eur J Anaesthesiol 2013; 30:529–536

ORIGINAL ARTICLE

The effect of deep vs. awake extubation on respiratory

complications in high-risk children undergoing
adenotonsillectomy
A randomised controlled trial
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Britta S. von Ungern-Sternberg, Kylie Davies, Mary Hegarty, Thomas O. Erb and Walid Habre

CONTEXT There is ongoing debate regarding the optimal bronchospasm, persistent coughing, airway obstruction,
timing for tracheal extubation in children at increased risk of desaturation <95%).
perioperative respiratory adverse events, particularly follow-
RESULTS There were no differences between the two
ing adenotonsillectomy.
groups with regard to age, medical and surgical parameters.
OBJECTIVE To assess the occurrence of perioperative The overall incidence of complications did not differ between
respiratory adverse events in children undergoing elective the two groups; tracheal extubation in fully awake children
adenotonsillectomy extubated under deep anaesthesia or was associated with a greater incidence of persistent
when fully awake. coughing (60 vs. 35%, P ¼ 0.028), whereas the incidence
of airway obstruction relieved by simple airway manoeuvres
DESIGN Prospective, randomised controlled trial.
in children extubated while deeply anaesthetised was greater
SETTING Tertiary paediatric hospital. (26 vs. 8%, P ¼ 0.03). There was no difference in the
incidence of oxygen desaturation lasting more than 10 s.
PATIENTS One hundred children (<16 years), with at least
one risk factor for perioperative respiratory adverse events CONCLUSION There was no difference in the overall inci-
(current or recent upper respiratory tract infection in the past dence of perioperative respiratory adverse events. Both
2 weeks, eczema, wheezing in the past 12 months, dry extubation techniques may be used in high-risk children
nocturnal cough, wheezing on exercise, family history of undergoing adenotonsillectomy provided that the child is
asthma, eczema or hay fever as well as passive smoking). monitored closely in the postoperative period.
INTERVENTION Deep or awake extubation. TRIAL REGISTRATION Australian New Zealand Clinical
Trials Registry: ACTRN12609000387224.
MAIN OUTCOME MEASURE The occurrence of
perioperative respiratory adverse events (laryngospasm, Published online 21 January 2013

Introduction
Adenotonsillectomy is the most frequently performed frequently observed following tracheal extubation and
surgical procedure in children and is associated with a in the subsequent recovery period.1 They may lead to
high incidence of perioperative respiratory adverse serious sequelae, in particular an increased incidence of
events.1–3 Although these respiratory complications laryngospasm. This is further increased in children with
may occur at all stages of anaesthesia, they are most airway reactivity, a medical condition often encountered

From the Department of Anaesthesia and Pain Management, Princess Margaret Hospital for Children (BSU-S, KD, MH), the School of Medicine and Pharmacology,
University of Western Australia, Perth, Australia (BSU-S), the Division of Anaesthesia, University Children’s Hospital, Basel (TOE) and the Paediatric Anaesthesia Unit,
Geneva Children’s Hospital, University Hospitals of Geneva, Geneva, Switzerland (WH)
Correspondence to Professor Britta S. von Ungern-Sternberg, Department of Anaesthesia, Princess Margaret Hospital for Children, Roberts Road, Subiaco, WA 6008,
Australia
E-mail: [email protected]

0265-0215 ß 2013 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e32835df608

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 530 von Ungern-Sternberg et al.

in children scheduled for adenotonsillectomy.1 Consider- events (cold or flu in the previous 2 weeks, wheezing on
ing that tracheal extubation is a critical event during more than three occasions in the previous 12 months,
emergence from anaesthesia, and that complications wheezing on exercise, nocturnal dry cough, current or
arising at extubation may dictate the immediate post- past eczema,
2 family members with asthma,
2 family
operative course, we wished to investigate whether members with eczema,
2 family members with hay
performing tracheal extubation in deeply anaesthetised fever, mother or mother and father smoking) were
children compared with extubation in fully awake chil- included in the study.1 Eligibility for inclusion in the
dren would affect the incidence of perioperative respir- study was determined via a modified ISAAC (Inter-
atory adverse events. national Study of Asthma and Allergies in Childhood)
questionnaire administered by an anaesthesia research
Common teaching practice advocates awake extubation
nurse.1 Patients with known cardiac disease, airway or
following adenotonsillectomy; there are only a few stu-
thoracic malformations, need for premedication
dies that have investigated the effect of extubation
(for example midazolam, clonidine, ketamine) or a contra-
techniques on the incidence of respiratory adverse events
indication for deep extubation (such as gastro-oesophageal
following adenotonsillectomy. Some authors have found
reflux) were excluded from participation in the study.
no difference in the incidence of laryngospasm and
breath holding following awake vs. deep extubation,4,5 Demographics and patient characteristics, including the
whereas others have promoted a ‘no touch’ technique to presence/absence of obstructive sleep apnoea syndrome
enable tracheal extubation in the fully awake child with (OSAS), were recorded for all patients. OSAS was graded
the aim of preventing laryngospasm.6 Authors advocating according to our institutional clinical scoring parameters.7
the use of deep extubation suggest that the child is less Following inclusion into the study protocol, the children
likely to strain and cough during extubation and this were randomly assigned to either an ‘awake’ group or
might consequently reduce adverse events such as ‘deep’ group by computer-generated block randomis-
bronchospasm and laryngospasm. Conversely, those pro- ation, which was concealed in a closed envelope until
moting awake extubation argue that post-tonsillectomy the patient was in the induction room. Children were
patients have potentially soiled airways and that the randomised following the induction of anaesthesia and
return of airway reflexes will protect against the devel- the attending anaesthesiologist and data recorder in
opment of perioperative respiratory adverse events. Both theatre were then aware of the study arm the patient
techniques are currently practised and the choice is often was assigned to. The post anaesthesia care unit (PACU)
based on the anaesthesiologist’s preference or on institu- nurse and the parents remained blinded to the study arm
tional practice. From current evidence, it would appear throughout the perioperative period. Any respiratory
that in healthy children, the timing of extubation during adverse events were recorded by the attending anaes-
emergence from anaesthesia does not appear to alter the thesiologist or the data recorder in theatre during anaes-
clinical outcome.5 thesia and by the PACU nurse in the recovery period.
We recently identified, in a large prospective cohort study Routine anaesthesia monitoring included ECG, nonin-
in our institution, a population at a particularly high risk vasive blood pressure, capnography and pulse oximetry.
for perioperative respiratory adverse events.1 Moreover, Induction of anaesthesia was performed as deemed
on closer examination of the risk factors in our cohort, the appropriate by the attending anaesthesiologist using
timing of extubation appeared to affect the incidence of either inhalational induction with sevoflurane or intrave-
laryngospasm and severe coughing. We, therefore, nous induction with propofol (>3 mg kg1). All children
designed a prospective randomised controlled trial in were intubated with a cuffed tracheal tube. Cuff pressure
order to compare the incidence of laryngospasm, bronch- was routinely measured and adjusted to 15 to 20 cmH2O.
ospasm, severe coughing, desaturation less than 95%, Maintenance was standardised to sevoflurane in nitrous
airway obstruction and/or stridor following tracheal extu- oxide, while the use of muscle relaxants, selective
bation in deeply anaesthetised vs. fully awake children at NSAIDs and opioid analgesia were chosen and dosed
increased risk following adenotonsillectomy. by the attending anaesthesiologist. All children received
antiemetic prophylaxis with dexamethasone
Patients and methods (0.15 mg kg1 to a maximum of 8 mg) and ondansetron
Ethics approval for this study (1599/EP) was provided by (0.15 mg kg1 to a maximum of 8 mg). One experienced
the institutional Ethics Committee (Princess Margaret ENT surgeon, who used bipolar diathermy as his surgical
Hospital for Children) on 20 November 2008. The study technique, performed the majority of surgeries.
was registered with the Australian New Zealand Clinical
Trials Registry (15/06/2009) prior to the inclusion of Procedure for tracheal extubation
study participants: ACTRN12609000387224. Following Tracheal extubation in the ‘awake’ group was undertaken
parental written informed consent, 100 children (0 to 16 when the child had demonstrated facial grimacing,
years) undergoing elective adenotonsillectomy with one adequate tidal volumes and respiratory rate, coughing
or more risk factors for perioperative respiratory adverse with an open mouth or opening of their eyes and

Eur J Anaesthesiol 2013; 30:529–536

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 Respiratory complications in children 531

purposeful movements. Extubation in the ‘deep’ group increased work of breathing) and hoarse voice (defined as
was undertaken when the end-tidal sevoflurane level was a change of the child’s normal voice noticed by the
greater than 1 minimum alveolar concentration and the parent). As this information was acquired via the tele-
child was deemed to be in the surgical plane of anaes- phone from the parents, potential problems were sum-
thesia (central, equal pupils and regular respirations). All marised as general breathing problems.
children were placed on 100% oxygen prior to extubation.
None of the children received topical or intravenous Statistical analysis
lidocaine. All patients were transported in the lateral The occurrence of one or more postoperative respiratory
position to the PACU by the anaesthesiologist after adverse events was the primary outcome for the analysis.
ensuring that they were able to maintain adequate airway The occurrence of one or more respiratory complications
patency. The attending anaesthesiologist remained with in the perioperative period was regarded as a compli-
the patient until satisfied that the patient had a patent cation, independent of the number or type of compli-
airway and was responsive. Simple airway manoeuvres, cations. A two-group x2 test with a 0.05 two-sided
such as chin-lift, were performed by the anaesthesiologist significance level had an 80% power to detect the differ-
or the PACU nurse if airway obstruction was apparent, ence between the ‘awake’ group (proportion 0.35) and
with or without associated desaturations. Oxygen satur- ‘deep’ group (proportion 0.1; odds ratio 0.206), when the
ation was measured continuously until the patients were sample size of each group was 43. To allow for protocol
discharged from the PACU. All children received oxygen violations, seven additional patients were added into each
on arrival to the PACU until completely awake. They group. Sample size calculations were performed using the
were then placed in room air, unless the saturation was less nQuery Advisor 4.0 software (Statistical Solutions, Bos-
than 95% when supplemental oxygen was administered. ton, Massachusetts, USA). Data were analysed using a
two-group x2 test. Data are displayed as number (pro-
Oxygen saturation was recorded when the patients were
portion) or median (range) as appropriate. Results were
calm and the pulse oximeter showed consistent readings
analysed using SigmaStat for Windows (Version 3.11;
with no movement artefact. The lowest measured oxygen
Systat Software, San Jose, California, USA).
saturation values were recorded 10 min before tracheal
extubation and at 1, 2, 3, 5, 7, 10, 15, 20, 25 and 30 min
Results
after tracheal extubation. Episodes of laryngospasm,
One hundred children were included in this study (see
bronchospasm, desaturation less than 95%, airway
Fig. 1). There were no dropouts or protocol violations and
obstruction, severe coughing or postoperative stridor,
complete datasets were available for all children. Demo-
as well as all airway interventions, were recorded. We
graphic data and distribution of risk factors are presented in
defined laryngospasm as complete airway obstruction
Table 1. Two-thirds of the children were the American
with associated muscle rigidity of the abdominal and
Society of Anesthesiologists physical status 2, with the most
chest walls.1 Bronchospasm was defined as increased
common cause their history of OSAS. Few children had had
respiratory effort, particularly during expiration, and
a sleep study prior to surgery. Based on clinical OSAS
wheeze on auscultation. We defined airway obstruction
parameters,7 there was a tendency to more severe OSA
as the presence of partial airway obstruction in combi-
grade, as well as a higher incidence of upper respiratory
nation with a snoring noise and respiratory efforts.
tract infection, a history of passive smoking and wheezing
Coughing was defined as a series of pronounced, persist-
on exercise in children randomised to the deep group.
ent severe coughs lasting more than 10 s. The primary
outcome measure for analysis was defined as an oxygen There were similar proportions of inhalational and intra-
saturation less than 95% for more than 10 s. However, as venous induction between the groups (14 vs. 36 in the
oxygen saturation is recorded continuously in the recov- ‘awake’ group and 13 vs. 37 in the ‘deep’ group, respect-
ery area in line with our institutional guidelines, we also ively). All children received intraoperative opioids (fen-
captured shorter episodes of desaturation. Any treatment tanyl 1 to 2 mg kg1, morphine 0.05 to 0.1 mg kg1 or
needed in response to respiratory adverse events pethidine 0.5 to 1 mg kg1), with no difference in opioid
was recorded. use between the two groups. Forty-two patients in the
‘awake’ group received fentanyl and morphine, whereas
All children and parents were interviewed on the ward or
eight patients received pethidine. Forty-one patients in
at home (via telephone) during the first postoperative day
the ‘deep’ group received fentanyl and morphine,
regarding the level of pain and the presence or absence of
whereas nine patients received pethidine. Average fen-
respiratory adverse events by an anaesthesia research
tanyl usage in both groups was 1.4 mg kg1. The majority
nurse. Depending on the patient’s age, a visual analogue
of patients did not receive muscle relaxants, with no
score (1 to 10), Faces Pain Scale (revised) or Wong Baker
difference between the groups.
Faces chart was used. Parents were asked about general
breathing problems including severe snoring (defined as The rates of severe perioperative respiratory adverse
severe persistent snoring >10 s), breath holding (defined events (laryngospasm and bronchospasm) were very
as apnoea >10 s), difficulty breathing (any evidence of low in both groups (Table 2). At emergence from

Eur J Anaesthesiol 2013; 30:529–536

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 532 von Ungern-Sternberg et al.

Fig. 1

Enrolment
Assessed for eligibility (n = 254)

Excluded (n = 154)
♦ Not meeting inclusion criteria (n = 108)
♦ Declined to participate (n = 31)
♦ Other reasons (n = 15)

Randomised (n = 100)

Allocation
Allocated to intervention (n = 50) Allocated to intervention (n = 50)
♦ Received allocated intervention (n = 50) ♦ Received allocated intervention (n = 50)
♦ Did not receive allocated intervention (give ♦ Did not receive allocated intervention (give
reasons) (n = 0 ) reasons) (n = 0 )

Follow-Up

Lost to follow-up (give reasons) (n = 0) Lost to follow-up (give reasons) (n = 0)

Discontinued intervention (give reasons) (n = 0) Discontinued intervention (give reasons) (n = 0)

Analysis

Analysed (n = 50) Analysed (n = 50)

♦ Excluded from analysis (give reasons) (n = 0) ♦ Excluded from analysis (give reasons) (n = 0)

CONSORT patient flow diagram.

anaesthesia, the children extubated awake showed sig- Table 3. The children extubated deep had a lower
nificantly more severe coughing when compared with the incidence of hoarse voice as compared with the children
children who were extubated deep (58 vs. 8%, P <0.001). who were extubated awake (26 vs. 48%, P ¼ 0.038).
There were no differences in the incidence of respiratory
adverse events between the two groups during their stay
in PACU. If the data were combined for emergence and
Discussion
The overall incidence of laryngospasm and bronchos-
PACU, the children extubated awake had a higher inci-
pasm following tracheal extubation in children at high
dence of persistent coughing (60 vs. 35%, P ¼ 0.028),
risk for respiratory complications who underwent adeno-
whereas the children who were extubated deep had more
tonsillectomy was very low, demonstrating the general
episodes of partial airway obstruction (26 vs. 8%,
safety of both the awake and deep extubation techniques.
P ¼ 0.033) relieved by chin lift or jaw thrust. However,
However, children who had their trachea extubated while
whereas there was no difference in the number of epi-
they were awake had a higher incidence of severe cough-
sodes of oxygen desaturation lasting more than 10 s
ing at emergence and a higher rate of hoarse voice on the
between the groups (24% ‘deep’ group vs. 36% ‘awake’
first postoperative day. Although there was no difference
group, P ¼ 0.28), shorter desaturations (SpO2 <95%
in the number of episodes of oxygen desaturation
<10 s) tended to be more common and of longer duration
between the groups (24% ‘deep’ group vs. 36% ‘awake’
in the awake group (see Fig. 2).
group, P ¼ 0.28), the episodes tended to be more common
The assessment of overall pain on day 1, breathing and of longer duration in the awake group. In contrast, the
problems within the first 24 h and hoarse voice reported children who were extubated while deeply anaesthetised
during the postanaesthetic interview are reported in showed an overall higher incidence of partial airway

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 Respiratory complications in children 533

Table 1 Demographics of 100 children undergoing adenotonsillectomy and extubated deep or awake
Deep Awake

Age; years 4 [1 to 14] 5 [1 to 14]

Weight; kg 18 [12.9 to 64.0] 20 [12.7 to 84.9]
Sex (male: female) 17 (34%): 33 (66%) 24 (48%): 26 (52%)
ASA physical status 1 16 (32%) 16 (32%)
2 33 (66%) 32 (64%)
3 1 (2%) 2 (4%)
OSAS Yes: No 38 (76%): 12 (24%) 34 (68%): 16 (32%)
Mild 7 (14%) 14 (28%)
Moderate 15 (30%) 12 (24%)
Severe 16 (32%) 8 (16%)
Cold 19 (38%) 12 (24%)
Wheezing 15 (30%) 18 (36%)
Wheezing on exercise 11 (22%) 8 (16%)
Nocturnal dry cough 14 (28%) 14 (28%)
Current eczema 10 (20%) 9 (18%)
Past eczema 17 (34%) 17 (34%)
Family history of Asthma 30 (60%) 31 (62%)
Eczema 25 (50%) 20 (40%)
Hay fever 29 (58%) 27 (54%)
Passive smoking 30 (60%) 23 (46%)
Number of risk factors 1 8 (16%) 7 (14%)
2 4 (8%) 8 (16%)
3 13 (26%) 13 (26%)
4 5 (10%) 7 (14%)
5 9 (18%) 6 (12%)
6 3 (6%) 6 (12%)
7 4 (8%) 2 (4%)
8 2 (4%) 0 (0%)
9 2 (4%) 1 (2%)
1 to 2 12 (24%) 15 (30%)
3 to 5 27 (54%) 26 (52%)

6 11 (22%) 9 (18%)
Induction of anaesthesia Inhalational 13 (26%) 14 (28%)
Intravenous 37 (74%) 36 (72%)
Opioids administered Fentanyl and morphine 41 (82%) 42 (84%)
Pethidine 9 (18%) 8 (16%)
Fentanyl (mg kg1) 1.4 (0.9 to 2) 1.4 (1 to 2)
Morphine (mg kg1) 0.065 (0.05 to 0.1) 0.07 (0.05 to 0.1)
Pethidine (mg kg1) 0.9 (0.8 to 1) 1 (0.8 to 1.2)
Muscle relaxants Yes: No 1 (2%): 49 (98%) 2 (4%): 48 (96%)

Data are median [range], or number (proportion).

obstruction, when the assessment time of emergence of younger children and in children with moderate or severe
anaesthesia and PACU were combined. However, there OSAS. However, both groups received similar intraopera-
was no evidence for an increased risk for oxygen desa- tive opioid agents and doses. It is, therefore, unlikely that
turation following either technique. the type of agent or the dose of opioids used influenced
the incidence of coughing in the awake group. Similarly,
One limitation of this study is that the anaesthesia the use of muscle relaxants was at the discretion of the
technique was not completely standardised. We did attending anaesthesiologist. The majority of patients did
not specify the doses of opioids, and the attending not receive muscle relaxants (with no difference between
anaesthetist could adjust the dose of opioid as deemed the groups) as adenotonsillectomy surgery commonly
clinically appropriate, for example reducing the dose in takes only 10 to 15 min in our institution, by which time

Table 2 Respiratory complications at emergence from anaesthesia, in PACU and at emergence and PACU combined
Emergence PACU Emergence and PACU
Deep Awake P value Deep Awake P value Deep Awake P value

Bronchospasm 0(0%) 0 (0%) NS 0 (0%) 1 (2%) NS 0 (0%) 1 (2%) NS

Laryngospasm 1(2%) 1 (2%) NS 0 (0%) 1 (2%) NS 1 (2%) 1 (2%) NS
Coughing 4(8%) 29 (58%) <0.001 15 (30%) 14 (28%) NS 18 (36%) 30 (60%) 0.028
Desaturation 2(4%) 8 (16%) NS 11 (22%) 12 (24%) NS 12 (24%) 18 (36%) NS
Airway obstruction 5(10%) 2 (4%) NS 9 (18%) 2 (4%) NS 13 (26%) 4 (8%) 0.033
Stridor – – 0 (0%) 2 (4%) NS 0 (0%) 2 (4%) NS
Overall complications 10 (20%) 31 (62%) <0.001 24 (48%) 23 (46%) NS 28 (56%) 37 (74%) NS

Data are number (proportion). NS, not significant.

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 534 von Ungern-Sternberg et al.

Fig. 2

100

98

96

SpO2 94

92

90
Deep extubation
Awake extubation
88

86
10 min prior

1 min post

2 min post

3 min post

4 min post

5 min post

7 min post

10 min post

15 min post

20 min post

25 min post

30 min post
Time with regards to extubation

Assessment of oxygen saturation 10 min prior to extubation and immediately postextubation in children who were extubated deep vs. awake. Data
include desaturations of any duration. Data are median and standard error.

muscle relaxants would not be reversible (sugammadex is to be higher than that previously reported,1 bronchos-
not routinely used in our hospital). pasm and laryngospasm were rarely encountered. This
may reflect the fact that anaesthesia was predominantly
In this study, we included children with known suscepti-
provided by specialist consultant anaesthesiologists, a
bility for reactive airways,8–10 who have previously been
factor that was demonstrated to be protective against
demonstrated to be at increased risk for the occurrence of
respiratory adverse events in previous studies.1,2
perioperative respiratory adverse events.1 We, therefore,
However, this study was not powered sufficiently to
expected to observe a higher incidence of postoperative
detect a difference in the incidence of laryngospasm or
respiratory complications in our study population.6 More-
bronchospasm independently.
over, it has been established that ENT surgery, in
particular adenotonsillectomy, is associated with a sig- Children with a history suggestive of OSAS or confirmed
nificantly higher incidence of respiratory adverse OSAS are known to have an increased incidence of
events.2,3 The investigation of a specific tracheal extuba- respiratory adverse events following adenotonsillectomy,
tion technique for this type of surgery in high-risk chil- in particular airway obstruction and oxygen desatura-
dren may be beneficial in establishing evidence-based tion.11–13 Although a large number of children in this
guidelines that can be used to inform clinical practice. study had a clinical history suggestive of OSAS, there was
Although the overall incidence of postoperative no difference between the two groups. However, the
respiratory complications observed in this study appeared children in the ‘deep’ group demonstrated a tendency
towards more severe grades of OSAS. Therefore, it is
unlikely that the difference in results obtained in this
Table 3Assessment of sore throat, overall pain on day 1, breathing
problems within the first 24 h and hoarse voice during the study was affected by the presence of OSA. Nevertheless,
postanaesthetic interview the potential effect of intraoperative doses of opioids on
Awake Deep P value the measured outcome cannot be dismissed, particularly
as it has been demonstrated that reducing the dose of
Overall pain day 1, 4 [0 to 10] 4.5 (0 to 9) NS
scale (0 to 10)
intraoperative morphine may decrease the incidence of
Breathing problems 20 (40%) 17 (34%) NS respiratory adverse events.14
in first 24 h
Hoarse voice 24 (48%) 13 (26%) 0.038 Episodes of severe coughing are often reported following
tracheal extubation in a fully awake child.1 When it
Pain scale: depending on the patient’s age, either a visual analogue score (1 to
10), Faces Pain Scale (revised) or Wong Baker Faces chart was used. Data are occurs, coughing may affect surgical haemostasis and
median [range], or number (proportion). NS, not significant. potentially increase postoperative bleeding. The timing

Eur J Anaesthesiol 2013; 30:529–536

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 Respiratory complications in children 535

of tracheal extubation is a matter of controversy among that are used increasingly for adenotonsillectomy in the
paediatric anaesthesiologists. Whereas supporters of deep paediatric population may have a different risk profile
tracheal extubation may argue for greater efficiency and with regard to the timing of the removal of the airway
quicker room turnover using this technique, those in device due to their less invasive nature. Furthermore,
favour of awake extubation stress the importance of the use of different maintenance agents (other than
the perioperative set-up, including PACU facilities, in sevoflurane as evaluated in this study) may also change
their decision-making process. It has to be pointed out the recovery profile.
that in our study, the patients in the ‘deep’ group were
In summary, our findings demonstrate that tracheal
extubated during the surgical stage of anaesthesia after
extubation after adenotonsillectomy is not associated
ensuring adequate spontaneous ventilation. However,
with a high incidence of laryngospasm or bronchospasm,
the attending anaesthesiologist stayed with the patient
both complications that may be potentially life-threaten-
until adequate airway control was established. Addition-
ing. Our study did show that children who had their
ally, our PACU is staffed with experienced nurses who
trachea extubated awake experienced severe persistent
manage patients on a one-to-one basis at all times, in
coughing leading to a higher rate of hoarseness in the
accordance with our institutional guidelines. This
postoperative period. Conversely, children who had their
allowed for good postoperative supervision of the patient
trachea extubated while they were still deeply anaesthe-
and the immediate use of simple airway manoeuvres in
tised had a higher incidence of partial airway obstruction,
cases of airway obstruction. However, if deep extubation
as defined by the patient requiring a simple manoeuvre
is practised in a setting with lower acuity postoperative
such as a chin lift or jaw thrust. Reassuringly, these
care, then the higher incidence of partial airway obstruc-
episodes of airway obstruction were managed by means
tion we observed might be associated with an increased
of standard airway manoeuvres and were not associated
risk of oxygen desaturation.
with desaturation.
In this study, the children who were extubated awake
showed a strong tendency towards more episodes and Conclusion
longer durations of oxygen desaturation, although this In conclusion, our results demonstrate that there was no
was not significant. This finding is in line with the results overall superior extubation technique in high-risk chil-
of two previous studies in healthy children that reported dren undergoing adenotonsillectomy. Awareness of the
lower oxygen saturation values immediately after extu- potential for serious respiratory problems in the post-
bation when compared with children extubated deep.4,5 operative period, as well as processes to recognise and
This is supported by evidence demonstrating that the prevent these complications, may be as important as the
degree of wakefulness does not necessarily correlate with extubation technique in the management of these
the occurrence of oxygen desaturation.15 patients.
The incidence of hoarseness was higher in the children
who were extubated awake. Our results are in accordance Acknowledgements
Assistance with the study: the authors thank all the children and
with previous studies suggesting that higher rates of their families who participated in this study.
postoperative hoarseness in children extubated awake
can be attributed to the greater incidence of persistent Financial support and sponsorship: this study was funded by the
coughing in the perioperative period.16 Accordingly, and Princess Margaret Hospital Foundation, Woolworths Australia and
the Department of Anaesthesia and Pain Management, Princess
in line with current literature, we found no differences in
Margaret Hospital for Children.
postoperative stridor or postoperative pain5 between the
two groups. This would suggest that surgery-related pain Conflicts of interest: none declared.
was not a factor in the causation of hoarseness and did not
bias our results. References
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Awake extubation after adenotonsillectomy is still taught for respiratory complications in paediatric anaesthesia: a prospective
cohort study. Lancet 2010; 376:773–783.
as the standard technique in many institutions. There is 2 Mamie C, Habre W, Delhumeau C, et al. Incidence and risk factors of
no doubt that awake extubation remains the technique of perioperative respiratory adverse events in children undergoing elective
choice for the child with a difficult airway or in children at surgery. Paediatr Anesth 2004; 14:218–224.
3 Murat I, Constant I, Maud’huy H. Perioperative anaesthetic morbidity in
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in healthy children, or children with a high risk of post- Paediatr Anesth 2004; 14:158–166.
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