Endotracheal extubation is the most crucial step during emergence from general anesthesia and is usually carried out when patients are awake with return of airway reflexes. Alternatively, extubations can also be accomplished while patients are deeply anesthetized, a technique known as “deep extubation”, in order to provide a “smooth” emergence from anesthesia. Deep extubation is seldomly performed in adults, even in appropriate circumstances, likely due to concerns for potential respiratory complications and limited research supporting its safety. It is in this context that we designed our prospective study to understand the factors that contribute to the success or failure of deep extubation in adults.

In this prospective observational study, 300 patients, age ≥ 18, American Society of Anesthesiologists Physical Status (ASA PS) Classification I - III, who underwent head-and-neck and ocular surgeries. Patients’ demographic, comorbidity, airway assessment, O₂ saturation, end tidal CO₂ levels, time to exit OR, time to eye opening, and respiratory complications after deep extubation in the OR were analyzed.

Forty (13%) out of 300 patients had at least one complication in the OR, as defined by persistent coughing, desaturation SpO₂ < 90% for longer than 10s, laryngospasm, stridor, bronchospasm and reintubation. When comparing the complication group to the no complication group, the patients in the complication group had significantly higher BMI (30 vs 26), lower O₂ saturation pre and post extubation, and longer time from end of surgery to out of OR (p < 0.05).

The complication rate during deep extubation in adults was relatively low compared to published reports in the literature and all easily reversible. BMI is possibly an important determinant in the success of deep extubation.