Abstract
The purpose of this study was to compare the incidence of airway complications between extubation under deep anesthesia (deep extubation) and extubation when fully awake (awake extubation) in pediatric patients after general anesthesia. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) statement standards. The review protocol was registered with the International Prospective Register of Systematic Reviews (registration number: CRD 42018090172). Electronic databases were searched, without discrimination of publication year and language, to identify all randomized controlled trials investigating airway complications following deep or awake extubation after general anesthesia. The Cochrane tool was used to assess the risk of bias of trials. Randomized trials investigating airway complications of deep extubation compared with awake extubation after general anesthesia with an endotracheal tube and laryngeal mask airway (LMA) were sought. Overall airway complications, airway obstruction, cough, desaturation, laryngospasm and breath holding were analyzed using random-effect modelling. The odds ratio was used for these incidence variables. Seventeen randomized trials were identified, and a total of 1881 pediatric patients were enrolled. The analyses indicated deep extubation reduces the risk of overall airway complications (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.33–0.96, p = 0.04), cough (OR 0.30, 95% CI 0.12–0.72, p = 0.007) and desaturation (OR 0.49, 95% CI 0.25–0.95, p = 0.04) in children after general anesthesia. However, deep extubation increased the risk of airway obstruction compared with awake extubation (OR 3.38 CI 1.69–6.73, p = 0.0005). No difference was observed in the incidence of laryngospasm and breath-holding between the two groups regardless of airway device. The result of this analysis indicates that deep extubation may decrease the risk of overall airway complications including cough and desaturation but may increase airway obstruction compared with awake extubation in pediatric patients after general anesthesia. Therefore, deep extubation may be recommended in pediatric patients to minimize overall airway complications except airway obstruction and the clinicians may choose the method of extubation according to the risk of airway complications of pediatric patients.
Highlights
During general anesthesia, artificial airway devices, including endotracheal tube or laryngeal mask airways (LMA), are inserted for the maintenance of airway patency to accommodate for the decreased tone of pharyngeal and laryngeal muscles [1,2]
Pediatric patients may be vulnerable to airway complications, such as hypoxemia or laryngospasm compared to adults [3,4], since they have immature alveoli, increased dead space, and increased metabolic rate [5]
Meta-analysis suggests that deep extubation in pediatric patients reduced the risk of overall complications including cough and desaturation compared with awake extubation
Summary
Artificial airway devices, including endotracheal tube or laryngeal mask airways (LMA), are inserted for the maintenance of airway patency to accommodate for the decreased tone of pharyngeal and laryngeal muscles [1,2]. These devices are removed during emergence from general anesthesia. Some investigators, including Archie Brain who pioneered LMA, recommend awake extubation to prevent oxygen desaturation and upper airway obstruction [6] This camp asserted that there is a higher incidence of oxygen desaturation [7] and airway complications like upper airway obstruction [8] following early removal of LMA in pediatric patients. The objective of this meta-analysis of RCTs was to compare the incidence of airway complications between deep extubation and awake extubation in pediatric patients undergoing general anesthesia
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