Perioperative Medicine

ABSTRACT
Background: Practice patterns surrounding awake extubation of pediatric
surgical patients remain largely undocumented. This study assessed the value

Assessment of Common of commonly used predictors of fitness for extubation to determine which
were most salient in predicting successful extubation following emergence

Criteria for Awake

from general anesthesia with a volatile anesthetic in young children.
Methods: This prospective, observational study was performed in 600
Extubation in Infants and children from 0 to 7 yr of age. The presence or absence of nine commonly
used extubation criteria in children were recorded at the time of extubation

Young Children including: facial grimace, eye opening, low end-tidal anesthetic concentration,

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spontaneous tidal volume greater than 5 ml/kg, conjugate gaze, purposeful
movement, movement other than coughing, laryngeal stimulation test, and
T. Wesley Templeton, M.D., Eduardo J. Goenaga-Díaz, M.D.,
oxygen saturation. Extubations were graded as Successful, Intervention
Martina G. Downard, M.D., Christopher J. McLouth, Ph.D., Required, or Major Intervention Required using a standard set of criteria. The
Timothy E. Smith, M.D., Leah B. Templeton, M.D., Intervention Required and Major Intervention Required outcomes were com-
Shelly H. Pecorella, M.D., Dudley E. Hammon, M.D., bined as a single outcome for analysis of predictors of success.
James J. O’Brien, M.D., Douglas H. McLaughlin, B.S.,
Ann E. Lawrence, M.D., Phillip R. Tennant, M.D., Results: Successful extubation occurred in 92.7% (556 of 600) of cases.
Facial grimace odds ratio, 1.93 (95% CI, 1.03 to 3.60; P = 0.039), purposeful
Douglas G. Ririe, M.D., Ph.D.
movement odds ratio, 2.42 (95% CI, 1.14 to 5.12; P = 0.022), conjugate
Anesthesiology 2019; 131:801–8 gaze odds ratio, 2.10 (95% CI, 1.14 to 4.01; P = 0.031), eye opening odds
ratio, 4.44 (95% CI, 1.06 to 18.64; P = 0.042), and tidal volume greater than
5 ml/kg odds ratio, 2.66 (95% CI, 1.21 to 5.86; P = 0.015) were univariately
EDITOR’S PERSPECTIVE associated with the Successful group. A stepwise increase in any one, in any
order, of these five predictors being present, from one out of five and up to
What We Already Know about This Topic five out of five yielded an increasing positive predictive value for successful
• Emergence from anesthesia and extubation is a critical time in extubation of 88.3% (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3),
pediatric anesthesia when there is an increased risk of adverse 96.3% (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and 100% (95%
events CI, 90 to 100).
• Complications are more likely if extubation occurs prematurely Conclusions: Conjugate gaze, facial grimace, eye opening, purposeful
during light anesthesia movement, and tidal volume greater than 5 ml/kg were each individually
• Predictors of successful extubation have been identified in critically associated with extubation success in pediatric surgical patients after volatile
unwell children and in the intensive care environment but these anesthetic. Further, the use of a multifactorial approach using these predic-
predictors have related to presence of ongoing cardiopulmonary tors, may lead to a more rational and robust approach to successful awake
embarrassment rather than judgement of appropriate plane of
extubation.
anesthesia
(ANESTHESIOLOGY 2019; 131:801–8)
What This Article Tells Us That Is New
• For an awake-extubation in a child that has had volatile anesthesia,
facial grimace, purposeful movement, conjugate gaze, eye opening,
and tidal volume greater than 5 ml/kg are all associated with suc- exist few, if any studies to guide the clinician in managing awake
cessful extubation extubation in pediatric patients following general anesthesia.
• The chances of successful extubation steadily increase as more of Most studies looking at predictors of successful extuba-
these features are present tion in children, defined as extubation without the need
for prompt intervention or reintubation, have been retro-

I nduction and emergence remain two of the most criti-

cal times when caring for pediatric patients because of the
increased risk of adverse events at these points of transition.1–4
spective cohort analyses of patients undergoing high-risk
procedures such as cardiac surgery or liver transplanta-
tion.5–7 Typically, these studies have centered around pro-
Interestingly, routine practice patterns surrounding awake extu- cedure-specific factors such as bypass time and amount
bation in children remain largely undocumented, and there of blood products transfused rather than more routine

This article is featured in “This Month in Anesthesiology,” page 1A. This article is accompanied by an editorial on p. 769. This article has a visual abstract available in the online version.
Submitted for publication December 27, 2018. Accepted for publication June 3, 2019. From the Department of Anesthesiology (T.W.T., E.J.G-D., M.G.D., T.E.S., L.B.T., S.H.P., D.E.H.,
J.J.O’B., D.H.M, A.E.L., P.R.T., D.G.R.); and the Department of Biostatistics and Data Science (C.J.M.), Wake Forest School of Medicine, Winston-Salem, North Carolina. Current
affiliation for D.H.M. is the Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina.
Copyright © 2019, the American Society of Anesthesiologists, Inc. All Rights Reserved. Anesthesiology 2019; 131:801–8. DOI: 10.1097/ALN.0000000000002870

ANESTHESIOLOGY, V 131 • NO 4 October 2019 801

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<zdoi;. Inc. Unauthorized reproduction of this article is prohibited.
DOI: 10.1097/ALN.0000000000002870>
 Perioperative Medicine

behavioral characteristics like eye opening or inhalation

anesthetic level. Numerous other studies have focused on Table 1.  Catalogue of Predictors of Successful Extubation in
extubation in children in the neonatal or pediatric intensive Pediatric Patients Less than 7 Yr of Age Observed in This Study
care unit.8–10 In all of these studies though, failure is most 1. Eye opening
often a result of ongoing cardiopulmonary embarrassment 2. Facial grimace
and not simply a miscalculation of anesthetic depth at extu- 3. Patient movement other than coughing
bation. As a consequence, any insights garnered from them 4. Conjugate gaze
5. Purposeful movement
are likely to be of limited value in the setting of routine 6. End tidal anesthetic less than:
extubation in the operating room.   Sevoflurane: 0.2%
In more routine settings, the extubation criteria used by   Isoflurane: 0.15%
  Desflurane: 1.0%
clinicians can vary significantly and frequently reflect expe- 7. Oxygen saturation greater than 97%
rience and training bias. Some clinicians have attempted to

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8. Positive laryngeal stimulation test
reduce the complexity of evaluating the timing of extu- 9. Tidal volume greater than 5 ml/kg
bation by either extubating patients deep or deferring this
decision to the recovery room. However, the clinician’s abil-
ity to correctly judge the optimal time to extubate a pedi- pediatric patients for more than 20 yr. Predictors of success-
atric patient awake following inhalational anesthesia still ful extubation that were used are summarized in table 1 and
remains essential.11–13 Commonly used criteria for awake were chosen based on the opinion and routine practice of
extubation in children include: eye opening, facial grimace, the nine pediatric anesthesiologists in our group. Further,
movement other than coughing, purposeful movement, we assumed that all nine attending anesthesiologists at our
conjugate gaze, and end tidal anesthetic concentration institution would potentially use different criteria based
below a predetermined level.14–16 Other criteria include on their training bias or experience, with some attendings
adequate oxygenation, reversal of neuromuscular blockade, potentially choosing to use certain criteria in preference to
and the laryngeal stimulation test. A positive laryngeal stim- others with attendant differences in successful extubation.
ulation test is defined as a return to spontaneous ventila- Patients older than 7 yr of age were excluded, as were
tion in less than 5 s after gentle stimulation of the glottis patients with a known difficult airway, tracheostomy in situ,
by cephalad, caudad motion of the endotracheal tube in a patients anticipated to require postoperative mechanical
patient ventilating spontaneously at emergence, and is an ventilatory support immediately after their surgical pro-
indicator that the patient may have passed through stage 2 cedure, and patients undergoing deep extubation. Deep
and is ready to be extubated.4 extubation was defined as any extubation where the intent
At this point, most, if not all, of these criteria have not of the attending clinician was to extubate the patient at
been validated beyond anecdotal experience, and it is a deep plane of inhalational anesthesia where the patient’s
unclear which, if any, is of greater importance as patients airway reflexes have been ablated. Patients who underwent
transition from deeper to lighter levels of inhalational anes- total intravenous anesthesia, were maintained on propofol
thesia.Therefore, we performed a prospective, observational after inhalation induction, or who received a bolus dose of
study to evaluate routine practice and the predictive value of propofol electively before extubation were also excluded.
various extubation criteria with the assertion that random Patients intubated with a nasotracheal tube were excluded
overlap and variance in different clinicians’ practice would due to potential issues of nasal bleeding and other known
allow us to determine which factors individually or collec- issues associated with a nasal endotracheal tube that might
tively are most important in the awake extubation of young potentially confound or distort the data set. Emergency
pediatric patients emerging from inhalational anesthesia. cases were not excluded so long as they did not meet other
exclusionary criteria.To ensure some degree of randomness
Materials and Methods in age and case selection, we attempted to capture as many
After Institutional Review Board approval, we prospec- consecutive cases as were available on a given day, but we
tively observed 600 pediatric awake extubations during were limited in some cases by availability of a research assis-
the course of 10 months at our institution. Our institu- tant or other demands extant in the continued delivery of
tion is an academic tertiary care pediatric center where all care at our institution. All cases observed were performed
pediatric surgical subspecialties are represented. All extu- during the normal operating room day schedule Monday
bations were supervised by an attending anesthesiologist. through Friday from 7:00 to 18:00. We recorded demo-
All attendings except one were pediatric fellowship trained, graphic information on all patients including age, gender,
and hailed from seven different training institutions in the weight, American Society of Anesthesiologists physical class
United States, creating a diversity of training biases.The one status, and type of surgery. We also recorded the presence of
attending that was not fellowship trained completed a pedi- an upper respiratory tract infection. An upper respiratory
atric cardiology fellowship and anesthesia residency, but not tract infection was defined as any upper respiratory tract
a pediatric anesthesia fellowship, and has routinely cared for infection symptom including cough, cold, nasal drainage

802 Anesthesiology 2019; 131:801–8 Templeton et al.

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 Evaluating Predictors of Extubation in Children

(clear or otherwise), and/or associated fever within the past necessary (40/0.069 = 580 observations).17,18 Rounding
7 days by observation on the day of surgery or parental his- up, we decided on a final sample size of 600.
tory.The use of midazolam premedication and the presence Descriptive statistics were performed on all data, and
or absence of asthma were also recorded. between group differences for successful versus “interven-
At the time of emergence and extubation, an indepen- tion required” extubation were compared using two tailed,
dent observer not directly involved in the care of the patient two sample, independent t tests for continuous and chi-
recorded the presence or absence of all nine of the extu- square tests for categorical variables or Fisher exact tests if
bation criteria evaluated in the study. Tidal volumes were expected cell counts were fewer than five. The normality
recorded directly from the anesthesia ventilator.The Aestiva assumption within each group was assessed using both the
(GE Healthcare, USA) and Perseus (Drager, Germany) Shapiro–Wilks test and by visually inspecting histograms
anesthesia work stations were used for all patients. End tidal or Q-Q plots, and all variables analyzed with t tests were
anesthetic levels and end tidal carbon dioxide (ETco2) were

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verified to have met this assumption. An initial positive pre-
measured using the GE gas analyzer module E-CAI0V-00 dictive value and odds ratio for success using a chi-square
(GE Healthcare) or the gas analysis module on the Perseus analysis was performed for each of the nine predictors with
anesthesia work station. The highest measurement of P < 0.05 considered significant.Variables that had a bivari-
ETco2within 10 s of extubation was recorded. Following ate significant relationship with successful extubation were
extubation, the patient was assessed and the extubation was then entered into a multiple logistic regression model. The
graded based on specific criteria and was assigned a value multiple logistic regression model resulted in complete sep-
of successful, intervention required, or major intervention aration of the data points, where the collection of predictors
required. Criteria for each group are summarized in table 2. were perfectly able to separate the outcome groups. When
The intervention groups (intervention required and major complete separation occurs, maximum likelihood estimates
intervention required) were combined for analysis a priori. do not exist, and thus, odds ratios cannot be calculated. As
The criteria chosen for the successful, intervention required, a result, the multiple logistic regression results are not pre-
and major intervention required groups were selected in an sented. Finally, the number of bivariate significant predictors
attempt to reflect clinically relevant events and outcomes. present was totaled for each individual, and the relationship
between the number of positive predictors and successful
Statistical Methods and Sample Size extubation was assessed.
Not knowing what the event rate would be, we chose an Univariate chi-square analysis was also performed on
initial sample size of 300 patients to create a multivari- the impact of upper respiratory tract infection, asthma,
able logistic regression model with seven predictors. To midazolam premedication in children 1 yr of age or older,
ensure sufficient statistical power, we conducted an a pri- inhalation anesthetic choice, age less than 1 yr of age, use
ori interim analysis of event rates over the first 4 months of nondepolarizing neuromuscular blocker, and airway
of the study. This yielded a combined event rate of 6.9%. procedure on unsuccessful extubation. In looking at the
Given this event rate, we used the rule of 10 events per association of premedication with midazolam with the
predictor variable in a logistic regression to revise the intervention required plus major intervention required
sample size and reduced the number of potential predic- group, we chose to analyze only patients older than 1 yr of
tor variables to be included in the model to four. Given age as the rate of premedication with midazolam in chil-
this, we estimated that a sample size of 580 would be dren less than 1 yr at our institution is exceedingly small

Table 2.  Summary of Criteria for Grading Extubation

Successful Intervention Required Major Intervention Required

No oxygen desaturation less than 92% or if the Oxygen desaturation less than 92% for greater than 30 s, Oxygen desaturation less than 92% for greater
patient does desaturate it is for less than 30 s but less than 1 min than 1 min
Patient requires CPAP with 100% oxygen for less Patient requires CPAP with 100% oxygen for greater Patient requires CPAP with 100% oxygen for
than 30 s. than 30 s, but less than 2 min. greater than 2 min.
Patient has inspiratory stridor, but this does not lead to Laryngospasm occurred according to attending
desaturation for greater than 1 min or intervention clinician.
beyond CPAP with 100% oxygen for less than 2 min. Urgent or emergent administration of propofol or
succinylcholine after extubation
Breath holding or apnea for greater than 10 s
Reintubation

Patients having any one of the criteria will be assigned to the greatest intervention outcome based on independent observation of that patient’s extubation.
CPAP, continuous positive airway pressure.

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 Perioperative Medicine

and not comparable to its fairly routine clinical use in chil- one out of five, up to five out of five yielded an increasing
dren 1 yr of age or older. Lastly, a separate post hoc analysis positive predictive value for successful extubation of 88.3%
of ETco2 and its association with the intervention required (95% CI, 82.4 to 94.3), 88.4% (95% CI, 83.5 to 93.3), 96.3%
plus major intervention required group was performed. (95% CI, 93.4 to 99.2), 97.4% (95% CI, 94.4 to 100), and
All statistical analyses were performed using SAS version 100.0% (95% CI, 90 to 100) (table 5).
9.4 (SAS Institute Inc., USA). The most prevalent criteria leading to rating an extuba-
tion as major intervention required was breath-holding or
Results apnea for greater than 10 s (12 of 15 [80.0%]). Laryngospasm
or continuous positive airway pressure for greater than
Patients 2 min were the next most prevalent with both present in 11
We observed 600 extubations in children between the ages of 15 (73.3%) patients, with these last two overlapping in 7

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of 0 and 7 yr of age. A summary of the types and preva- of 11 (63.6%) patients. Of the 29 patients requiring inter-
lence of surgical procedures are presented in table 3 with vention, but not requiring a major intervention, 28 of 29
the most common cases being general surgery (154 of 600 (96.6%) required continuous positive airway pressure longer
[25.6%]), airway surgery (139 of 600 [23.1%]), and urologic than 30 s and less than 2 min; 17 of 29 (58.6%) had Spo2 less
cases (116 of 600 [19.3%]). All patients received intravenous than 92% for 30 s to 1 min; and 7 of 29 (34.5%) had stri-
intraoperative opioids. The dose and type were adminis- dor not progressing to desaturation for more than 1 min or
tered according to the routine practice of the clinicians car- requiring intervention beyond continuous positive airway
ing for a given patient and were not dictated by the study pressure with 100% oxygen for less than 2 min. No patients
protocol. There were no missing data points for any patient. whose extubation was rated as intervention required had
only stridor.
Primary Results
Secondary Results
The rate of successful extubation was 92.7% (556 of 600).
The combined rate of extubations requiring intervention There was no significant difference observed between those
was 7.3% ([44 of 600] intervention required plus major extubations requiring intervention (intervention required
intervention required): intervention required, 4.8% (29 of plus major intervention required) and those that were con-
600) plus major intervention required, 2.5% (15 of 600). sidered successful in terms of age, weight, American Society
A univariate, chi-square analysis of eight predictors and of Anesthesiologists status, or gender. A univariate analy-
Fisher exact analysis of the remaining predictor used in the sis found upper respiratory tract infection and midazolam
study yielded five predictors which were significantly asso- premedication in children 1 yr of age or older to be asso-
ciated with extubation success (table  4). These predictors ciated with extubations requiring intervention (interven-
were facial grimace (odds ratio, 1.93 [95% CI, 1.03 to 3.60]; tion required plus major intervention required: odds ratio,
P  =  0.039); purposeful movement (odds ratio, 2.42 [95% 2.57 [(95% CI, 1.29 to 5.13); P  =  0.007] and odds ratio,
CI, 1.14 to 5.12]; P  =  0.022), conjugate gaze (odds ratio, 2.83 [(95% CI, 1.06 to 7.60); P  =  0.031]), respectively.
2.10 [95% CI, 1.14 to 4.01]; P = 0.031), eye opening (odds Upper respiratory tract infection, as defined by the study,
ratio, 4.44 [95% CI, 1.06 to 18.64]; P = 0.042), and tidal was noted in 15.2% (91 of 600) of patients. Additionally, an
volume greater than 5 ml/kg (odds ratio, 2.66 [95% CI, 1.21 analysis of ETco2 at extubation revealed an association with
to 5.86]; P = 0.015). Additionally, a stepwise increase in any the intervention required plus major intervention required
one of these five predictors in any order being present, from group in patients extubated with an ETco2 greater than 55

Table 3.  Summary of Types of Procedures and Prevalence in Patients Extubated Successfully and Those Requiring Intervention

Number of Procedures Number of Patients with Number of Patients Requiring

Type of Surgical for Each Type of Successful Extubation (%) Intervention (%)
Procedure N = 600 Surgery (%) N = 556 N = 44

Airway procedures 139 (23.1) 130 (23.4) 9 (20.4)

Plastics and head and neck surgery not 58 (9.7) 53 (9.7) 5 (9.1)
involving the airway
Orthopedic 61 (10.1) 56 (10.1) 5 (11.4)
General surgery 154 (25.6) 144 (25.9) 10 (22.7)
Urology 116 (19.3) 109 (19.6) 7 (15.9)
Ophthalmology 10 (1.7) 9 (1.6) 1 (2.3)
Neurosurgery 24 (4.0) 23 (4.1) 1 (2.3)
Other 38 (6.3) 32 (5.8) 6 (13.6)

804 Anesthesiology 2019; 131:801–8 Templeton et al.

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 Evaluating Predictors of Extubation in Children

Table 4.  Prevalence, Positive Predictive Value, and Univariate Chi-square or Fisher Exact Analysis of Nine Commonly Used Predictors of
Extubation Success in Pediatric Surgical Patients

Prevalence of
Predictor with Positive 95% CI Odds Ratio for P Value for
Successful Predictive of Positive Successful Chi-square
Predictor of Successful Extubation Extubation Value Predictive Value Extubation 95% CI Analysis

Facial grimace 0.56 0.95 0.97–0.92 1.93 1.03–3.60 0.039

Eye opening* 0.17 0.98 0.95–1.00 4.44 1.06–18.64 0.032
Conjugate gaze** 0.63 0.95 0.93–0.97 2.14 1.14–4.01 0.018
Low End Tidal Agent Concentration 0.31 0.93 0.91–0.95 1.07 0.55–2.09 0.848

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Purposeful movement 0.37 0.96 0.93–0.99 2.42 1.14–5.12 0.022
Movement Other Than Coughing 0.77 0.92 0.90–0.94 0.85 0.40–1.82 0.677
Positive Laryngeal Stimulation Test† 0.88 0.92 0.90–0.95 0.91 0.47–1.75 0.313
Tidal volume > 5 ml/kg 0.92 0.94 0.91–0.96 2.66 1.21–5.86 0.015
Spo2 > 97% 0.92 0.93 0.91–0.95 2.05 0.87–4.88 0.102

*Fisher exact test was used instead of chi-square because one of the cell counts was less than 5. **N = 535 because not all attendings checked for conjugate gaze in all patients.
†N = 423 because not all attendings chose to check for a positive laryngeal stimulation test

of some of these factors at the time of extubation.To put this

Table 5.  Positive Predictive Value of Stepwise Increase in more practical terms, at the time of emergence the cli-
in Number of Five Factors Found to Be Significant Using a nician, for example, may note that conjugate gaze and tidal
Univariate Chi-square Analysis for Successful Extubation volume greater than 5 ml/kg are present. If the clinician
chooses to extubate at this point, our study would predict
Number of Univariate a success rate of 88.4%. If, however, the clinician waits for
Predictors Present at Positive
Extubation Out of a Predictive just one more predictor, such as facial grimace or purpose-
Possible 5 N Value (%) 95% CI (%) ful movement, their probability of success becomes 96.3%.
It should be noted, that although the rate of intervention
1 of 5 112 88.4 82.4–94.3
required plus major intervention required events was zero
2 of 5 164 88.4 83.5–93.3
3 of 5 163 96.3 93.4–99.2 in patients with five out of five of these predictors present,
4 of 5 114 97.4 94.4–100.0 the number of extubations observed in this group (N = 30)
5 of 5 30 100.0 90–100* was relatively small, and the 0% intervention required plus
*The lower bound of the 95% CI was calculated using the 1-(3/N) rule for instances major intervention required event rate must be evaluated
in which the event rate is zero.19 with some caution in this context. Using the 3/N rule for
instances in which an event rate is zero and N is the total
number of events, the lower bound of the 95% CI is 90%.19
mmHg (odds ratio, 3.06 [95% CI, 1.60 to 5.83]; P = 0.001). One unanticipated finding of this study was that spon-
Asthma, use of nondepolarizing neuromuscular blocker, taneous tidal volumes greater than 5 ml/kg were asso-
maintenance potent inhalational anesthetic choice, airway ciated with success in preference to other criteria we
procedures, age less than 1 yr of age, and emergency case assumed would be more important, such as low end tidal
status were not found to be significantly associated with inhalational anesthetic concentration. This may have been
extubations requiring intervention. A summary of these because end tidal inhalational anesthetic concentration is
findings is presented in table 6. an imprecise measure of the concentration of inhalational
anesthetic within the central nervous system.20 Additionally,
Discussion anesthetic concentration effects could be altered by a com-
plex synergy with various sedatives (such as midazolam and
The primary finding of this study was that among the fac- opioids). The most obvious explanation for small tidal vol-
tors studied to assess fitness for awake extubation following ume being a risk was the potential contribution of resid-
an inhalational anesthetic in children less than 7 yr of age, ual weakness impacting successful extubation. However, no
the most important are facial grimace, eye opening, pur- patient requiring intervention was rescued with additional
poseful movement, tidal volume greater than 5 ml/kg, and reversal, and neuromuscular blockade was not associated
conjugate gaze. Further, because no predictor appears to be with patients requiring intervention. We theorize that this
far superior to another, a stepwise, multifactorial approach finding may actually be related to the rapid and shallow
is likely to be more useful to the clinician than using one or pattern of breathing typically associated with light levels
two favorites, especially given the difference in prevalence of inhalational anesthesia.21 Thus, inadequate tidal volume

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 Perioperative Medicine

Table 6.  Demographics and Univariate Analysis of Risk Factors for the IR+MIR Group

Demographic Factors S IR+MIR P Value for t test comparison

N = 556 N = 44 of demographic factors for S
versus IR+MIR
Mean age (years) ± SD 2.5 ± 2.0 2.7 ± 2.1 0.514
Mean weight (kg) ± SD 13.7 ± 7.1 15.8 ± 11.6 0.250

Factors potentially associated with S (n) IR+MIR (n) Odds Ratio 95% CI for P Value for Chi-square or
Extubation Requiring Intervention (Prevalence %) (Prevalence for IR+MIR Odds Ratio for Fisher Exact Analysis of
(IR+MIR) %) IR+MIR Association of Factor and
IR+MIR
ASA Status

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I 148 (26.7%) 10 (22.7%) 0.81 0.39–1.68 0.567
II 282 (50.8%) 25 (56.8%) 1.28 0.69–2.38 0.437
III or IV* 125 (22.5%) 9 (20.5%) 0.89 0.42–1.89 0.754
Male 369 (66.4%) 31 (70.5%) 1.20 0.62–2.36 0.580
Age < 1 yr 191 (34.4%) 15 (34.1%) 1.02 0.53–1.95 0.951
Emergency case status† 14 (2.5%) 1 (2.3%) 0.90 0.12–7.00 1.000
Airway procedure 130 (23.4%) 9 (20.4%) 0.83 0.39–1.78 0.639
URI 78 (14.0%) 13 (29.5%) 2.57 1.29–5.13 0.007
Asthma† 35 (6.3%) 4 (9.1%) 1.54 0.52–4.54 0.513
ETco2 > 55 mmHg 89 (16.0%) 17 (38.6%) 3.06 1.60–5.83 0.001
Use of NMB 191 (34.4%) 19 (43.2%) 1.45 0.78–2.70 0.239
Midazolam‡ 232 (62.9%) 24 (82.8%) 2.83 1.06–7.60 0.031
Sevoflurane 310 (51.6%) 19 (43.2%) 0.71 0.38–1.32 0.283
Isoflurane 201 (36.2%) 20 (45.5%) 1.47 0.79–2.73 0.220
Desflurane 68 (12.2%) 5 (11.4%) 0.92 0.35–2.42 0.866

*ASA status III and IV were collapsed because of a 0% prevalence with extubation requiring intervention (IR+MIR) outcome for ASA status equals IV. †Fisher Exact test used because
IR+MIR cell count was <5. ‡Total N = 600 for all risk factors for extubation requiring intervention except for midazolam where N = 398 because children < 1 yr of age were excluded
from this analysis.
ASA, American Society of Anesthesiologists; ETco2, end-tidal carbon dioxide; IR+MIR, intervention required plus major intervention required; NMB, nondepolarizing neuromuscular
blocker; S, successful; URI, upper respiratory tract infection.

may actually be an indicator or surrogate indicator that the patients that were extubated successfully, that certain predic-
patient has not yet passed out of stage 2. tors such as tidal volume greater than 5 ml/kg and conjugate
It was also of interest that conjugate gaze achieved sig- gaze are fairly early indicators reflected by their increased
nificance. In the design phase of the study, a majority of prevalence in 92% and 63% of patients extubated successfully,
attendings felt that conjugate gaze was potentially sugges- respectively. Further, we can infer that purposeful movement
tive of readiness for extubation, but was at best a second- or eye opening are likely to be later signs, presenting in only
ary predictor and not something they tended to use as a 37% and 17%, respectively, of patients extubated successfully.
primary measure of readiness. In fact, in 65 of 600 (10.8%) In situations where one or more criteria are absent, as not
cases, attendings chose not to check for it at all. It would all criteria occur in exactly the same order every time, an
appear, however, that conjugate gaze is a fairly specific indi- evaluation of which of these criteria is present, including
cator that a patient has passed through stage 2. those that did not achieve significance, may give additional
Eye opening, purposeful movement, and facial grimace guidance to the clinician in assessing the risk and timing of
were less surprising as these predictors are well known to extubation. For example, a positive laryngeal stimulation test
most clinicians. The one critique of these three predictors may be reassuring in a patient with tidal volumes greater than
though, is that they appear to be fairly late signs of fitness 5 ml/kg and conjugate gaze, with no other criteria present,
for extubation as indicated by their lower prevalence in but by itself, its high prevalence in patients extubated suc-
those extubated successfully when compared to some other cessfully would suggest that it occurs relatively early in the
predictors, and waiting for one or more of them may pro- process of emergence and as such the patient may still be at
long emergence and extubation. increased risk of laryngospasm.
It is important to recognize the occurrence of these factors Now the conservative clinician might suggest that per-
is dependent on time, and an assessment of which predictor haps extubation should be delayed until all five of these pre-
is present can also guide the clinician in determining where dictors are present, as they will all eventually become present
the patient is in the emergence process. Although we did with time. While this will likely increase the rate of success
not specifically record which predictors occurred in which slightly, it may be impractical and unnecessary, especially as
order, we can infer from the prevalence of these predictors in the time to extubation after completion of surgery becomes

806 Anesthesiology 2019; 131:801–8 Templeton et al.

Copyright © 2019, the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this article is prohibited.
 Evaluating Predictors of Extubation in Children

unwieldy. Additionally, there appears to be progressively volume greater than 5 ml/kg, and facial grimace may lead
smaller benefit in terms of predictive value when going from to increased rates of successful extubation in young children
three to four or four to five predictors, as compared to going undergoing anesthesia and surgery. Further, this informa-
from two to three predictors. In higher risk patients, though, tion may allow the clinician to approach awake extubation
this may represent an appropriate strategy. in a more rational fashion than was available previously.
Factors that were associated with a lack of success More prospective study is necessary to further clarify the
included: upper respiratory tract infection symptom within interactions of other comorbidities such as obesity, upper
7 days of the surgical procedure, midazolam premedication respiratory tract infection, and sleep disordered breathing
in children greater than 1 yr of age, and post hoc an ETco2 on the predictive value of these different criteria.
greater than 55 mmHg. While we cannot say that there is a
causal relationship between extubations requiring interven- Acknowledgments
tion and these factors, their association with the extubations

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The authors would like to acknowledge Forrest A. Roberson,
requiring intervention would suggest that they may alter
B.S., East Carolina School of Medicine, Greenville,
the predictive value of the five criteria identified in this
North Carolina, and Marina Lin, B.S., Department of
study individually and/or collectively. As a result, the cli-
Anesthesiology, Wake Forest University, Winston-Salem,
nician may want to exercise additional caution at the time
North Carolina, for assisting with extensive data collec-
of extubation in these settings. Of these three, an ETco2
tion; Addie Larimore, B.A., Department of Anesthesiology,
greater than 55 mmHg appeared to have the greatest asso-
Wake Forest University, for editorial assistance in prepar-
ciation with extubations requiring intervention. Obviously,
ing manuscript; and would like to acknowledge the Study
multiple factors, alone and in combination can lead to
Coordinator Pool, Biostatistics Core, and Regulatory
reduced alveolar ventilation and thus elevations of ETco2.
Knowledge & Support Program of the Wake Forest Clinical
Thus, it is difficult to make specific recommendations to
and Translational Science Institute, which is supported by
the practicing clinician, but this may represent an area for
the National Center for Advancing Translational Sciences,
future study. At this time, we are aware of only one study
National Institutes of Health (Bethesda, Maryland) through
by Baijal et al. in children undergoing adenotonsillectomy
grant No. UL1TR001420.
which specifically mentions the impact of an ETco2 greater
than 55 mmHg, at the time of extubation, stating that it was
only associated with minor respiratory complications in the
Research Support
postanesthesia care unit.11 Support was provided solely from institutional and/or
The limitations of this study include its observational departmental resources.
design and the fact that it was conducted at a single center.
It is possible that practice patterns between attendings were Competing Interests
more similar than first appreciated leading to bias and pos- The authors declare no competing interests.
sible confounding with similar criteria being used by dif-
ferent attendings. Additionally, these results do not apply to
Correspondence
“awake” removal of a supraglottic airway device or “deep”
extubation.The results and possible conclusions of this study Address correspondence to Dr. Templeton: Department of
also, only apply to cases in which an inhalational anesthetic Anesthesiology, Wake Forest School of Medicine, Medical
is used for maintenance and not to cases where propofol or Center Boulevard, Winston-Salem, North Carolina 27157-
total intravenous anesthesia are used for maintenance. This 1009. Email: ttemplet@wakehealth.edu. This article may be
is because potent inhalational anesthetics have different accessed for personal use at no charge through the Journal
mechanisms of action and different interactions with reac- Web site, www.anesthesiology.org.
tive airway reflexes.22 Also, it may be that certain preexisting
factors, such as age, upper respiratory tract infection, sleep References
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808 Anesthesiology 2019; 131:801–8 Templeton et al.

Copyright © 2019, the American Society of Anesthesiologists, Inc. Unauthorized reproduction of this article is prohibited.