European Journal of Cardiovascular Medicine

Smooth emergence from General anesthesia with minimal coughing is often considered to be hallmark of an experienced anesthesiologist, possible adverse effects of cough being high intrathoracic pressures resulting in increased venous and intra-abdominal pressures leading to increased venous bleeding. Rarely, severe coughing may also disrupt an abdominal wound closure.^[1] Respiratory complications after tracheal extubation are three times more common than during tracheal intubation. Incidence of respiratory complications dramatically decrease when extubation was performed when eyes were open, with spontaneous ventilation.^[2] Almost a third of major airway complications occurred during emergence and in the recovery period, further highlighting that this is a high-risk phase of anaesthesia. Laryngospasm is the reflex closure of the glottis by adduction of the true and/or false cords and is caused by stimulation of the larynx [by saliva, blood, vomitus or foreign body (including laryngoscope, airway device ortracheal tube)]. It can be prevented by ensuring removal of airway debris while the patientremains at a sufficient depth of anaesthesia.^[3,4] Extubation under deep anesthesia is a safe option and reduces extubation stress and improves patient comfort.^[5] In order to avoid extubation under light anesthesia, a technique called "no touch" extubation has been proposed. As soon as the patient awakens spontaneously and opens his eyes, extubation is performed.^[6]

Objectives of the Study

This study aims to compare and evaluate the absolutely awake extubation ("No touch") technique versus the conventional extubation technique in adult patients undergoing elective faciomaxillary surgeries under general anesthesia, with respect to the following parameters;

Quality of emergence assessed using a 20-point scoring system.

Incidence of emergence airway complications including breath-holding, tube-biting, laryngospasm, apnea, aspiration, and hypoxemia.

Hemodynamic responses during and after extubation.

The present randomized, comparative, two-group controlled double-blinded study was conducted over six months at hospitals attached to Bangalore Medical College and Research Institute. Patients aged 18–60 years with ASA physical status I–II scheduled for elective faciomaxillary surgery under general anesthesia with endotracheal tube insertion were included in the study. Patients who had chronic airway disease (COPD. asthma, chronic cough) , on sedatives or ACE inhibitors, those who belonged to ASA class III and IV and those who refused participation were excluded from the study.

A total of 60 adult patients were randomly allocated into two groups of 30 each using computer-generated randomization. In Group 1 patients (Conventional Extubation), after completion of surgery sevoflurane was discontinued, throat pack removed and secretions suctioned. Patients were then turned to lateral position and extubation was done once they regained consciousness with spontaneous eye opening and had adequate breathing efforts with an intact gag reflex. In Group 2 ("No Touch" Awake Extubation), suctioning and throat pack removal were performed while patient was still under anesthesia. After placing the patient laterally, sevoflurane was discontinued and extubation was delayed until the patient spontaneously opened their eyes or responded to verbal commands without physical stimulation.

Primary outcomes included the time from surgery completion to spontaneous eye opening. Hemodynamic parameters (HR, SBP, DBP) were recorded at baseline and at 2, 4, 5, 10, 15-, 20-, 25-, and 30-minutes post-surgery. The incidence of adverse airway events (breath-holding, tube-biting, laryngospasm, apnea, aspiration, hypoxemia) was noted. A 20-point scoring system was used to assess emergence quality. Data was entered and analyzed using SPSS-Software. Categorical data was presented as frequencies and proportions, while continuous data was expressed as mean and standard deviation. Appropriate statistical tests were employed and a p-value of less than 0.05 was considered statistically significant, ensuring robust analysis.

0.05 was considered statistically significant, ensuring robust analysis.

The age distribution was comparable between the two groups with the majority in both groups being between 31–45 years (50.0% in the Conventional Extubation group and 43.3% in the No Touch Awake Extubation group). The distribution of demographic characteristics was statistically comparable between the two groups, ensuring their baseline similarity and allowing a fair comparison of extubation techniques.

The diagnosis and surgical procedure in both the groups were well-balanced, supporting a fair comparison of extubation techniques without any possibility of surgical bias. (Table 1)

Post-surgical heart rates showed no significant difference between groups, with gradual declines over time. The Conventional Extubation group had a slightly higher mean heart rate initially (85.40 ± 7.86 bpm) compared to the No Touch group (82.47 ± 12.41 bpm), but values remained all time within the physiologically acceptable limits and eventually was comparable at subsequent time points. No statistical significance was noted throughout the 30-minute observation period, suggesting that heart rate variation was comparable between the two extubation techniques, implying minimal impact of the extubation method. (Table 2)

Mean arterial pressure (MAP) was significantly higher in the No Touch Awake Extubation group at all time points, starting from post-surgery (85.17 ± 7.02 mmHg vs. 76.43 ± 10.44 mmHg, p < 0.001) across 30 minutes time period. Though statistically significant, this consistent elevation in MAP was well within acceptable range and never exceeded the normal physiological values suggesting the comparability in both groups. The No Touch method resulted in better hemodynamic stability post-extubation, potentially reducing the risk of hypotensive events and enhancing patient recovery.

Comparison of the Quality of Emergence (QOE) and the Duration till Eye Opening

The quality of emergence, assessed using a 20-point scale, was significantly higher in the No Touch Awake Extubation group (17.70 ± 1.47) compared to the Conventional Extubation group (16.10 ± 1.49) with a p-value of <0.001. This statistically significant difference suggests that patients undergoing the No Touch extubation technique had a more favorable emergence profile, characterized by better airway control and reduced agitation when compared to the Conventional extubation group. The improved quality of emergence supports the potential benefits of this technique in enhancing patient comfort and reducing complications during the recovery phase. (Table 3)

The time taken for spontaneous eye opening was markedly shorter in the No Touch Awake Extubation group (4.73 ± 2.05 minutes) compared to the Conventional Extubation group (10.20 ± 2.88 minutes), with a highly significant p-value of <0.001. This substantial reduction in emergence time suggests that the No Touch technique facilitates faster recovery from anesthesia, probably due to a better controlled and a more physiologically stable extubation process. The quicker return to consciousness may also translate to reduced airway risks and enhanced postoperative efficiency in clinical settings. (Table 4)

Comparison of Incidence of Adverse Airway Events

The incidence of adverse airway events was overall lower in the No Touch Awake Extubation group compared to the Conventional Extubation group. Breath-holding occurred in 23.3% of patients in the Conventional Extubation group versus 10.0% in the No Touch group, while tube biting was noted in 30.0% and 16.7% of cases, respectively. Laryngospasm, apnea, and hypoxia were reported only in the Conventional Extubation group. Other parameters like aspiration, airway adjunct use and excessive secretions showed no significant differences between the two groups. These findings support that the No Touch extubation technique may be helpful in reducing the incidence of adverse airway events, promoting a smoother emergence from anesthesia. (Table 5)

Our study was conducted over six months on 60 adult patients (ASA I–II) undergoing elective faciomaxillary surgery under general anesthesia. Participants were randomly allocated into two groups of 30 each: the Conventional Extubation group where extubation was performed after regaining of consciousness and spontaneous breathing. In "No Touch" Awake Extubation group extubation was delayed until spontaneous eye opening and response to verbal commands. Hemodynamic parameters, emergence quality (20-point scale), adverse airway events and time to eye opening were assessed.

Quality of Emergence

Emergence quality was superior with No Touch extubation in all studies. The present study and Kapil S et al.[7] both found significantly higher emergence scores in No Touch groups (p < 0.001)  with Kapil S et al. reporting a particularly notable improvement (18.05 vs. 13.45). Sheta SA et al,[8] found lower agitation and less wound oozing in No Touch patients,supporting a smoother emergence process. Tsui BCH et al.[9] reported no severe coughing or agitation reinforcing that No Touch leads to a more controlled recovery . Lulu suo et al.,[5] did a comparative study on patients undergoing nasal surgery and observed a lesser emergence agitation (EA) in deep extubation group similar to study done by Babu et al.[10] who observed  that  Extubation just before reversal of neuromuscular blockade resulted in lesser incidence of bucking and coughing with lesser postoperative bleeding compared to traditional technique of awake extubation. The lack of complications and improved emergence scores support that No Touch extubation not only enhances patient comfort but also reduces perioperative complications associated with agitation and airway reflex activation.

Time to Eye Opening

Emergence time findings varied between studies. The present study reported a significantly shorter time to eye opening in the No Touch group (4.73 vs. 10.20 minutes, p < 0.001), whereas Sheta SA et al.[8] found a longer emergence time in No Touch (14.2 vs. 8.3 min, p < 0.05). Kapil S et al.[7] found no significant difference in emergence time, and Tsui BCH et al.[9] reported a median extubation time of 7.7 min, though without a comparative group. The inconsistency in findings may stem from differences in anesthesia protocols and patient populations. However, given that No Touch reduces airway complications and enhances emergence quality, variations in emergence time are unlikely to affect its overall advantages in clinical practice.

Adverse Airway Events

Adverse airway events, including laryngospasm, breath-holding and tube-biting were significantly lower in the No Touch groups in all other studies. Our present study as well as that conducted by Sheta SA et al.,[8] and Tsui BCH et al.[9] did not have laryngospasm in No Touch technique patients, with Sheta SA et al. noting three cases in the Conventional group. In the study done by Tsui BCH et al. showed a 21-27% laryngospasm rate, but none in their No Touch group. Najar-Rodríguez DA et al.[11] found a 2% incidence of laryngospasm, which is much lower than reported literature rates of 5–21%, suggesting that even in pediatric populations, No Touch provides a safer emergence.In the study done by Dr. Tirmanwar Amar Govind Rao et al.,[6] “no touch" tracheal extubation had fewer airway-related complications, better haemodynamic stability and it may serve as a safe alternative to standard tracheal extubation, the finding of which agree with our study.In the systemic review and meta analysis, Koo CH., et al.,[12] analysed many randomised trials and concluded the result that deep extubation may decrease the risk of overall airway complications including cough and desaturation and hence recommended deep extubation in pediatric patients to minimize overall airway complications. The systematic review by Jubb[13] recommends a level for deep extubation to suppress post extubation cough in adults the aim of which aligns well with our present study.

Characteristics of the Study Subjects

The studies analyzed varied in population characteristics, with the present study, Kapil S et al.,[5] and Sheta SA et al.[6] focusing on adults, while Najar-Rodríguez DA et al.[8] and Tsui BCH et al.[7] examined pediatric populations. The present study and Sheta SA et al. had the most comparable demographics and similar gender distribution. Kapil S et al. focused on pituatory surgeries and implications of early smooth extubation which is the concern in faciomaxillary, ENT and Head and neck surgeries. The studies by Najar-Rodríguez DA et al. and case series Tsui BCH et al analysed “No touch” extubation in paediatric age group, the aims and outcomes of which were relatable with present study. Both Sheta SA et al. and the present study focused on airway management challenges associated with head and neck surgeries, whereas Kapil S et al. investigated different extubation considerations. The broad variation in study populations suggests that No Touch extubation is beneficial across diverse surgical contexts, though adult and pediatric outcomes though relatable, should be considered separately.

Variations in Vitals

Heart rate stability was assessed in many studies, with varied outcomes. The present study and Kapil S et al. found no statistically significant differences in HR between No Touch and Conventional extubation group. Sheta SA et al., however reported a significant reduction in HR in the No Touch group which may be beneficial in surgeries where haemodynamic fluctuations can increase surgical site bleeding risk.Najar-Rodríguez DA et al. and Tsui BCH et al. did not measure HR directly but reported stable oxygen saturation, indirectly supporting hemodynamic stability. Basnet et al.,[14] observed "no touch" extubation technique results in a more stable hemodynamic profile and fewer airway-related complications than standard awake extubation results of which align well with our study.

Mean arterial pressure (MAP) responses varied across studies, with our study reporting significantly higher MAP in the No Touch group, while studies done by Sheta SA et al. found lower MAP with this technique. Kapil S et al., Najar-Rodríguez DA et al., and Tsui BCH et al. did not provide direct MAP data but indicated stable emergence, inferring that MAP fluctuations were not clinically significant. The contrast findings in the present study and Sheta SA et al. might be due to differences in surgical stress responses.

Summary

The No Touch extubation technique consistently demonstrated advantages across diverse patient populations and surgical settings. It significantly reduces airway complications, enhances emergence quality and maintains hemodynamic stability although its impact on HR, MAP and emergence time varies. The most clinically relevant benefit is the significant reduction in laryngospasm, coughing and airway irritation making No Touch a preferred choice for surgeries involving head and neck regions or airway manipulation. While some previous studies reported shorter emergence times and others found prolonged emergence, the overall patient safety and comfort benefits outweigh any potential delays. Given the consistent superiority of No Touch in reducing complications, it may be considered a much sought technique for extubation in surgeries where airway management is a critical factor.

The No Touch Awake Extubation technique demonstrated superior outcomes compared to conventional extubation in elective faciomaxillary surgeries, aligning with the study objectives. It ensured better haemodynamic stability, fewer airway complications (less breath-holding, tube biting and no hypoxia) and faster emergence from anaesthesia with significantly reduced eye opening time. Additionally, it achieved a higher quality of emergence, enhancing patient recovery. These findings justify its use as a safer, more efficient extubation method, improving postoperative airway control and overall patient outcomes.

Acknowledgement

We sincerely thank the participants and faculty of theinstitute for helping us in each aspect of the study.

Declarations

Funding: None.

Conflict of Interest: None declared.

Ethical Approval: The study was approved by the Institutional Ethics Committee.

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