Asleep Staged Extubation Technique (ASET): extraglottic endotracheal tube ventilation (EETV)


By Davide Cattano, M.D., Ph.D., D.ABA, C.M.Q.1, Mihir Rane, DO1

1Department of Anesthesiology, Mc Govern Medical School, UTHealth at Houston, Texas, USA






An asleep (deep) extubation of an easy airway has been part of routine anesthesia practice for years, similar to an awake extubation technique, recently conceptualized in DAS extubation algorithm.5 Different practical concerns drive the practitioner to decide on awake versus asleep (deep) extubation, and clinical practice guidelines should be tailored to weighing in the risks and benefits for both techniques.

Some of the main indications for awake extubation following emergence from general anesthesia include: protection of the airway and preservation of spontaneous ventilation and oxygenation; difficult mask ventilation encountered on induction; obstructive sleep apnea (OSA) and other concerns for upper airway obstruction; aspiration risk; the need for prompt post-extubation neurological exam.1-2,11 Conversely, some of the main  advantages of a deep extubation may include: a smooth, non-stimulating emergence from anesthesia; blunting extubation-related stress response and autonomic reflexes;12 faster operating room patient discharge time and turn over.13-14

For H&N surgery, the ideal extubation technique should answer the following considerations: be well tolerated by the patient (no bucking, coughing, gagging); avoid unnecessary manipulations for maintenance of the patent’s airway; preserve spontaneous ventilation and oxygenation; avoid or minimize the need for mask ventilation, which may be contraindicated or highly undesirable, e.g. after middle ear surgery.

As a solution to some of these unique challenges, we describe an asleep staged extubation technique (ASET) utilizing the extraglottic endotracheal tube ventilation (EETV), which we have developed and utilized since 2009 in different routine, as well as challenging extubation scenarios. The technique can be equally applied to orally and nasally intubated patients.


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