Answer:

To avoid bronchospasm triggered by coughing and straining caused by laryngeal and pharyngeal reflexes during emergence and extubation, patients may be extubated at surgical (deep) levels of anesthesia. However, the risks of aspiration, airway obstruction, and hypoventilation should be weighed against the benefits. With a history of severe COPD, chronic hypoxemia, and CO₂ retention, the patient is not a good candidate for extubation while deeply anesthetized. A systematic approach for emergence and extubation is illustrated in Figure 1.5. However, the guidelines do not include all possible patient-surgical-anesthetic conditions. Certainly, the practitioner’s clinical judgment is of utmost importance regarding the decision to extubate.

• Lien CA, Koff H, Malhotra V, et al. Emergence and extubation: a systemic approach. Anesth Analg. 1997;85:1177.
• Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103(suppl 1):i57-i65.