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However, inadequate data exists about the relative safety of deep and awake extubations in the adult population.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods<\/jats:title>\n            <jats:p>Adult patients (<jats:italic>n<\/jats:italic>=220) with favorable airways undergoing elective surgeries under general tracheal anesthesia were enrolled prospectively. Following a standardized volatile anesthetic regimen, patients were randomized to undergo deep or awake tracheal extubation. The primary outcome was the occurrence of at least one airway or respiratory complication. Secondary outcomes included airway interventions, hemodynamic parameters, severe emergence agitation, and sore throat severity.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results<\/jats:title>\n            <jats:p>Pre-extubation, awake extubations exhibited an increased rate of any airway and respiratory complications (risk ratio [RR] \u2013 5.1; 95% confidence interval [CI] \u2013 2.8-9.5; <jats:italic>p<\/jats:italic>&lt;.001), attributable to greater incidences of cough (RR \u2013 6.8; 95% CI \u2013 3.2-14.3, <jats:italic>p<\/jats:italic>&gt;.001) and hypoxemia (RR \u2013 3.6; 95% CI \u2013 1.3-10.6, <jats:italic>p<\/jats:italic>=.010). After extubation, a significantly decreased rate of one or more complications occurred in the awake extubation group (RR \u2013 0.7; 95% CI \u2013 0.6-1.0; <jats:italic>p<\/jats:italic>=.028). Awake extubations were associated with fewer incidences of airway obstruction (RR \u2013 0.2; 95% CI \u2013 0.1-0.4, <jats:italic>p<\/jats:italic>&lt;.001) and apnea (RR \u2013 0.3; 95% CI \u2013 0.1-0.9; <jats:italic>p<\/jats:italic>=.025), but higher rates of any severity cough (RR \u2013 2.9; 95% CI \u2013 1.6-5.2; <jats:italic>p<\/jats:italic>&lt;.001). Awake extubations required significantly fewer airway interventions after extubation (RR \u2013 0.2; 95% CI \u2013 0.1-0.6; <jats:italic>p<\/jats:italic>&lt;.001). No serious adverse events occurred.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions<\/jats:title>\n            <jats:p>Deep and awake extubations produce distinct airway and respiratory complication profiles, without either being conclusively safer. The risks posed by each technique during emergence and after extubation should be considered by anesthesia providers when formulating an extubation strategy.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Trial registration<\/jats:title>\n            <jats:p>This study was retrospectively registered at clinicaltrials.gov (NCT05361850) on April 23, 2022. <\/jats:p>\n          <\/jats:sec>","DOI":"10.1186\/s12871-025-03224-6","type":"journal-article","created":{"date-parts":[[2025,7,31]],"date-time":"2025-07-31T17:49:03Z","timestamp":1753984143000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["A comparison of deep versus awake tracheal extubation in adults: a randomized controlled trial"],"prefix":"10.1186","volume":"25","author":[{"given":"Michael A.","family":"Lee","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter W.","family":"Schenke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthew R.","family":"Faller","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Henry R.","family":"DeYoung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley R.","family":"Adams","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,7,31]]},"reference":[{"issue":"5","key":"3224_CR1","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1093\/bja\/aer058","volume":"106","author":"TM Cook","year":"2011","unstructured":"Cook TM, Woodall N, Frerk C, Fourth National Audit Project. 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Informed consent was obtained from all research subjects. Our study adhered to the World Medical Association Declaration of Helsinki, with the exception of trial registration before recruitment of the first subject, which was accomplished retrospectively before trial conclusion. Ignorance of the primary investigator, research personnel turnover during the COVID-19 pandemic, and administrative oversight were the root causes of this error. The only significant protocol change made after IRB approval and study initiation was formalizing the anesthesia provider\u2019s discretion to forgo randomization and select an extubation method based on clinically compelling intraoperative events.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"The authors declare no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"387"}}