Dear Editor,
Little is mentioned about the importance of avoiding cough and laryngospasm during extubation in the Operating Room (OR) in pediatric patients with suspected or confirmed SARS-CoV-2 infection. Coughing is an important source of viral contagion among humans and must be considered a high-risk complication for the health workers. Laryngospasm, more frequent in children than in adults, compels to intervene with positive pressure on the patient’s airway increasing the described risk. Different from intubation in the OR, where the anesthesiologist has certain control on the procedure, extubation and emergence from anesthesia have a greater degree of uncertainty.

Recently, 2020 consensus guidelines on pediatric airway management in patients with the coronavirus disease, from the Society for Pediatric Anesthesia’s Pediatric Difficult Intubation Collaborative and the Canadian Pediatric Anesthesia Society, have been published. For extubation, they recommend the use of closed in-line suction, deep extubation with techniques to minimize coughing and bucking (total IV anesthesia or dexmedetomidine), the use of protective barrier with a suction device under it to create negative pressure and emerging, and recovering of suspected COVID-19 patients in the OR, followed by direct transfer to the inpatient ward. However, there are some issues not mentioned in the guidelines that could help in the success of the extubation.

The patient position during extubation is associated with different outcomes. H. Jung el al. found that deep extubation in children in lateral decubitus had better SpO2 values in the first five minutes compared with extubation in supine decubitus (mean and standard deviation 98.3% ± 2.1% and 96.8% ± 2.5%, 95% IC 0.5–2.5, p =  0.003) and lower incidence of stridor and laryngospasm (2% and 18%, relative risk = 1.9, 95% IC 1.4–2.7, p =  0.03).

There is evidence about other drugs’ effectiveness in preventing cough during extubation. In children, Sanicop et al. reported a 29,9% and 18,92% reduction in laryngospasm and cough when 1.5 mg.kg-1 intravenous lidocaine was used 3 minutes before extubation compared to placebo. Propofol 0.25 mg.kg-1 and ketamine 0.25 mg.kg-1 also have showed being effective for such purpose.

The timing of extubation according to the child’s breathing cycle is another point of interest. The author of an educational review about extubation in children mentions that he extubates the child at the end of spontaneous inspiration without suction or positive pressure, arguing that at this point the child’s lungs are full of O2-enriched air and that the first trans laryngeal movement of air that follows directs all secretions away from the laryngeal structures decreasing the risk of laryngospasm.

According to the former, from the perspective of respiratory complications associated with extubation, it is safer for the health personnel to perform the extubation to a deep anesthetized patient, during spontaneous ventilation at the end of inspiration and in lateral decubitus. Special attention must be given to the use of the medications described for coughing and laryngospasm prevention after the withdrawal of the orotracheal tube.

Finally, health institutions must develop safe extubation protocols to patients and caregivers and perform a close surveillance of adherence and results.