Awake versus deep airway device removal in pediatric tonsillectomy: a systematic review and meta-analysis

Background and objectives Tonsillectomy, with or without adenoidectomy, is among the most common pediatric surgeries, associated with a high incidence of perioperative respiratory adverse events. The timing of airway device removal, during deep anesthesia or after awakening, may influence these outcomes. Methods PubMed, Embase and CENTRAL were systematically searched for studies comparing awake and deep airway device removal in pediatric otolaryngology surgery. The primary analysis was restricted to Randomized Controlled Trials (RCTs). The primary outcome was laryngospasm; secondary outcomes included cough, oxygen desaturation and airway obstruction. Risk Ratios (RR) with 95% Confidence Intervals (95% CI) were pooled using random-effects models. Results Seven studies (six RCTs and one observational study, the latter used only in sensitivity analyses), including 1,571 children, were analyzed. Deep airway device removal was associated with a higher risk of airway obstruction (RR = 1.82; 95% CI 1.10–3.03; p = 0.020) and a lower risk of cough (RR = 0.57; 95% CI 0.43–0.75; p < 0.001), with no evidence of a difference between the Laryngeal Mask Airway (LMA) and Endotracheal Tube (ETT) subgroups (p for subgroup differences = 0.992). Laryngospasm did not differ significantly (RR = 0.99; 95% CI 0.43–2.30; p = 0.984). Desaturation was lower with deep removal in the RCT-only analysis (RR = 0.62; 95% CI 0.44–0.88; p = 0.007). Conclusions Deep airway device removal was associated with less coughing, with no evidence that this effect differed between LMA and ETT. Deep removal may increase airway obstruction, though sensitive to individual studies. Desaturation findings were sensitive to study design and sare not definitive.