Endotracheal Tube Intolerance and Respiratory Airflow Perception

Eligible patients will be enrolled for observation. Based on whether coughing occurs before extubation after emergence from anesthesia, patients will be divided into a case group (those who develop coughing) and a control group (those who do not).

Non-invasive cuff blood pressure readings will be recorded before, during, and after extubation. Post-extubation pain scores and sedation levels (assessed using the Ramsay Sedation Scale) will also be documented.

General demographic characteristics, smoking and smoking cessation history, presence of snoring during sleep, comorbid conditions (with particular emphasis on sleep apnea-hypopnea syndrome), history of pulmonary diseases, mode of spontaneous breathing, and surgical and anesthetic data will be collected.

Primary outcome: occurrence of coughing before extubation after emergence from anesthesia.

Definition of coughing: Coughing is defined as the occurrence of cough in a patient who has emerged from anesthesia after administration of reversal agents at the end of surgery, while the tracheal tube is still in place and connected to the ventilator in manual ventilation mode (with the adjustable pressure limiting [APL] valve set at 0 cmH₂O), and when extubation criteria have been met but the tube has not yet been removed.

Severity of coughing is graded as follows:

0 = no cough;

• = single cough;
• = more than one non-sustained cough;
• = sustained and repetitive cough with head lifting.

Data collection methods: General demographic and surgical/anesthetic data will be retrieved retrospectively from the patients' medical and anesthesia records. Other relevant data, including the occurrence and severity of coughing, pain scores, sedation levels, and mode of spontaneous breathing, will be recorded directly by the investigators in the case report forms (CRFs).

Investigators: research staff who have undergone standardized training.

This is an exploratory, unmatched case-control study designed to investigate the association between coughing during emergence from general anesthesia and the mode of spontaneous breathing (nasal vs. oral) in patients. In the pilot study, the proportion of nasal breathing in the case group (cough) was 65%, while that in the control group (no cough) was 35%. With a two-sided significance level (α = 0.05) and a statistical power of 90%, the required sample size per group was calculated using the Schlesselman formula to be 89 patients. Accounting for a 20% dropout rate, a total of 224 patients (112 per group) are planned for final enrollment. If the observed difference in exposure proportions is smaller than anticipated, the recruitment period will be extended or the analytical strategy will be adjusted accordingly.

Inclusion criteria

• Patients undergoing general anesthesia with endotracheal intubation;
• Written informed consent obtained.

Exclusion criteria

• Patients with severe psychiatric disorders;
• Deaf or mute patients who are unable to answer questions;
• Patients who develop postoperative cognitive dysfunction and are consequently unable to answer questions;
• Patients who withdraw from the study prematurely;
• Patients who are extubated after being transferred to the recovery room or intensive care unit (i.e., extubation not performed in the operating room).