Postoperative Respiratory Complications in Non-Intubated vs Intubated Thoracoscopic Surgery

Overview

This randomized, controlled, double-blind non-inferiority study compared postoperative pulmonary complications (PPCs) and intraoperative safety between non-intubated VATS (NIVATS) and intubated VATS (IVATS) in patients undergoing thoracoscopic surgery. The study found that NIVATS was not inferior to IVATS regarding the incidence of PPCs in patients with BMI < 25 kg/m2 and ASA I–II. Both anesthesia techniques were performed safely with comparable surgical outcomes.

Background

Thoracic surgery has advanced significantly with the use of double-lumen bronchial tubes (DLT) enabling one-lung ventilation (OLV), facilitating video-assisted thoracic surgery (VATS). However, intubated VATS (IVATS) is associated with complications such as intraoperative circulatory fluctuations, postoperative sore throat, residual muscle relaxants effects, and mechanical ventilation-related lung injuries. Postoperative pulmonary complications (PPCs) are common and adversely affect recovery and hospital stay. Non-intubated VATS (NIVATS) has emerged as an alternative to avoid intubation and mechanical ventilation, maintaining spontaneous breathing, but its impact on PPCs and intraoperative safety requires further evaluation.

Data Highlights

A total of 130 patients were enrolled; 120 completed the trial (60 per group). Inclusion criteria included ASA grade I–II, BMI < 25 kg/m2, and no severe cardiovascular or respiratory disease. The study was powered with a non-inferiority margin of 10% for PPC incidence, with statistical power of 95.7%. Both groups underwent single-port VATS for lung cancer radical resection or wedge resection under anesthesia by the same senior anesthesiologist.

Key Findings

• NIVATS was not inferior to IVATS in terms of the incidence of postoperative pulmonary complications.
• IVATS is associated with complications related to double-lumen tube intubation and mechanical ventilation, including circulatory fluctuations and lung injury.
• NIVATS avoids intubation and mechanical ventilation, maintaining spontaneous breathing during surgery.
• Both anesthesia techniques were safely administered by experienced anesthesiologists with comparable surgical outcomes.
• The study population included patients with BMI < 25 kg/m2 and ASA physical status I–II, limiting generalizability to higher-risk patients.

Clinical Implications

NIVATS offers a feasible and safe alternative to IVATS in selected low-risk patients undergoing thoracoscopic surgery, potentially reducing complications related to intubation and mechanical ventilation. Clinicians should consider patient selection criteria such as BMI and ASA status when opting for NIVATS. Further studies are needed to evaluate NIVATS in higher-risk populations and complex surgeries.

Conclusion

This study supports the non-inferiority of NIVATS compared to IVATS regarding postoperative pulmonary complications and intraoperative safety in low-risk thoracoscopic surgery patients. NIVATS may be considered a viable anesthesia option to minimize intubation-related adverse effects.

References

1. Zhou et al. 2021 -- Evaluation of Postoperative Respiratory Complications and Intraoperative Safety in Non-Intubated versus Intubated Anesthesia for Thoracoscopic Surgery