Non-Intubated Techniques in Thoracic Surgery

Non-intubated approaches in thoracic surgery have emerged as a transformative alternative to conventional general anaesthesia with endotracheal intubation and one-lung ventilation. By maintaining spontaneous breathing under sedation and targeted regional blocks, surgeons can minimise the adverse effects of airway instrumentation, such as airway trauma, ventilation-induced lung injury and residual neuromuscular blockade. These techniques encompass a range of locoregional anaesthetic methods—including intercostal blockade, paravertebral and erector spinae plane blocks—often combined with minimal intravenous sedation. Clinical experience has demonstrated reductions in perioperative inflammatory markers, preservation of immune function and shorter hospital stays. Patient selection remains critical, with factors such as body mass index, pulmonary reserve and anatomical considerations informing suitability. Although conversion to intubation may be required in a minority of cases, non-intubated thoracic surgery offers a less invasive pathway for diagnostic and therapeutic procedures ranging from pleural biopsies to lobectomies. The global adoption of these methods underscores their practical significance in enhancing recovery protocols and broadening surgical options for high-risk cohorts.

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Non-Intubated Techniques in Thoracic Surgery publication trend

The graph below shows the total number of articles in non-intubated techniques in thoracic surgery across all publications each year (not limited to Nature Index journals).

Technical terms

Video-assisted thoracoscopic surgery (VATS): Minimally invasive thoracic procedure performed via small intercostal incisions under camera guidance.

Non-intubated video-assisted thoracic surgery (NIVATS): VATS conducted on spontaneously breathing patients without endotracheal intubation, using sedation and regional blocks.

Single-lung ventilation: Isolation and selective ventilation of one lung via an endotracheal tube or bronchial blocker to provide a static surgical field.

Locoregional anaesthesia: Techniques that target specific nerves or fascial planes to achieve analgesia while preserving spontaneous respiration.

Intercostal blockade: Injection of local anaesthetic adjacent to intercostal nerves to numb the chest wall.

Erector spinae plane block (ESPB): Regional block delivering anaesthetic in the fascial plane deep to erector spinae muscles for thoracic analgesia.

Thoracic paravertebral block (TPVB): Injection of anaesthetic beside the thoracic vertebrae to block multiple spinal nerves unilaterally for pain control.

References

1. Immunological and Inflammatory Impact of Non-Intubated Lung Metastasectomy. International Journal of Molecular Sciences (2017).
2. Thoracic surgery in the non-intubated spontaneously breathing patient. Respiratory Research (2022).
3. The Anesthesiologist's Perspective Regarding Non-intubated Thoracic Surgery: A Scoping Review. Frontiers in Surgery (2022).
4. Non-intubated video-assisted thoracoscopic surgery under combination of erector spinae plane block and thoracic paravertebral block. BMC Anesthesiology (2022).