This work was supported by the third batch of the Ningbo Health Youth Technical Cadre program (Dr. Binbin Zhu), and the Zhejiang Medical Association Clinical Research Fund Project (Dr. Bin Gao) (2018ZYC-A66).

The study was approved by the Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (KY20181215) on December 10, 2018.
1. Inclusion criteria
<ol>
	<li>Include all patients (aged &#62;18 years) undergoing pulmonary bullae resection, pulmonary wedge resection, or lobectomy.</li>
</ol>
2. Exclusion criteria
<ol>
	<li>Exclude patients based on an American Society of Anesthesiologists (ASA) physical status c...

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

The authors have nothing to disclose.

The advantages of this protocol are as follows: (i) providing a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery; (ii) minimizing over-sedation while providing a safe and pain-free operating environment for patients undergoing thoracic surgery; (iii) minimizing the patient&#39;s spontaneous breathing and mediastinal oscillations during the procedure, taking into account the associated technical challenges. This was achieved by providing pre-emptive intraoperative local ane...

In the past decade, non-intubated video-assisted thoracic surgery (NIVATS) anesthesia has gradually been accepted in clinical practice1,2,3. Although this novel strategy enhances the rapid recovery of patients and avoids the complications of general anesthesia (GA) and one-lung ventilation4, many surgeons regard this approach as less desirable than the traditional lung isolation technique.
Blood oxygen levels decline with age, and some patients may have decreased or borderline pulmonary function. GA may be associated with an increased risk of complications in such patients, including delayed emergence from anesthesia, airway complications, hoarseness, hypoxia, and arytenoid dislocation5,6,7,8,9. In contrast, multiple studies have documented shorter hospital stays among patients managed with NIVATS, as well as a reduction in respiratory complications compared to general anesthesia among low-risk patients10; additionally, successful surgery has even been reported in high-risk patients with very poor pulmonary function11,12,13.
Spontaneous ventilation during surgery is achieved with carefully administered local anesthesia or a regional nerve block supplemented with sedation, but the cough reflex with unexpected lung movement can be problematic during NIVATS. There is little emphasis on and no standard treatment for mediastinal flutter, irritating cough, or tachypnoea, which may disrupt a surgical procedure. In preliminary observations, the results showed that sevoflurane could decrease the respiratory rate and the occurrence of mediastinal flutter during NIVATS while maintaining spontaneous breathing14. Therefore, it could be hypothesized that sevoflurane inhalation may prevent coughing and reduce the requirement for mechanical ventilation, thereby reducing post-operative pulmonary complications (PPCs).
Firstly, this report presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. Secondly, a retrospective study was conducted to investigate the potential benefits of non-intubated anesthesia on post-operative outcomes.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>20-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383012</td>
			<td>Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.</td>
		</tr>
		<tr>
			<td>24-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383033</td>
			<td>Thoracoscopic vagal block techniques</td>
		</tr>
		<tr>
			<td>Anesthesia&#160;machine</td>
			<td>Drager</td>
			<td>A300</td>
			<td>Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate</td>
		</tr>
		<tr>
			<td>Atropine</td>
			<td>Jiuquan Dadeli Pharma</td>
			<td>H62020772</td>
			<td>Control of heart rate</td>
		</tr>
		<tr>
			<td>BIS</td>
			<td>COVIDIEN</td>
			<td>B277243</td>
			<td>Monitor the level of consciousness</td>
		</tr>
		<tr>
			<td>Disposable nerve block needle</td>
			<td>Tuoren Medical Device&#160;</td>
			<td>202303007</td>
			<td>Nerve block</td>
		</tr>
		<tr>
			<td>Facial mask</td>
			<td>Emedica</td>
			<td>EM01-105S</td>
			<td>Provides an effective non-invasive breathing circuit</td>
		</tr>
		<tr>
			<td>Fentanyl.</td>
			<td>Renfu Pharma</td>
			<td>21D04021</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Flurbiprofen</td>
			<td>Daan Pharma</td>
			<td>H20183054</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Laryngeal mask&#160;</td>
			<td>Ambu Aura-i</td>
			<td>2012-2664652</td>
			<td>Airway management to preserve voluntary breathing</td>
		</tr>
		<tr>
			<td>Levobupivacaine</td>
			<td>Rundu Pharma</td>
			<td>H20050403</td>
			<td>Local Anaesthesia</td>
		</tr>
		<tr>
			<td>Lidocaine</td>
			<td>Kelun Pharma</td>
			<td>F221129C</td>
			<td>Local skin infiltration</td>
		</tr>
		<tr>
			<td>Norepinephrine</td>
			<td>Lijun Pharma</td>
			<td>H61021666</td>
			<td>Control of blood pressure</td>
		</tr>
		<tr>
			<td>Portable color doppler ultrasound</td>
			<td>SonoSite</td>
			<td>M-Turbo</td>
			<td>Guided nerve block</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Guorui Pharma</td>
			<td>H20030114</td>
			<td>Sedation and hypnosis</td>
		</tr>
		<tr>
			<td>Ropivacaine</td>
			<td>Aspen Pharma</td>
			<td>6091403219940</td>
			<td>Paravertebral nerve block</td>
		</tr>
		<tr>
			<td>Saline</td>
			<td>Kelun Pharma</td>
			<td>c221201E1</td>
			<td>Assisted subsonic localisation</td>
		</tr>
		<tr>
			<td>Sevoflurane</td>
			<td>&#160;Shanghai Hengrui Pharmaceutical Co.,Ltd</td>
			<td>9081931</td>
			<td>Anesthesia induction and maintenance</td>
		</tr>
		<tr>
			<td>Sufentanil</td>
			<td>Jiangsu Enhua Pharmaceutical Co., Ltd</td>
			<td>H20203650</td>
			<td>Postoperative analgesia</td>
		</tr>
	</tbody>
</table>

non-intubated video-assisted thoracoscopic surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Non-Intubated Video-Assisted Thoracoscopic Surgery

This research presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. The protocol of NIVATS is based on multimodal analgesia, including ultrasound-guided thoracic paravertebral blockade. A thoracoscopic make a block, and plural infiltration anesthesia.Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex. This protocol provides a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery, minimizes oversedation, while providing a safe and a pain-free operating environment for patients. We maintain the patient's spontaneous breathing and minimize mediastinal oscillations during the procedure, while taking into account the associated aided technical challenges.

Clinical data were retrospectively collected on 58 consecutive patients undergoing non-intubated video-assisted thoracoscopic surgery from January 2016 to December 2022. The patients were given a preoperative visit by the anesthesiologist and provided with a detailed explanation of the contents of the anesthesia informed consent form prior to the anesthesia. The patients were allowed to choose one of the two groups (the NIVATS group or GA group) of anesthesia, and they signed an informed consent form.
<p class="jove_...

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

Non-Intubated Ultrasound-Guided Thoracic Paravertebral Blockade Under Anesthesia

Begin by adjusting the temperature of the operating room to between 24 to 26 degrees Celsius. Insert a 20-gauge top-winged infusion needle into the elbow vein of the non-surgical hand of the patient. Now monitor the electrocardiography, blood pressure, pulse oxygen saturation, and respiratory rate of the patient.Apply a Bispectral Index Quatro Sensor to the patient's forehead. To induce anesthesia by continuous oxygen administration, insert a laryngeal mask airway. Maintain the sevoflurane concentration at 1.5 to 2%and an oxygen flow rate of 0.5 to one liter per minute.Monitor the inhaled oxygen concentration, the end tidal carbon dioxide, the body temperature, and the level of consciousness. Place the patient in a lateral decubitus position and place the ultrasound probe directly above the spinous processes of the third and seventh thoracic vertebrae. Obtain a cross-sectional image of the spinous processes.Move the ultrasound probe laterally to show the transverse process in its entirety. Move it outward to visualize the transverse process, transverse rib joints, and the ribs. Keep moving the probe caudally until the transverse process, pleura, and the thoracic paravertebral space are detected in the image.Under ultrasound guidance, insert a block needle with the in plain approach from the lateral to the medial side. Next, carefully increase the aspiration before the injection to ensure no blood reflux is seen. After injecting 0.5 milliliters of ropivacaine, visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space.Maintain a Bispectral Index value of 40 to 60. Using an infusion pump, continuously perfuse norepinephrine. Perform arterial blood gas analysis 15 minutes before the end of the surgery.Inject one milligram per kilogram of flurbiprofen 30 minutes before the end of the surgery. The pulmonary complication rate was observed to be significantly lower in the non-intubated video-assisted thoracic surgery, or NIVATS group, related to the general anesthesia, or GA group. Six patients in the GA group developed postoperative pneumothorax.Three patients in the GA group developed plural effusion compared to one in the NIVATS group, which was not statistically significant. Seven patients in the GA group developed pneumonia compared to none in the NIVATS group, and the difference between the two groups was statistically significant. Additionally, three GA patients developed pulmonary atelectasis and two developed pulmonary embolisms.Neither group developed acute respiratory distress syndrome. The NIVATS group showed reduced intraoperative blood loss at 20 milliliters, shorter mean surgery duration, and post-anesthesia care unit stay time. Furthermore, the chest drain was removed from the NIVATS group on day two and the GA group on day three, which was significant.Significant differences were observed in the amount of postoperative chest drainage between the NIVATS and the GA group. Three patients in the GA group had prolonged ICU stays, and four had postoperative chest tightness with shortness of breath. Relative to the GA group, the NIVATS group had significantly shorter hospital stay lengths at five days.

1.0K Views.  Second Affiliated Hospital of Zhejiang University School of Medicine.  Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

Summary