Clinical Evaluation of Non-intubated Spontaneous Ventilation Video-Assisted Thoracoscopic Surgery in Patients with Non-Small Cell Lung Cancer and compromised Pulmonary Function: A Propensity Score-Matched Analysis
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XiaodongZheng1
HuiLiu2
GuangjianLiu3
JunzhengZhou1✉Emailxwk2015@126.com
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ShiweiNie1✉YunXu4
WeiminZhang2
Master of Medicine
ChiefPhysician11Thoracic SurgeryAnyang Tumor HospitalNO.1 Huanbin North RoadAnyang CityHenanChina
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Department of AnesthesiologyThe First Affiliated Hospital of Guangzhou Medical UniversityNo. 151, Yanjiang West Road, Yuexiu DistrictGuangzhou CityGuangdong Province3Department of Anesthesiology, Taihe HospitalHubei University of MedicineShiyanHubeiChina
4Department of AnesthesiologyAnyang Tumor HospitalNO.1 Huanbin North RoadAnyang CityHenanChina
Xiaodong Zheng 1#, Hui Liu 2#, Guangjian Liu 3#, Junzheng Zhou 1, Shiwei Nie1, Yun Xu 4, Weimin Zhangz,2,*
All authors state: Clinical trial number not applicable
(1 Thoracic Surgery, Anyang Tumor Hospital, NO.1 Huanbin North Road, Anyang City,Henan, China;
2 Department of Anesthesiology, The First Affiliated Hospital of Guangzhou Medical University, No. 151, Yanjiang West Road, Yuexiu District, Guangzhou City, Guangdong Province;
3Department of Anesthesiology, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China; 4Department of Anesthesiology, Anyang Tumor Hospital, NO.1 Huanbin North Road, Anyang City,Henan, China. )
z,2Xiaodong Zheng,Hui Liu and Guangjian Liu contributed equally to this work.
*Correspondence:Weimin Zhang, Chief Physician, Master of Medicine, E-mail: xwk2015@126.com
Abstract
Objectives
This study was designed to assess the feasibility and safety of non-intubated spontaneous ventilation video-assisted thoracoscopic surgery (VATS) in patients diagnosed with non-small cell lung cancer (NSCLC) and compromised pulmonary function.
Methods
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A retrospective analysis was conducted on a cohort of 162 patients with NSCLC and impaired pulmonary function who underwent either non-intubated video-assisted thoracoscopic surgery (NIVATS, n = 86) or intubated video-assisted thoracoscopic surgery (VATS, n = 76) between January 2021 and May 2025. In the NIVATS group, surgical procedures included 37 lobectomies (48.7%) and 39 segmentectomies or wedge resections (51.3%), whereas the intubated VATS group underwent 46 lobectomies (53.5%) and 40 segmentectomies or wedge resections (46.5%). To control for potential confounding factors, 1:1 propensity score matching (PSM) was performed, resulting in two balanced groups of 62 patients each with comparable baseline characteristics. Short-term surgical outcomes were then compared between the two groups.Results
Following propensity score matching, no statistically significant differences were observed between the non-intubated and intubated VATS groups in terms of surgical duration, anesthesia time, procalcitonin (PCT) levels, or cardiovascular complications. However, significant differences were observed in several postoperative outcomes, including duration of chest tube placement (2.66 ± 3.35 vs. 3.53 ± 2.39 days; p = 0.001), post-anesthesia awakening time (7.98 ± 2.55 vs. 15.69 ± 3.68 minutes; p < 0.001), incidence of hypoxemia and hypercapnia, postoperative bowel function (assessed by time to flatus and defecation), length of hospital stay, incidence of throat discomfort, postoperative pulmonary complications, and patient-reported postoperative satisfaction.
Conclusions
Non-intubated VATS is a feasible and safe alternative to conventional intubated VATS in carefully selected patients with NSCLC and compromised pulmonary function. This technique may facilitate enhanced postoperative recovery and represents a viable management option for specific patient populations.
Keywords:
non-intubated video-assisted thoracoscopic surgery
Non-Small Cell Lung Cancer
Impaired Pulmonary Function
Propensity score matching analysis
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Background
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With the extension of human life expectancy, the proportion of elderly patients diagnosed with lung cancer has been steadily increasing [1]. Video-Assisted Thoracoscopic Surgery (VATS) remains the preferred first-line treatment modality for elderly lung cancer patients seeking curative intervention and long-term survival. Among this population, concomitant respiratory diseases and compromised pulmonary function are frequently observed. During single-lung ventilation utilizing double-lumen endotracheal intubation, there is an elevated risk of ventilator-induced alveolar pressure injury, which may precipitate severe cardiorespiratory complications [2–3]. Moreover, certain non-elderly patients with impaired pulmonary function—including those with comorbid chronic obstructive pulmonary disease (COPD), emphysema, interstitial pneumonia, or those requiring contralateral reoperation following unilateral lobectomy—may also be precluded from surgical treatment due to their inability to tolerate one-lung ventilation [4].With the widespread adoption of the enhanced recovery after surgery (ERAS) concept, the anesthesia technique of maintaining spontaneous breathing without tracheal intubation—referred to as "Tubeless" anesthesia—has been increasingly implemented in clinical practice across China. Accumulating evidence indicates that Tubeless anesthesia, when combined with video-assisted thoracoscopic surgery (VATS) for lung resection, demonstrates favorable safety and reliability. This approach can significantly reduce airway injuries caused by tracheal intubation, barotrauma associated with one-lung ventilation, and a range of adverse events linked to general anesthetic agents, such as sedatives, opioids, and muscle relaxants. These adverse effects include postoperative nausea and vomiting, delayed emergence from anesthesia, residual neuromuscular blockade, difficulty with extubation, and the risk of gastroesophageal reflux with subsequent aspiration. As a result, Tubeless anesthesia may facilitate faster postoperative recovery [5–7]. However, due to potential intraoperative risks associated with this technique—including persistent hypoxemia, hypercapnia, aspiration pneumonia, and an increased likelihood of intraoperative bleeding caused by mediastinal shift or enhanced diaphragmatic movement—its precise clinical benefits and optimal indications remain subjects of ongoing debate within the medical community [8].
Currently, the application of Tubeless anesthesia technology in lung cancer patients with poor pulmonary function remains an area yet to be fully elucidated, and its clinical benefits remain ambiguous. In this study, a prospective controlled trial was conducted to investigate the feasibility and safety of Tubeless anesthesia in combination with video - assisted thoracoscopic surgery (VATS) for treating non - small cell lung cancer (NSCLC) patients with poor pulmonary function. The aim was to broaden the scope of indications and surgical criteria for lung resection.
Methods
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This clinical study was conducted in the Anyang Tumor Hospital, approved by our Institutional Ethical Board (NO.2025KY05H01). A
This study was conducted in accordance with the Declaration of Helsinki (October 2013) and clinical practice guidelines. A
Informed consent was obtained from all subjects involved in the study.Participants
This study consecutively recruited 162 patients who underwent Single-incision thoracoscopic radical resection of lung cancer from January 2021 to March 2025. The main inclusion criteria were as follow: those American Society of Anesthesiologists (ASA) physical status I–III, and those with Inclusion Criteria for Patients with Compromised Pulmonary Function Referencing the Chinese Expert Consensus on the Diagnostic Criteria of Adult Pulmonary Function [9] and the international GOLD diagnostic criteria [10], patients with compromised pulmonary function should meet two of the following criteria (Criterion *1) is mandatory): *1).(I) Exercise Function Testing: A walking distance of less than 400 m or a stair - climbing height of less than 22 m, with a GOLD classification of 2–4.(II) FEV₁/FVC% ≤ 70%.(III) FEV₁ ≤ 1.6 L.(IV) Pre - operative blood gas analysis showing PaO₂ ≤ 80 mmHg or PaCO₂ ≥ 45 mmHg; 2).Patients with pathologically confirmed non - small cell lung cancer (NSCLC) after surgery; 3)Tumor diameter ≤ 4 cm; 4)Eastern Cooperative Oncology Group (ECOG) performance status ≤ 1; 5)Absence of severe arrhythmias, such as atrial fibrillation and frequent premature ventricular contractions; 6)Absence of severe cardiac insufficiency.
The exclusion criteria were as follows: Patients with hemodynamic instability;those with a PaCO₂≥50 mmHg after the improvement of pulmonary function; those with dense pleural adhesions. Those currently using at the clinical stage N2; those with an American Society of Anesthesiologists (ASA) physical status classification of ≥ 4; those with an estimated operative time exceeding 3 hours; those with contraindications to epidural anesthesia, such as abnormal coagulation function or spinal deformity, epidural anesthesia is contraindicated; patients whose anesthesia method is converted from tubeless to tracheal intubation during the operation.
Anesthesia and surgical procedures
In the NIVATS group, all patients underwent thoracoscopic surgery under a nonintubated anesthetic regimen utilizing the three-portal approach, as previously described. A subset of patients received a target-controlled infusion of propofol (2–4 µg/mL) and remifentanil (1–3 ng/mL), along with intravenous dexmedetomidine (0.5–1 µg/kg/h). The depth of anesthesia was maintained with a bispectral index value between 40 and 60. A laryngeal mask airway (LMA) was inserted upon loss of consciousness, and end-tidal carbon dioxide partial pressure (PETCO₂) was continuously monitored using capnography. The remaining patients received epidural anesthesia via catheter placement at the T6–T7 or T7–T8 interspace. Anesthesia was maintained with 0.375% ropivacaine, with the sensory block level adjusted to between the second and tenth intercostal nerves. All patients received standard intraoperative monitoring; however, PETCO₂ monitoring was not performed in those receiving epidural anesthesia. Arterial catheterization was employed for continuous blood pressure monitoring and arterial blood gas analysis when SpO₂ was ≤ 93%. Central venous catheterization was performed based on the specific surgical requirements and patient condition. During the operation, oxygen was administered at a flow rate of 3–5 L/min with an FiO₂ of 100%. Following the completion of the main surgical procedures—defined as resection of the lung lesion, lymph node dissection, and pleural lavage—synchronous intermittent mandatory ventilation (SIMV) was initiated to facilitate carbon dioxide elimination. Dopamine or norepinephrine was administered to maintain a mean arterial pressure (MAP) greater than 60 mmHg. Upon completion of surgery, patients were transferred to the Postanesthesia Care Unit (PACU) for removal of the laryngeal mask airway (LMA) or epidural catheter. All patients received self-controlled intravenous analgesia postoperatively and were subsequently transferred to either the Intensive Care Unit (ICU) or General Ward based on their clinical condition.
In the VATS group, a Mallinckrodt double-lumen endobronchial tube was inserted with the assistance of cisatracurium, followed by the initiation of one-lung ventilation. A protective ventilation strategy was employed to maintain adequate oxygenation, consisting of low tidal volumes (5–6 mL/kg) and an extended expiratory phase.
Surgical Procedure
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The thoracoscopic procedures were similar in NIVATS and VATS groups, which followed the consensus guidelines of the American Association for Thoracic Surgery (AATS). The patient was placed in a full lateral decubitus position. The surgical procedure for each patient was determined according to the stage and location of the lesion in computed tomography images. Anatomical resection includes radical resection of lung cancer and segmental resection; Non-anatomical resection includes lung wedge resection, bullae resection, and lung volume reduction surgery.Outcomes Measures
The primary outcomes were complications associated with anesthesia, duration of surgery, duration of anesthesia, and post-operative pulmonary complications. Our secondary outcomes included intraoperative blood loss volume, the emergence time following anesthesia, the time to first ambulation after surgery.
Statistical analysis
Continuous data were assessed for skewness by using the Shapiro–Wilk test and were expressed as mean ± standard deviation (SD) or median (IQR). Categorical variables were presented as the number (%). Numerical variables were analyzed using independent samples t-test or Mann–Whitney U test. Categorical variables were compared using Pearson χ2 test or Fisher’s exact test. Generalized linear models were used to compare the intensity of POST between the group B and group T.Univariate analysis using logistic regression was performed to calculate the predictors of POST as odds ratios (ORs) with 95% confdence intervals (CIs). If these variables yielded P < 0.1, they were incorporated into the subsequent multivariate adjusted ordinal logistic regression analysis. P < 0.05 was considered as statistically signifcant. IBM SPSS Statistics (version. 23.0, IBM Corp, Armonk, NY. USA) and R package (version: 4.3.1) was used for the statistical analysis.
Results
In total, 162 patients were screened from January 2021 to March 2025 in this study. Among them, 38 patients did not meet the inclusion criteria, 124 patients refused to participate this study. Finally, 124 patients were randomly assigned to the NIVATS group (n = 62) and the VATS group (n = 62) (Fig. 1).
Prior to the matching analysis, statistically significant differences were identified between the two patient groups in terms of surgical approach and pTNM staging.A 1:1 propensity score matching was then performed based on the following baseline variables: gender, age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, surgical approach, and TNM staging. Following the matching process, 62 patients were included in both the non-tracheal intubation group and the conventional tracheal intubation group. After matching, no statistically significant differences were found between the two groups with respect to gender, age, smoking history, BMI, ASA score, cardiopulmonary comorbidities, pathological type, surgical approach, or TNM staging. This demonstrates a high degree of intergroup comparability, thereby strengthening the validity and reliability of the subsequent comparative analysis. (Table 1).
Perioperative Anesthetic and Surgical Rehabilitation-Related Indicators
Following propensity score matching, no statistically significant differences were observed between the NIVATS group and the VATS group in terms of operative time, anesthesia duration, and cardiovascular complications. However, the NIVATS group demonstrated superior outcomes in several postoperative and intraoperative parameters, including a lower incidence of intraoperative hypoxemia, shorter postoperative anesthesia emergence time, earlier time to first ambulation, shorter postoperative hospital length of stay, reduced incidence of throat discomfort, higher postoperative patient satisfaction, and pulmonary complications. All these differences were statistically significant. Moreover, the NIVATS group exhibited a higher incidence of hypercapnia compared to the VATS group.(Table 2).
VATS (n = 62) | NIVATS (n = 62) | Standardized differences | |
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Duration of anaesthesia, mins | 142.90 ± 54.59 | 129.79 ± 41.52 | 0.135 |
Duration of tourniquet, mins | 123.48 ± 55.55 | 115.13 ± 41.66 | 0.345 |
Time to anesthetic emergence, mins | 15.69 ± 3.68 | 7.98 ± 2.55 | <0.001 |
The restoration of bowel function following surgery, hours | 21.35 ± 6.26 | 30.48 ± 7.02 | <0.001 |
Duration of chest tube placement, days | 3.53 ± 2.39 | 2.66 ± 3.35 | 0.001* |
Postoperative Length of Stay,days | 7.38 ± 2.69 | 6.00 ± 3.10 | 0.009 |
CRP on postoperative day 1, mg/L | 95.95 ± 80.73 | 60.50 ± 34.18 | 0.001 |
Procalcitonin(PCT), ng/mL | 0.53 ± 0.74 | 0.36 ± 0.59 | 0.334* |
QOR-15 score # | 117.39 ± 7.22 | 125.97 ± 5.57 | <0.001 |
| Abbreviations:CRP, C-reactive protein, *Rank-sum test; #Score on the third day post-operation | |||
Analysis of Perioperative Complications
Regarding intraoperative complications, the incidence of hypoxemia necessitating intervention was 17.7% in the NIVATS group, significantly lower than the 38.7% observed in the VATS group. On the contrary, the incidence of hypercapnia necessitating requiring was 33.9% in the NIVATS group, significantly higher than the 17.7% observed in the VATS group. Moreover, the incidence of tracheal intubation-related complications (including hoarseness and pharyngeal pain) and pulmonary complications was also significantly reduced in the NIVATS group compared to the VATS group, with a statistically significant difference. Despite being associated with a lower overall incidence of cardiovascular complications compared to the VATS group, the NIVATS group did not demonstrate a statistically significant difference.(Table 3).
Before propensity score matching | After propensity score matching | |||||
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VATS (n = 86) | NIVATS (n = 76) | Standardized differences | VATS (n = 62) | NIVATS (n = 62) | Standardized differences | |
Age, years | 69.64 ± 6.42 | 68.24 ± 6.96 | 0.184 | 69.95 ± 6.66 | 69.47 ± 6.00 | 0.672 |
Sex, male,n (%) | 51(59.3) | 41(53.9) | 0.492 | 33() | 36() | 0.588 |
BMI, kg/m2 | 23.10 ± 2.48 | 23.45 ± 2.42 | 0.354 | 23.34 ± 2.35 | 23.48 ± 2.28 | 0.728 |
ASA physical status,n (%) | 0.118 | 0.183 | ||||
Ⅰ | 19(22.1) | 27(35.6) | 14(17.9) | 17(14.3) | 0.581 | |
Ⅱ | 63(73.2) | 44(57.8) | 45(78.6) | 40(83.9) | ||
Ⅲ | 4(4.7) | 5(6.6) | 3(3.5) | 5(1.8) | ||
Smoking, n (%) | 36(41.9) | 30(39.5) | 0.758 | 26(58.9) | 27(62.5) | 0.856 |
pTNM staging system,n (%) | 0.440 | 0.803 | ||||
Ⅰ | 75(87.2) | 63(82.9) | 52(92.9) | 53(92.9) | ||
Ⅱ-Ⅲ | 11(12.8) | 13(17.1) | 10(7.1) | 9(7.1) | ||
surgical procedure,n (%) | 0.542 | 0.719 | ||||
Pulmonary lobectomy | 46(53.5) | 37(48.7) | 31(55.4) | 33(53.6) | ||
Lung partial resection | 40(46.5) | 39(51.3) | 31(44.6) | 29(46.4) | ||
Histopathological type | 0.959 | 0.287 | ||||
Adenocarcinoma | 75(87.2) | 67(88.2) | 54(91.1) | 54(83.9) | 0.815 | |
Squamous carcinoma | 9(10.5) | 7(9.2) | 6() | 7(12.5) | ||
others | 2(2.3) | 2(2.6) | 2(0) | 1(3.6) | ||
NIVATS (n = 62) | VATS (n = 62) | Standardized differences | |
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Pulmonary complications | |||
Pulmonary infection ,n (%) | 3(4.8) | 12(19.4) | 0.013 |
Pneumothorax after surgery n(%) | 3(4.8) | 11(17.7) | 0.023 |
Complications associated with anesthesia | |||
Hypercapnia,n(%) | 21(33.9) | 11(17.7) | 0.040 |
Hypoxemian,n(%) | 11(17.7) | 24(38.7) | 0.009 |
Pharyngolaryngeal pain,n(%) | 11(17.7) | 27(43.5) | 0.002 |
Cardiovascular complications | 0.284 | ||
Arrhythmia,n(%) | 3(4.8) | 5(8.1) | |
Pulmonary embolism,n(%) | 0(0) | 1(1.6) | |
Cardiac dysfunction,n(%) | 3(4.8) | 4(6.5) | |
| Discussion | |||
| For patients with early-stage (stage I) lung cancer and poor pulmonary function, surgery remains the first-line treatment strategy for achieving radical resection. Even when partial lobectomy (such as wedge resection or segmentectomy) is performed, as long as the resection margin is maintained at ≥ 2 cm, a therapeutic outcome comparable to that of radical surgery can be achieved. Compared with non-surgical treatment options, surgical treatment can significantly improve the long-term prognosis of patients [11–12]. In lung cancer patients with relatively poor pulmonary function, various anesthesia - related complications are more prone to occur during tracheal intubation and one - lung ventilation. These complications include ventilator - associated barotrauma, physical airway injuries caused by tracheal intubation, hypoxemia resulting from ventilation - perfusion (V/Q) mismatch, and lung ischemia - reperfusion injury, etc[13 – 14]. Many scholars hold the view that TUBELESS anesthesia, by combining epidural anesthesia with intrathoracic vagal nerve block and supplemented with appropriate sedation, enables bilateral lung ventilation on the premise of preserving the patient's spontaneous respiration. This can significantly reduce the incidence of anesthesia-related adverse reactions, cardiopulmonary complications, and the intensity of postoperative stress responses [5 – 7]. | |||
| The primary intraoperative risks associated with non - tracheal intubation anesthesia encompass hypoxemia and hypercapnia [15]. Secondary risks include intraoperative hemorrhage [5], mediastinal flutter [16], hemodynamic instability [5][8]. Among those, hypoxemia and hypercapnia are the clinical concerns that draw the greatest attention from anesthesiologists and thoracic surgeons. In this study, patients in both groups were supplied with 100% pure oxygen inhalation (FiO₂=1.0). The results indicated that the incidence of hypoxemia necessitating clinical intervention in the non - tracheal intubation group was lower than that in the tracheal intubation group. Potential contributing factors are as follows:Firstly, during spontaneous respiration, the active expansion of the thoracic cage facilitates the maintenance of the patency of bronchioles and alveoli, thereby augmenting the effective pulmonary oxygenation area. Conversely, under non - spontaneous respiration conditions, a significant portion of the inhaled oxygen remains outside the alveoli. Moreover, the ventilator has to overcome the elastic resistance of the thoracic cage, which reduces the oxygenation efficiency. Secondly, patients with impaired lung function inherently have limited oxygenation capabilities. As such, single - lung ventilation struggles to meet the oxygenation requirements of the body. Furthermore, the incidence of carbon dioxide retention that necessitated intervention in the non - tracheal intubation group was higher than that in the tracheal intubation group. It is hypothesized that this could be attributed to impaired ventilation function. | |||
| During the intraoperative period, the incidences of arrhythmia and abnormal blood pressure in the non - intubation group were higher than those in the intubation group. It is hypothesized that this could be attributed to the relatively shallow depth of anesthesia under the state of spontaneous respiration, rendering patients more sensitive to external cardiac stimuli. Nevertheless, the difference did not reach statistical significance. Throughout the anesthesia process, no life - threatening anesthesia - related adverse events occurred in either group of patients. Existing research has demonstrated that the administration of high - flow and high - concentration oxygen (FiO₂) during one - lung ventilation may give rise to an increase in reactive oxygen species, consequently inducing lung injury [17]. Conversely, maintaining a moderately elevated end - tidal carbon dioxide partial pressure can significantly enhance local cerebral oxygen saturation and contribute to the improvement of early postoperative cognitive function [18]. Research findings indicate that the incidence of intraoperative conversion to tracheal intubation ranges from 2.8% to 11% [7][9][19]. Intraoperative hemorrhage, one of the prevalent intraoperative complications, is regarded as a significant contributing factor to conversion to thoracotomy. | |||
| The common causes of intraoperative bleeding during TUBELESS surgery encompass vascular lacerations that occur as a result of cough reflexes or mediastinal oscillations while managing crucial blood vessels. The authors postulate that the judicious administration of muscle relaxants prior to the transection of key blood vessels and lymph node dissection not only does not augment the anesthesia - related risks but can also significantly mitigate the incidence of cough reflexes and mediastinal oscillations, thereby diminishing the risk of intraoperative bleeding. Furthermore, stringent case selection is of utmost importance. For patients with an anticipated operative duration exceeding three hours, preoperative carbon dioxide retention, copious sputum production, or a body mass index (BMI) greater than 30kg/m², the risks associated with TUBELESS surgery are substantially elevated, necessitating a cautious approach to patient selection [11]. In their clinical practice, the authors have established a BMI inclusion criterion of ≤ 27kg/m² for TUBELESS anesthesia. With the ongoing advancements in non-tracheal intubation anesthesia techniques, the majority of the aforementioned risks can be effectively circumvented or substantially mitigated through appropriate interventions [16][19]. | |||
| The findings of this study indicate that the incidence of cardiopulmonary complications following TUBELESS surgery is lower than that of the tracheal intubation group. However, the difference does not reach a statistically significant level, potentially attributable to the relatively small sample size. Thus, further investigations with a larger sample size are warranted for confirmation. Patients with impaired pulmonary function are particularly vulnerable to ventilator-associated barotrauma. These patients exhibit a higher incidence of postoperative pulmonary air leakage, and the duration of thoracic tube placement is notably longer compared to those in the non-tracheal intubation group. Additionally, an extended duration of thoracic tube placement may trigger aseptic inflammatory exudation and stress responses, consequently increasing the volume of postoperative thoracic drainage [5][20]. The non-tracheal intubation group, characterized by a reduced consumption of opioids and muscle relaxants, demonstrates a marked superiority over the tracheal intubation group in terms of the time to early postoperative mobilization and the recovery of gastrointestinal function. The results of this study align with numerous published reports [5][20–21]. Notably, in elderly patients, the benefits of non-intubation anesthesia are even more pronounced [2–3]. These results suggest that non-intubation anesthesia techniques hold promise in facilitating rapid postoperative recovery among patients with compromised lung function. Postoperative sore throat is a crucial factor influencing patients' satisfaction with anesthesia. Previous research has revealed that approximately 10% to 43.3% of patients who underwent double-lumen tracheal intubation experienced sore throat within 24 hours postoperatively [22]. Even in cases of single-lumen tracheal intubation, the incidence remains as high as 57.5% [23]. The results of the present study demonstrate that non-intubation anesthesia techniques can effectively reduce the incidence of postoperative sore throat and hoarseness, thereby enhancing patients' postoperative satisfaction. In addition, in the event of life - threatening hypoxemia, hypercapnia, massive hemorrhage, hemodynamic instability, or severe mediastinal oscillations that compromise surgical safety during the operation, prompt conversion to tracheal intubation and the implementation of ventilator - assisted ventilation are not only essential but also highly advisable measures [16]. | |||
| Although non-intubated anesthesia techniques demonstrate certain advantages in reducing perioperative complications and promoting rapid postoperative recovery, their clinical application remains controversial, particularly concerning surgical safety and the efficacy of oncological radical treatment[8][24]. Alghamdi[8] reported that during non-intubated anesthesia, bilateral lung ventilation may restrict surgical field exposure, potentially triggering a pronounced cough reflex during mediastinal lymph node dissection and thereby compromising the completeness of dissection. A study focusing on patients aged 75 years and older found that the number of dissected lymph nodes was lower in the non-intubated group compared to the intubated group. however, no significant difference in long-term survival rates was observed [2]. Moreover, some scholars contend that there is no substantial difference in the completeness of mediastinal lymph node dissection between non-tracheal intubation and tracheal intubation techniques [5][7]. Another perspective posits that non-intubated anesthesia may reduce surgical trauma and preserve immune function, thereby enhancing postoperative quality of life and potentially exerting a favorable impact on long-term survival. Certain studies indicate that the three-year survival rate for patients undergoing non-intubated anesthesia surpasses that of those receiving tracheal intubation anesthesia [25]. However, This conclusion is derived from small-sample retrospective analyses and requires further validation through high-quality prospective studies. | |||
| Regarding tumor resection extent, this study strictly adhered to the principles of radical oncological resection based on lesion characteristics. Three surgical approaches—lobectomy, segmentectomy, and wedge resection—were employed. For subsolid nodules smaller than 2 cm, the rate of mediastinal lymph node metastasis is relatively low; thus, the number of dissected lymph nodes has limited impact on long-term survival. Evidence also suggests that wedge resection can achieve comparable long-term survival outcomes when compared to anatomical resection [4][11]. | |||
| The data from this study indicate no significant differences between the non-tracheally intubated and tracheally intubated groups concerning both the total number of dissected lymph nodes and the number of involved lymph node stations. Furthermore, no severe adverse events such as massive hemorrhage (≥ 1000 ml) or intraoperative mortality were observed. Regarding differences in long-term survival rates, continued follow-up will be necessary for comprehensive evaluation. | |||
| Limitation | |||
| First, there is considerable heterogeneity in the diagnostic criteria for low pulmonary function and the inclusion criteria, and a universally recognized standardized framework is still lacking.Second, this study is a single-center investigation with a limited sample size, which may affect the generalizability of the findings.Third, the clinical benefits observed in patients with low pulmonary function remain to be validated by long-term postoperative survival data from systematic follow-up. | |||
| Conclusion | |||
| Non-intubated anesthesia combined with video-assisted thoracoscopic surgery (VATS) for the treatment of patients with non-small cell lung cancer (NSCLC) and impaired pulmonary function demonstrates favorable safety and feasibility. This approach can effectively reduce the incidence of postoperative complications and promote rapid postoperative recovery. However, the successful application of this strategy depends on close collaboration between experienced anesthesiologists and thoracic surgeons. Preoperatively, strict patient selection based on surgical indications is required, along with the formulation of individualized anesthetic and surgical plans and the preparation of appropriate emergency protocols. Intraoperatively, continuous monitoring of cardiorespiratory parameters is essential, and conversion to tracheal intubation anesthesia should be promptly performed when clinically indicated to ensure patient safety. | |||
Fig. 1
The fowchart of the study
Note
Data are presented as mean ± SD, median (interquartile range), or number of patients (%).
Abbreviations
BMI, body mass index; ASA, American Society of Anesthesiologists; pTNM, Pathologic Tumor Node Metastasis
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Funding
This work was supported by Joint Construction Program of Henan Province [LHGJ20240527].
Competing interests
The authors declare no competing interests.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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Author Contribution
Author ContributionsXiaodong Zheng: Conceptualization, Methodology, Investigation, Formal analysis, Writing - Original Draft.Hui Liu: Review & Editing.Guangjian Liu: Resources, Investigation.Junzheng Zhou: Supervision, Project administration.Shiwei Nie: Writing - Software, Validation, Data Curation, Visualization.Yun Xu：Data Curation，Formal analysis.Corresponding Author Weimin Zhang: Conceptualization, Supervision, Writing - Review & Editing, Funding acquisition.All authors have read and agreed to the published version of the manuscript.Xiaodong Zheng,Hui Liu and Guangjian Liu contributed equally to this work.
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