Role, benefits and limitations of non-intubated anesthesia in thoracic surgery
Non-intubated video-assisted thoracoscopic surgery (NIVATS) is rapid growing in recent decades. Firstly the rationale of NIVATS was focused on avoidance of the adverse effects of excessively deep anesthesia, tracheal intubation, controlled ventilation, and residual muscle relaxation, particularly in patients with chronic respiratory failure or other comorbidity. Because NIVATS was proven feasible and safe with superior outcomes and lower costs, it has been increasingly advocated as an alternative for patients with a low risk for GA and the use of conventional lung separation devices. Anesthesia for NIVATS is considered on the basis of active protection rather than conventional safety. The role of anesthesia in NIVATS is to combine different systemic anesthetics and variable regional anesthesia with the goals to precisely manage airway and breathing, sedation or anesthesia, intraoperative and postoperative analgesia, stabilizing hemodynamics, and intraoperative cough control. By close cooperation between surgeons and anesthesiologists, the benefits of NIVATS include enhancing recovery with improved analgesia, reduced chest drainage, early oral intake, early ambulation, and potentially less stress and inflammatory responses associated with operations. However, there are still limitations on anesthesia for NIVATS such as excessive respiratory and mediastinal movement after artificial pneumothorax, and the complexity and difficulty of performing operations. As NIVATS is still developing to apply on variable patients and operations, the costs and benefits of different combinations on anesthesia for NIVATS should be carefully assessed.