Application Of Non-intubated Anesthesia With Spontaneous Breathing In Video-assisted Thoracoscopic Partial Lung Resections

PartⅠ:Review on application of non-intubated anesthesia in video-assisted thoracoscopic surgery for partial lung resectionsNon-intubated with spontaneous breathing general anesthesia for video-assisted thoracic surgery（VATS）refers to the patients achieved the thoracoscopic surgery without the use of airway devices,while maintaining spontaneous breathing,supplemented by regional anesthesia,vein sedation and analgesics.This is a controversial topic in thoracic anesthesia in recent years.The main points of the debate were mainly on its feasibility,safety,indications and whether it could improve patients’recent or long-term prognosis.This is a review about the progress of non-intubated general anesthesia with spontaneous breathing applied to VATS for lung resection in recent years.PartⅡ:Non-intubated versus intubated general anesthesia for video-assisted thoracoscopic surgery:a prospective,randomized,controlled trialBackground:Retrospective observational studies indicated non-intubated general anesthesia could promote recovery and reduce postoperative complications in patients receiving video-assisted thoracoscopic lung surgery（VATS）.We conducted a randomized controlled trial to compare the rate of airway injury in patients receiving VATS under intubated vs.non-intubated general anesthesia.Methods:This prospective,randomized,controlled trial included the patients who underwent elective thoracoscopic lung resection from September 2018 to September2019.The randomized numbers were generated from computer program and were randomly assigned to the non-intubated general anesthesia for VATS group（NIVATS）and general anesthesia with double-lumen endobronchial tube for VATS group（GAVATS）.Patients and followers were blinded to this study.Standard anesthesia protocol was followed.Clinical trial registration:Chi CTR1800018198.The primary outcome was the incidence of glottic injury.The secondary outcomes included the incidence of postoperative sore throat（POST）;hoarseness;perioperative respiratory adverse events,such as cough,laryngospasm or bronchospasm（defined as requiring positive pressure ventilation>20cm H₂O or deep muscle relaxation）,hypoxemia（defined as Sp O₂ less than 90%for more than 10 seconds）,high carbon dioxide state（defined as end-expiratory CO₂≥60mm Hg for more than 10 seconds）;the determination of lung injury-related markers（Heparan Sulfate and Human Syndecan-1）and postoperative pulmonary complications（These complications included severe hypoxemia,bronchospasm,suspected pulmonary infection,respiratory failure,atelectasis,pleural effusion,pneumothorax and aspiration pneumonia）.It also included other clinical and postoperative recovery indicators.Result:After screening 277 patients from the same surgical team who underwent thoracoscopic lung resection.57 patients were excluded,220 eligible patients were randomized with 1:1（110 patients in each group）and 187 completed the analysis（109patients in NIVATS group,108 patients in GAVATS group）.The rate of glottal injury was 9.2%（10/109）in the NIVATS group versus 37.0%（40/108）in the GAVATS group（relative risk[RR]:0.25;95%confidence interval[CI]:0.13-0.47;P<0.01）.The NIVATS group also had lower rate of postoperative sore throat（8.3%vs 38.9%;RR:0.21;95%CI:0.11-0.41,P<0.01）and hoarseness（2.8%vs 19.4%;RR:0.14;95%CI:0.04-0.46;P<0.01）.Postoperative cough score and pulmonary complications did not differ between the groups.Compared with patients in GAVATS group,those in NIVATS group developed lower pain score,earlier motor recovery,improved quality of life score and satisfaction degree（P<0.05）.Conclusion:With the cooperation of multiple teams,it is safe and feasible to perform thoracoscopic partial lung resection with non-intubated anesthesia for specific patients.It could reduce the rate of airway injury and postoperative pain,accelerate postoperative recovery,and improve patient satisfaction.Because of the disadvantages of NIVATS,anesthesiologists needed to weigh the pros and cons and choose the appropriate anesthesia strategy for specific population and surgery.Part Ⅲ: Prediction model of poor mediastinal motion during thoracoscopic surgery with non-intubated general anesthesia:model establishment and internal verification Background: Poor mediastinal motion is the most common unstable factor in nonintubated surgery and often affects the surgeons’ delicate operation.The purpose of this study was to analyse related factors and establish a predictive model for assessing the risk of poor mediastinal swings in patients during non-intubated surgery.Methods: A consecutive series of patients who underwent thoracoscopic lung resections from January 2017 to August 2019 in the Shanghai Chest Hospital were included to develop a prediction model（prospective collection and retrospective analysis）.Outcome variable: whether there was poor mediastinal movement during the operation（as assessed by the same group of surgeons）.Multivariable logistic regression analysis was applied to build a prediction model.The C-index or the area under the curve was used to judge the discrimination.The calibration plots verified consistency.Internal validation of the model was conducted.Result: A total of 148 patients were included in the study.The incidence of mediastinal swing during the operation was 20.95%（31/148 cases）.The factors included in the predictive nomogram included: age,gender,body mass index,whether it used intrathoracic vagal blockade and ventilation function.Among them,age（the best cut off 56 y,odds ratio [OR] 3.94;95% confidence interval [95% CI] 1.39-11.86;P =0.01）,gender（Female,OR,0.13;95% CI,0.04-0.40;P <0.01）and whether it used intrathoracic vagal blockade（Yes,OR,0.02;95% CI,0.00-0.15;P <0.01）wereindependent risk factors.The model has good consistency and discrimination（C-index = 0.84;95% CI,0.77-0.91）.It still has good discrimination after internal verification（C-index=0.80）.Conclusion: We have established and validated a novel nomogram that can be used to predict the probability of poor mediastinal motion during surgery for patients undergoing thoracoscopic surgery with non-intubated general anesthesia,providing clinical evidence to help clinicians to choose a suitable anesthetic for different patients.