Gliding the blade through a breathing space: a non-intubated approach to tracheal and carinal surgery

Surgery involving tracheal or carinal resection presents unique challenges in maintaining effective ventilation and oxygenation. Traditionally, double-lumen endotracheal intubation with cross-field ventilation has been the standard technique for such procedures (1,2). In recent years, however, a novel approach has emerged: non-intubated spontaneous ventilation (NISV) during tracheal or carinal resection surgery.

Dr. He and his team successfully applied this technique, performing tracheal and carinal resections while patients remained spontaneously breathing (3). Their accompanying animation illustrates the resection and reconstruction of the carina in a patient without an endotracheal tube in place (3).

The benefits of this approach are immediately apparent. The absence of an endotracheal tube improves surgical exposure. The elimination of double-lumen tube intubation and cross-field ventilation simplifies airway management. Additionally, spontaneous ventilation (SV) avoids the physiological effects of positive-pressure ventilation on lung mechanics and hemodynamics.

These technical advantages have translated into promising procedural outcomes. In a cohort of 18 patients undergoing either video-assisted thoracoscopic trachea or carina surgery with NISV, the median operative time was notably shorter {162.5 [interquartile range (IQR), 75] min} compared to 14 patients with conventional double-lumen intubation [260 (IQR, 126) min] (4). Oxygenation, measured by lowest intraoperative peripheral capillary oxygen saturation (SpO₂), was comparable between groups {94.2% [standard deviation (SD) 4.9%] vs. 93.9% (SD 4.5%)}. Although the SV group demonstrated higher end-tidal CO₂ [47.7 (SD 4.2) vs. 39.1 (SD 5.7) mmHg], values remained within clinically acceptable limits. Postoperative outcomes, including pain, complications, and hospital length of stay, were also similar. However, due to the small sample size, statistical significance was not assessed.

The concept of non-intubation SV is not entirely new in thoracic surgery. In 2004, Pompeo et al. conducted a randomized trial of NISV thoracoscopic wedge resection, reporting a significantly shorter hospital stay in the NISV group than in the intubation group (2 vs. 3 days, P=0.02) (5). Chen et al. also demonstrated the feasibility of NISV thoracoscopic lobectomy, with comparable operative times and a trend toward shorter postoperative stays (6). Conversion to intubation occurred in 10% of cases in the NISV group, mainly due to hypoxemia, inadequate analgesia, or intraoperative bleeding.

More recently, Dr. He’s group published the largest retrospective comparative study of NISV versus intubated video-assisted thoracoscopic resection for non-small-cell lung cancer, using propensity score matching. Among 136 matched pairs, the NISV group demonstrated shorter postoperative fasting time [6.7 (SD 1.3) hours vs. 12.3 (SD 2.0) hours] and reduced postoperative hospital stay (7.4 vs. 8.6 days; P<0.05) (7). Nine patients in the NISV group required conversion to intubation.

Reports of NISV techniques for tracheal or carinal resection remain limited to case reports and small case series (4,8-13). While this technique shows potential advantages—particularly shorter operative durations—it remains limited by stringent patient selection and the need for significant institutional experience. In Dr. He’s reported cohort, patients selected for NISV were generally healthy (ASA I or II), non-obese [body mass index (BMI) <25 kg/m²], and without anticipated airway difficulties or prolonged surgical duration (4). Such criteria would exclude a substantial proportion of patients in Western populations. Nevertheless, as institutional expertise grows, some of these criteria may be safely relaxed. For example, a BMI threshold of <30 kg/m² has been explored in lung cancer resection using the NISV approach (14).

Recently, Dr. He’s team combined NISV with robotic-assisted thoracoscopic surgery, further expanding the boundaries of this technique (15). In this cohort, total operative times ranged from 5 hours 5 minutes to 9 hours 55 minutes (15). However, such complex procedure place even greater demands on surgical and anesthetic expertise, as well as patient selection, to ensure safety.

Conventional intubation and cross-field ventilation remains the current standard care for tracheal or carinal resection and reconstruction, with a well-established safety profile (16). Nonetheless, in carefully selected patients and at experienced centers, NISV technique may offer benefits such as reduced anastomosis time and shorter postoperative hospital stay. As more institutions adopt this approach and report their outcomes, larger datasets and prospective studies will be crucial in determining the role of NISV in modern thoracic surgery.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-557/prf

Funding: This work was supported by the American Heart Association (No. 23CSA1052735). The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Heart Association.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-557/coif). The authors have no conflicts of interest to declare.

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