Electronic patient-reported outcomes for outpatient care after non-intubated thoracic surgery in early-stage lung cancer

Introduction

Minimally invasive thoracic surgery (MITS) has substantially improved postoperative recovery in patients with early-stage lung cancer, offering reduced surgical trauma, faster convalescence, and fewer complications compared to open procedures (1). Traditionally, MITS relies on double-lumen endotracheal tube (DLT) and positive-pressure ventilation to maintain optimal surgical exposure and airway control (2). However, this technique is associated with potential risks, including ventilator-induced lung injury, airway trauma, and postoperative symptoms such as sore throat, cough, and, in rare cases, tracheal stenosis (3).

To mitigate these drawbacks, non-intubated thoracic surgery (NITS), performed under spontaneous ventilation without endotracheal intubation, has emerged as a promising alternative. Accumulating evidence suggests that NITS can shorten hospital stays, reduce postoperative complications, and improve intraoperative oxygenation without compromising surgical safety (4,5).

Despite these advantages, existing research on NITS remains largely physician-centered, emphasizing intraoperative physiological parameters while underreporting subjective, patient-centered outcomes such as pain, fatigue, and functional recovery (6,7). In particular, long-term symptom trajectories and outpatient experiences remain insufficiently explored due to limited follow-up and the absence of sensitive assessment tools (8).

From a nursing perspective, NITS presents both opportunities and challenges. The avoidance of intubation shifts greater responsibility to nursing teams for managing spontaneous respiration, pain, early mobilization, and psychological support (9). Additionally, the trend toward accelerated discharge in NITS heightens the need for structured, individualized follow-up strategies. Traditional nursing assessments—based on periodic clinical evaluations and passive symptom reporting—are often inadequate for capturing early fluctuations in recovery or preclinical signs of complications (10).

Electronic patient-reported outcomes (ePROs) represent an emerging solution to these limitations (11). Delivered through mobile or web-based platforms, ePROs enable patients to self-report symptoms such as pain, dyspnea, sleep disturbance, and fatigue in real time. This facilitates continuous, multidimensional monitoring of recovery and enables timely, nurse-led interventions (12). Furthermore, ePROs support a paradigm shift from reactive to predictive nursing care by enhancing communication between patients and care teams (13).

To date, there is a paucity of research evaluating the systematic integration of ePROs into perioperative care pathways for NITS. The present prospective, single-center cohort study addresses this gap by embedding ePRO surveillance throughout the inpatient and outpatient phases of recovery. Our primary objective was to assess whether ePROs enhance symptom management and functional recovery in patients undergoing NITS. By foregrounding the nursing perspective, we aim to provide empirical evidence for a digitally enabled, patient-centered model of thoracic perioperative care. We present this article in accordance with the TREND reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1270/rc).

Methods

Study design and participants

This prospective, single-center, non-randomized observational cohort study was conducted at the National Center for Respiratory Medicine/First Affiliated Hospital of Guangzhou Medical University between March 10 and December 27, 2023. The study compared postoperative recovery and symptom trajectories in patients undergoing NITS versus those receiving DLT surgery.

Eligible participants met the following criteria: (I) radiographically confirmed, resectable early-stage lung cancer; (II) age between 18 and 75 years; (III) absence of severe cardiopulmonary dysfunction or systemic illness likely to compromise perioperative safety (e.g., uncontrolled hypertension, diabetes mellitus, or coronary artery disease); and (IV) provision of written informed consent.

The study protocol was approved by the Institutional Ethics Committee of the National Center for Respiratory Medicine/First Affiliated Hospital of Guangzhou Medical University (approval No. ES-2024-073-02) and was prospectively registered on ClinicalTrials.gov (identifier: NCT06118229). Quarterly audits were conducted to ensure data integrity and safeguard participant rights. All patients provided written informed consent prior to their inclusion in the study. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Surgical and anaesthetic procedures

The allocation to the NITS or DLT group was performed consecutively based on surgeon preference, preoperative feasibility, and patient consent.

NITS Group (Group I): Patients in the intervention group underwent uniportal video-assisted thoracoscopic lobectomy or sublobar resection without endotracheal intubation, following the standardized NITS protocol (14). Anesthesia was achieved via local infiltration with lidocaine at the incision site, intercostal and vagus nerve blocks, and intravenous propofol combined with low-dose fentanyl for conscious sedation. No epidural anesthesia was administered in either group. A single 3–4 cm incision was made for thoracoscopic access. Throughout the procedure, patients maintained spontaneous ventilation, and non-invasive monitoring was used to track oxygen saturation, heart rate, blood pressure, and respiratory rate. After surgery, patients recovered in the post-anesthesia care unit (PACU) and were transferred to the ward once they were fully awake and hemodynamically stable.

DLT Group (Group C): Patients in the control group underwent standard thoracoscopic resection under general anesthesia with double-lumen endotracheal intubation. Anesthesia induction included midazolam, fentanyl, and propofol, followed by insertion of a left-sided double-lumen tube and mechanical ventilation in volume-controlled mode. Anesthetic maintenance was achieved using sevoflurane and propofol. The surgical approach mirrored that used in the NITS group. Postoperative care in the PACU and general ward followed institutional protocols.

Peri-operative nursing protocols

Both groups received evidence-based perioperative nursing care. In the NITS group, nursing interventions emphasized preoperative education on spontaneous breathing techniques, coached respiratory exercises, and psychological support. Intraoperatively, nurses coordinated closely with anesthesiologists to monitor oxygenation and ventilation. Postoperative care prioritized multimodal analgesia, assisted coughing, early ambulation, and daily collection of ePROs, as previously described (13). Key components of the enhanced respiratory support and patient education were demonstrated in Video S1, which included coached breathing exercises and assisted coughing techniques.

In the DLT group, preoperative education focused on intubation and postoperative airway clearance strategies. Postoperative nursing interventions included analgesia titration, respiratory physiotherapy, and routine vital signs monitoring. In both groups, structured nursing assessments were conducted daily during hospitalization, with telephone or in-person follow-up on postoperative day 7 (POD7) and 30 (POD30).

Outcomes and data collection

The primary endpoint was the trajectory of ePROs—pain, cough, dyspnea, sleep disturbance, fatigue, somnolence, distress, impaired ambulation, and limitations in activities of daily living—captured with a Chinese-validated ePRO tool adapted from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and its lung cancer module (QLQ-LC13), as previously described and validated (13). During admission, patients completed electronic questionnaires each morning at 09:00; after discharge, the same instruments were administered electronically or by telephone on POD7 and POD30. Research nurses provided all participants with hands-on training on the ePRO platform prior to surgery. Post-discharge, automated reminders and follow-up phone calls were used to ensure adherence. Due to these measures, the completion rate for the ePRO assessments at POD7 and POD30 was 100% for all 60 participants.

Secondary endpoints comprised conventional surgical metrics: operative time, intra-operative blood loss, chest-tube dwell time, cumulative drainage, and length of post-operative stay. Dedicated research nurses prospectively recorded all perioperative variables.

Statistical analysis

Statistical analyses were performed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables are reported as mean ± standard deviation and compared using independent-samples t-tests. Categorical variables are presented as counts (percentages) and compared using chi-squared tests. Multivariable linear and logistic regression models were constructed to adjust for potential confounders when assessing the association between surgical approach and study outcomes. A two-sided P value <0.05 was considered statistically significant. Missing data were addressed using multiple imputation techniques to minimize attrition bias.

Results

A total of 60 patients with radiologically confirmed early-stage lung cancer were consecutively enrolled and equally assigned to the non-intubated thoracoscopic surgery group (Group I, n=30) or the double-lumen intubation group (Group C, n=30) (Figure 1). Baseline demographic and clinical characteristics were comparable between groups, with no statistically significant differences in age (62.87 vs. 61.03 years; P=0.25), sex distribution (male/female: 14/16 vs. 15/15; P=0.79), or surgical procedure type (lobectomy vs. sublobar resection; P=0.19) (Table 1).

Figure 1 Flow chart of patient inclusion. PRO, patient report outcome.

Perioperative recovery indicators

Patients in the NITS group demonstrated significantly faster postoperative recovery (Table 2). The mean length of hospital stay was markedly shorter in NITS than in DLT group (3.47 vs. 5.37 days; P<0.001). Chest tube duration was also significantly reduced (1.57 vs. 2.60 days; P=0.001), as was the cumulative chest drainage volume (49.7 vs. 71.0 mL; P=0.02). Operative time (98.87 vs. 100.77 minutes; P=0.27) and intraoperative blood loss (22.17 vs. 25.17 mL; P=0.39) did not differ significantly between groups.

Postoperative symptom assessment via ePROs

ePRO data were collected for all patients on POD7 and POD30, covering nine symptom domains: pain, cough, dyspnea, sleep disturbance, fatigue, somnolence, psychological distress, difficulty mobility, and activity limitation. Scores ranged from 0 (no symptoms) to 10 (severe symptoms).

On POD7, patients in the NITS group reported significantly lower symptom scores across all nine domains (Table 3). Mean scores for pain (2.53 vs. 4.50), cough (2.17 vs. 3.73), and dyspnea (2.27 vs. 3.43) were significantly lower in Group I than in Group C (all P<0.001). Similarly, scores for fatigue (2.43 vs. 3.50), sleep disturbance (2.33 vs. 3.67), somnolence (1.77 vs. 2.50), distress (2.40 vs. 3.77), mobility difficulty (2.30 vs. 2.83), and limitation in daily activities (2.40 vs. 3.43) were significantly improved in the NITS group (all P≤0.001).

At POD30, overall symptom scores improved in both groups. Several symptom domains continued to show statistically significant between-group differences, although the magnitude of these differences was smaller than at POD7 (Table 4). Specifically, patients in the NITS group reported lower scores for cough (2.10 vs. 2.50; P=0.02), fatigue (2.07 vs. 2.47; P=0.02), somnolence (2.03 vs. 1.47; P=0.01), distress (1.83 vs. 2.33; P=0.01), and activity limitation (1.93 vs. 1.50; P=0.02). Differences in pain, dyspnea, sleep disturbance, and mobility difficulty diminished over time and were no longer statistically significant by POD30.

Discussion

This prospective cohort study demonstrates that NITS, when integrated with real-time ePROs, is associated with significantly enhanced postoperative recovery in early-stage lung cancer patients. From a nursing standpoint, the combined approach of spontaneous ventilation and dynamic symptom monitoring resulted in improved PROs across multiple dimensions—including pain, fatigue, respiratory symptoms, and functional limitations—during both inpatient and outpatient phases of recovery. These findings not only confirm the clinical feasibility of NITS but also underscore the value of ePROs in facilitating high-quality, patient-centered perioperative care.

By eliminating endotracheal intubation and preserving spontaneous ventilation, NITS minimizes airway manipulation and reduces perioperative physiological stress. In our cohort, this translated into shorter chest tube duration, lower drainage volume, and a significant reduction in hospital stay. Notably, pain and respiratory symptoms were significantly milder in the NITS group, especially in the early postoperative period. These results align with previous studies suggesting that the avoidance of mechanical ventilation can mitigate ventilator-associated complications, improve intraoperative oxygenation, and reduce postoperative morbidity (15). The favorable physiological profile of NITS also creates a more conducive environment for individualized, nurse-led recovery interventions.

More importantly, our study highlights the value of ePROs as a transformative tool in thoracic postoperative care. Traditional nursing assessments rely heavily on episodic, in-person evaluations and objective physiological indicators, which often fail to capture subtle or fluctuating symptoms—particularly after discharge (16). In contrast, ePROs provide a continuous stream of real-time, patient-generated data on pain, sleep, mood, and mobility. This multidimensional view of recovery enables earlier recognition of complications, more precise symptom management, and timely, remote nursing interventions (17). For example, episodes of worsening dyspnea or psychological distress, as captured through ePRO platforms, can trigger proactive responses such as medication adjustments or tele-counseling—ultimately reducing unnecessary emergency visits and readmissions (18).

Notably, ePRO deployment compensates for clinicians’ limited ability to quantify the patient-centred benefits of non-intubated surgery. Conventional objective endpoints seldom capture subjective experiences such as fatigue or diminished activity, which are tightly linked to nursing outcomes. By supplying granular, patient-reported data, ePROs furnish a new evidence base that nurses can use to refine patient selection, optimise enhanced-recovery pathways, and highlight nursing’s pivotal role in peri-operative and outpatient management (19). Our findings are consistent with and build upon the work of Dai et al. (13), who demonstrated in a large randomized controlled trial (RCT) that ePRO-based symptom management improved quality of life after lung cancer surgery. Our study specifically extends this paradigm to the NITS population, suggesting that the benefits of ePROs are perhaps even more pronounced in an enhanced recovery setting where shorter hospital stays necessitate more robust remote monitoring. Similarly, the work of Basch et al. (18), which established a survival benefit for ePRO monitoring in routine cancer treatment, underscores the profound clinical impact of proactive symptom management. Our nurse-led ePRO model represents a practical application of this principle within the unique demands of the thoracic surgical recovery period.

The integration of ePROs into the postoperative care pathway for NITS represents a paradigm shift in how nursing teams monitor and manage recovery (20). Traditional postoperative assessments often rely on intermittent clinical evaluations, which may miss subtle but clinically significant changes in symptoms between visits. By contrast, ePROs provide a continuous, patient-centered stream of data, enabling nurses to detect trends—such as worsening pain or emerging dyspnea—before they escalate into complications requiring emergency intervention (21). This proactive approach aligns with the principles of precision nursing, where care is tailored not only to the surgical technique but also to the patient’s unique recovery trajectory. For example, a patient reporting increased fatigue via ePRO might benefit from earlier physiotherapy adjustments or nutritional support, while another with rising distress scores could be flagged for psychological counseling. Thus, ePROs transform postoperative nursing from a reactive to a predictive model, optimizing resource allocation and improving outcomes (22).

Moreover, the success of ePROs in this study underscores their potential to bridge the gap between hospital and home-based care, a critical juncture where patients often feel abandoned. In NITS, where hospital stays are shorter, the risk of unmet needs post-discharge is heightened (23). ePRO platforms facilitate bidirectional communication, allowing patients to report symptoms in real time and nurses to respond with timely guidance—whether through medication adjustments, reassurance, or triage for in-person evaluation. This continuity is especially valuable in low-resource settings or for elderly patients with limited mobility. Future iterations of ePRO systems could integrate artificial intelligence to analyze symptom patterns and automate alerts, further reducing nursing workload while enhancing vigilance. However, challenges such as digital literacy among older patients and data privacy concerns must be addressed to ensure equitable adoption. Ultimately, the marriage of NITS and ePROs exemplifies how technological innovation can humanize care, placing patient experiences at the heart of clinical decision-making.

Several limitations should be acknowledged. First, and most importantly, this was a single-center, non-randomized cohort study. The allocation to the NITS or DLT group was performed consecutively based on surgeon preference, intraoperative feasibility, and patient consent, which introduces a significant risk of selection bias. Although our baseline characteristics were well-matched, unmeasured confounding factors could still influence the outcomes. A large-scale, multicenter randomized controlled trial is necessary to definitively confirm our findings. Secondly, this study was performed with a relatively small sample size, and no formal a priori power calculation was performed, which may limit the generalizability of our findings and the power to detect more subtle differences between groups. Furthermore, neither patients nor care providers were blinded to the treatment allocation, which may have introduced performance and detection bias, particularly for subjective patient-reported outcomes. Patients in the NITS group may have had higher expectations for recovery, potentially influencing their symptom reports.

Future research should: (I) foster multidisciplinary collaboration among surgeons, anesthesiologists, nurses, and rehabilitation specialists to establish integrated, end-to-end care pathways; (II) enhance interoperability between ePRO platforms and electronic medical records to facilitate real-time analytics and personalized interventions; (III) expand sample sizes and extend follow-up periods to evaluate the impact of NITS and ePRO-guided nursing on long-term outcomes, including complication rates, readmissions, and overall survival.

Conclusions

Our findings suggest that combining NITS with ePRO-guided nursing represents a scalable, digitally enabled care model that improves functional recovery, reduces symptom burden, and reinforces continuity of care beyond hospital discharge. As healthcare systems increasingly emphasize personalized, value-based care, this integrated strategy may serve as a blueprint for modernizing thoracic perioperative management.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the TREND reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1270/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1270/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1270/prf

Funding: This work was supported by the Medical Science and Technology Research Foundation of Guangdong Province (Grant Nos. A2023415 and B2025603).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1270/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Institutional Ethics Committee of the National Center for Respiratory Medicine/First Affiliated Hospital of Guangzhou Medical University (Approval No. ES-2024-073-02). All patients provided written informed consent prior to their inclusion in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Wong MKH, Sit AKY, Au TWK. Minimally invasive thoracic surgery: beyond surgical access. J Thorac Dis 2018;10:S1884-91. [Crossref] [PubMed]
2. He J, Liang H, Wang W, et al. Tubeless video-assisted thoracic surgery for pulmonary ground-glass nodules: expert consensus and protocol (Guangzhou). Transl Lung Cancer Res 2021;10:3503-19. [Crossref] [PubMed]
3. Fabo C, Oszlanyi A, Lantos J, et al. Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review. Front Surg 2021;8:818456. [Crossref] [PubMed]
4. Mineo TC, Tamburrini A, Perroni G, et al. 1000 cases of tubeless video-assisted thoracic surgery at the Rome Tor Vergata University. Future Oncol 2016;12:13-8. [Crossref] [PubMed]
5. Prisciandaro E, Bertolaccini L, Sedda G, et al. Non-intubated thoracoscopic lobectomies for lung cancer: an exploratory systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2020;31:499-506. [Crossref] [PubMed]
6. Liu Y, Liang L, Yang H. Airway management in "tubeless" spontaneous-ventilation video-assisted thoracoscopic tracheal surgery: a retrospective observational case series study. J Cardiothorac Surg 2023;18:59. [Crossref] [PubMed]
7. Cherchi R, Grimaldi G, Pinna-Susnik M, et al. Retrospective outcomes analysis of 99 consecutive uniportal awake lung biopsies: a real standard of care? J Thorac Dis 2020;12:4717-30. [Crossref] [PubMed]
8. Wen Y, Jiang Y, Liang H, et al. Tubeless video-assisted thoracic surgery for lung cancer: is it ready for prime time? Future Oncol 2020;16:1229-34. [Crossref] [PubMed]
9. Zheng B, Chen M, Huang Y, et al. Long-term outcomes of modified enhanced recovery after surgery (mERAS) protocols in peri-operative management of minimally invasive esophagectomy. J Thorac Dis 2025;17:3053-63. [Crossref] [PubMed]
10. Considine J, Currey J. Ensuring a proactive, evidence-based, patient safety approach to patient assessment. J Clin Nurs 2015;24:300-7. [Crossref] [PubMed]
11. Wulczyn KE, Liu A, Lash JP, et al. Patient-Reported Symptoms Compared With Nephrologist Documentation During Outpatient Visits: A Retrospective Patient-Reported Outcome Measures Study. Kidney Med 2025;7:101011. [Crossref] [PubMed]
12. Grüne B, Menold H, Lenhart M, et al. Patient Compliance in Assessing Electronic Patient-Reported Outcome Measures after Urologic Surgery. Urol Int 2023;107:280-7. [Crossref] [PubMed]
13. Dai W, Feng W, Zhang Y, et al. Patient-Reported Outcome-Based Symptom Management Versus Usual Care After Lung Cancer Surgery: A Multicenter Randomized Controlled Trial. J Clin Oncol 2022;40:988-96. [Crossref] [PubMed]
14. He J, Liu J, Zhu C, et al. Expert consensus on tubeless video-assisted thoracoscopic surgery (Guangzhou). J Thorac Dis 2019;11:4101-8. [Crossref] [PubMed]
15. Hung MH, Hsu HH, Cheng YJ, et al. Nonintubated thoracoscopic surgery: state of the art and future directions. J Thorac Dis 2014;6:2-9. [Crossref] [PubMed]
16. Dai W, Wang Y, Liao J, et al. Electronic Patient-Reported Outcome-Based Symptom Management Versus Usual Care After Lung Cancer Surgery: Long-Term Results of a Multicenter, Randomized, Controlled Trial. J Clin Oncol 2024;42:2126-31. [Crossref] [PubMed]
17. Zhao Y, Liu W, Gao X, et al. Comparison of early patient-reported outcomes between uniportal thoracoscopic segmentectomy and wedge resection for peripheral small-sized non-small-cell lung cancer. J Cardiothorac Surg 2024;19:215. [Crossref] [PubMed]
18. Basch E, Deal AM, Dueck AC, et al. Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. JAMA 2017;318:197-8. [Crossref] [PubMed]
19. Tang L, Yu H, Dai W, et al. Symptom Trajectories Informing Patient Care After Lung Cancer Surgery: A Longitudinal Patient-Reported Outcome Study. Ann Surg Oncol 2023;30:2607-17. [Crossref] [PubMed]
20. Yu H, Yu Q, Nie Y, et al. Data Quality of Longitudinally Collected Patient-Reported Outcomes After Thoracic Surgery: Comparison of Paper- and Web-Based Assessments. J Med Internet Res 2021;23:e28915. [Crossref] [PubMed]
21. Wei X, Yu H, Dai W, et al. Patient-Reported Outcomes of Video-Assisted Thoracoscopic Surgery Versus Thoracotomy for Locally Advanced Lung Cancer: A Longitudinal Cohort Study. Ann Surg Oncol 2021;28:8358-71. [Crossref] [PubMed]
22. Basch E, Schrag D, Jansen J, et al. Symptom monitoring with electronic patient-reported outcomes during cancer treatment: final results of the PRO-TECT cluster-randomized trial. Nat Med 2025;31:1225-32. [Crossref] [PubMed]
23. Pompeo E, Rogliani P, Cristino B, et al. Awake thoracoscopic biopsy of interstitial lung disease. Ann Thorac Surg 2013;95:445-52. [Crossref] [PubMed]