HE Breathing: a new ventilation mode in airway surgery

Complex airway surgery, particularly tracheal/carinal resection and reconstruction, is still considered as the “crown jewel” of video-assisted thoracoscopic surgery (VATS). Notably, during these procedures, maintaining adequate oxygenation and preventing hypercapnia, while simultaneously ensuring optimal surgical conditions, remains a formidable challenge (1,2). Drawing on prior clinical experience, successful airway surgery hinges on close collaboration with a skilled anesthesia team, where the choice of ventilation mode—intubated or non-intubated (tubeless)—plays a critical role in achieving optimal procedural outcomes (3-5).

Intubated ventilation for airway surgery

Traditionally, airway surgery is performed under intubated general anesthesia with cessation of spontaneous breathing. However, this approach presents several significant challenges (Figure 1), primarily including: (I) mechanical ventilation may lead to complications, such as airway pressure-induced trauma, lung overdistension, repetitive alveolar collapse and reopening, and the release of pro-inflammatory mediators, all of which may cause lung injury and postoperative respiratory impairment (6-9). (II) After tracheal transection, endotracheal intubation with cross-field ventilation is necessary for distal airway ventilation. However, it may complicate end-to-end anastomosis by obstructing the view of surgical field and may require intermittent withdrawal to improve exposure (2,10). (III) To avoid airway resistance and ensure a stable operative environment during the mechanical ventilation, deep anesthesia—often achieved through opioids and muscle relaxants—are employed. However, its related postoperative adverse effects may be unavoidable, like nausea, vomiting, residual neuromuscular blockade or myasthenia, cognitive dysfunction and some life-threatening events (11-14).

Figure 1 Intubated ventilation for airway surgery. This figure illustrates video-assisted thoracoscopic surgery for carinal resection and reconstruction under intubated general anesthesia. (A) Before carinal resection, oxygenation is maintained through endotracheal intubation with mechanical ventilation. (B) After carinal resection, cross-field ventilation through endotracheal intubation is necessary. (C) During carinal reconstruction, the presence of the endotracheal tube obstructs the surgical field, complicating end-to-end anastomosis. (D) To improve exposure and maintain oxygenation during carinal reconstruction, intermittent withdrawal and reinsertion of the endotracheal tube are performed.

Although high-frequency jet ventilation, an alternative airway management allowing for control of oxygenation with minimal interference of surgical exposure and lower peak inspiratory pressure, has been applied in airway surgery, it still needs intubated general anesthesia with possible CO₂ retention, barotrauma, and hypothermia due to high rate of gas flow (15,16).

Non-intubated ventilation for airway surgery

During the last decade, non-intubated VATS is one of the most impressive advancements in thoracic surgery and anesthesia, which is performed safely under spontaneous ventilation anesthesia (through regional anesthesia and minimal sedation while avoiding opioids and muscle relaxants) (17,18). In 2016, Prof. He’s team reported the first large-scale comparative study on non-intubated versus intubated VATS for lung resection, demonstrating that the non-intubated approach was feasible and effective, with fewer postoperative complications and faster recovery (19). Subsequently, Prof. He’s team extended this technique from these basic thoracic procedures to complex airway surgeries, thoracic procedures to complex airway surgeries (20-22), developing a ventilation strategy in which patients maintain spontaneous breathing even after the airway is opened—referred to as “HE Breathing”.

HE Breathing ventilation mode is typically characterized by two distinct non-physiological airflow pathways: the contralateral airway stump ⇄ the main bronchial stump or the chest wall incision, and here, the surgical pleural cavity functions as a temporary transitional reservoir (Video 1). The opening of one pleural cavity results in the loss of its negative pressure, while the contralateral cavity preserves it. Within this structure, the ongoing spontaneous respiratory muscle movements and the pressure gradient across the opened trachea generate a driving force for breathing. Moreover, according to Bernoulli’s principle, the addition of a chest wall incision pathway significantly reduces airflow resistance, thereby enhancing gas exchange efficiency.

Advantages of HE Breathing ventilation mode for airway surgery

In a comparative study, Prof. He’s team successfully performed thoracoscopic carinal (4 patients) and tracheal (14 patients) resections under the HE Breathing ventilation mode, achieving shorter anastomosis times (22.5–40 vs. 45–86 minutes), operative duration (162.5 vs. 260 minutes) and potentially postoperative hospital stays (11.5±4.3 vs. 13.2±6.3 days), compared with the conventional intubated ventilation method (4). These results underscore the significant advantages of HE Breathing ventilation mode in enhancing surgical safety, reducing perioperative mortality and promoting faster recovery. Key contributing factors include:

• Spontaneous breathing minimizes lung injury and infection risks associated with mechanical ventilation. The naturally regulated rhythm and depth of spontaneous breathing may enhance respiratory efficiency and oxygenation. Although it is known that hypercapnia may occur, permissive hypercapnia can improve hemodynamics, enhance ventilation-perfusion matching, and provide protective effects against inflammatory responses (23).
• Using a laryngeal mask instead of an endotracheal tube avoids intubation-related injuries (e.g., throat pain, mucosal ulceration and airway rupture). The associated reduction in reflexive coughing may also help prevent early anastomotic rupture.
• The absence of a tube within the surgical area optimizes visualization and precision during resection and anastomosis, vastly simplifying this technically demanding procedure. Accordingly, the ischemia-reperfusion time of the airway is reduced, facilitating more efficient anastomotic reapproximation and recovery.
• The combination of local anesthesia (e.g., infiltration of the vagus nerve, extensive intercostal nerves and lung surface) and mild intravenous anesthesia, rather than general deep anesthesia, reduced postoperative adverse effects related to muscle relaxants, as well as heavy sedatives and analgesics, particularly in the prolonged airway surgeries.

With the collaborative efforts of surgeons and anesthesiologists, HE Breathing ventilation mode has emerged as an innovative technique in airway surgery, offering significant advantages. Further investigations into its respiratory dynamics and other underlying mechanisms are warranted. Prof. He’s team has successfully extended its application to robotic-assisted VATS (24), and it is anticipated that this technique will achieve broader adoption and benefit a wider range of patients in the future.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1308/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1308/coif). J.H. serves as the Executive Editor-in-Chief of Journal of Thoracic Disease. The other 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.

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. Gonzalez-Rivas D, Yang Y, Stupnik T, et al. Uniportal video-assisted thoracoscopic bronchovascular, tracheal and carinal sleeve resections†. Eur J Cardiothorac Surg 2016;49:i6-16. [Crossref] [PubMed]
2. Smeltz AM, Bhatia M, Arora H, et al. Anesthesia for Resection and Reconstruction of the Trachea and Carina. J Cardiothorac Vasc Anesth 2020;34:1902-13. [Crossref] [PubMed]
3. Li LT, Chitilian HV, Alfille PH, et al. Airway management and anesthesia for airway surgery: a narrative review. Transl Lung Cancer Res 2021;10:4631-42. [Crossref] [PubMed]
4. Jiang L, Liu J, Gonzalez-Rivas D, et al. Thoracoscopic surgery for tracheal and carinal resection and reconstruction under spontaneous ventilation. J Thorac Cardiovasc Surg 2018;155:2746-54. [Crossref] [PubMed]
5. Chitilian HV, Bao X, Mathisen DJ, et al. Anesthesia for Airway Surgery. Thorac Surg Clin 2018;28:249-55. [Crossref] [PubMed]
6. Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004;32:1817-24. [Crossref] [PubMed]
7. Della Rocca G, Coccia C. Acute lung injury in thoracic surgery. Curr Opin Anaesthesiol 2013;26:40-6. [Crossref] [PubMed]
8. Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg 2005;101:957-65. [Crossref] [PubMed]
9. Gothard J. Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol 2006;19:5-10. [Crossref] [PubMed]
10. Schieren M, Wappler F, Defosse J. Anesthesia for tracheal and carinal resection and reconstruction. Curr Opin Anaesthesiol 2022;35:75-81. [Crossref] [PubMed]
11. Murphy GS, Szokol JW, Avram MJ, et al. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesth Analg 2013;117:133-41. [Crossref] [PubMed]
12. Jiang L, Depypere L, Rocco G, et al. Spontaneous ventilation thoracoscopic thymectomy without muscle relaxant for myasthenia gravis: Comparison with "standard" thoracoscopic thymectomy. J Thorac Cardiovasc Surg 2018;155:1882-1889.e3. [Crossref] [PubMed]
13. Hausman MS Jr, Jewell ES, Engoren M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 2015;120:1405-12. [Crossref] [PubMed]
14. Sessler DI, Sigl JC, Kelley SD, et al. Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesiology 2012;116:1195-203. [Crossref] [PubMed]
15. Qiu Y, Yu F, Yao F, et al. The efficacy of high-frequency jet ventilation on intraoperative oxygen saturation compared to cross-field ventilation in patients undergoing carinal resection and reconstruction. J Thorac Dis 2022;14:3197-204. [Crossref] [PubMed]
16. Perera ER, Vidic DM, Zivot J. Carinal resection with two high-frequency jet ventilation delivery systems. Can J Anaesth 1993;40:59-63. [Crossref] [PubMed]
17. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721-31. [Crossref] [PubMed]
18. Boisen ML, Rao VK, Kolarczyk L, et al. The Year in Thoracic Anesthesia: Selected Highlights from 2016. J Cardiothorac Vasc Anesth 2017;31:791-9. [Crossref] [PubMed]
19. Liu J, Cui F, Pompeo E, et al. The impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: a propensity score matching analysis. Eur J Cardiothorac Surg 2016;50:920-5. [Crossref] [PubMed]
20. Liu J, Li S, Shen J, et al. Non-intubated resection and reconstruction of trachea for the treatment of a mass in the upper trachea. J Thorac Dis 2016;8:594-9. Erratum in: J Thorac Dis 2016;8:E473. [Crossref] [PubMed]
21. Peng G, Cui F, Ang KL, et al. Non-intubated combined with video-assisted thoracoscopic in carinal reconstruction. J Thorac Dis 2016;8:586-93. Erratum in: J Thorac Dis 2016;8:E641. [Crossref] [PubMed]
22. Shao W, Phan K, Guo X, et al. Non-intubated complete thoracoscopic bronchial sleeve resection for central lung cancer. J Thorac Dis 2014;6:1485-8. [Crossref] [PubMed]
23. Sinclair SE, Kregenow DA, Lamm WJ, et al. Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury. Am J Respir Crit Care Med 2002;166:403-8. [Crossref] [PubMed]
24. Li S, Ai Q, Liang H, et al. Nonintubated Robotic-assisted Thoracic Surgery for Tracheal/Airway Resection and Reconstruction: Technique Description and Preliminary Results. Ann Surg 2022;275:e534-6. [Crossref] [PubMed]