Non-Intubated Video-Assisted Thoracoscopic Surgery
May 26th, 2023
Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.
This research presents a step-by-step protocol detailing the execution of non-intubated video assisted thoracoscopic surgery. The protocol of N-I-V-A-T-S is based on multimodal analgesia, including ultrasound guided thoracic paravertebral blockade, a thoracoscopic vagal block, and proloinfiltration anesthesia. Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex.
This protocol provides a sevoflurane inhalation anesthesia regiment to reduce the cough reflex during thoracoscopic surgery. Minimize the over sedation while providing a safe and a pain-free operating environment for patients. We maintain the patient spontaneous breathing and minimize mediastinal oscillations during the procedure while taking into account the associated technical challenges.
Begin by adjusting the temperature of the operating room to between 24 to 26 degrees Celsius. Insert a 20 gauge top-winged infusion needle into the elbow vein of the non-surgical hand of the patient. Now monitor the electrocardiography, blood pressure, pulse, oxygen saturation, and respiratory rate of the patient.
Apply a Bispectral Index Quatro Sensor to the patient's forehead. To induce anesthesia by continuous oxygen administration, insert a laryngeal mask airway. Maintain the sevoflurane concentration at 1.5 to 2%and an oxygen flow rate of 0.5 to one liter per minute.
Monitor the inhaled oxygen concentration, the end tidal carbon dioxide, the body temperature, and the level of consciousness. Place the patient in a lateral decubitus position and place the ultrasound probe directly above the spinous processors of the third and seventh thoracic vertebrae. Obtain a cross-sectional image of the spinous processes.
Move the ultrasound probe laterally to show the transverse process in its entirety. Move it outward to visualize the transverse process, transverse rib joints and the ribs. Keep moving the probe cardinally until the transverse process, pleura, and the thoracic paravertebral space are detected in the image.
On the ultrasound guidance, insert a block needle with the in plain approach from the lateral to the medial side. Next, carefully increase the aspiration before the injection to ensure no blood reflux is seen. After injecting 0.5 milliliters of ropivacaine, visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space.
Maintain a bispectral index value of 40 to 60. Using an infusion pump, continuously perfuse norepinephrine. Perform arterial blood gas analysis 15 minutes before the end of the surgery.
Inject one milligram per kilogram of flurbiprofen 30 minutes before the end of the surgery. The pulmonary complication rate was observed to be significantly lower in the non-intubated video assisted thoracic surgery, or NIVTAS group related to the general anesthesia, or GA group. Six patients in the GA group developed postoperative pneumothorax.
Three patients in the GA group developed plural effusion compared to one in the NIVATS group, which was not statistically significant. Seven patients in the GA group developed pneumonia compared to none in the NIVATS group, and the difference between the two groups was statistically significant. Additionally, three GA patients developed pulmonary atelectasis and two developed pulmonary embolisms.
Neither group developed acute respiratory distress syndrome. The NIVATS group showed reduced intraoperative blood loss at 20 milliliters, shorter mean surgery duration, and post-anesthesia care unit stay time. Furthermore, the chest drain was removed from the NIVATS group on day two and the GA group on day three, which was significant.
Significant differences were observed in the amount of postoperative chest drainage between the NIVTAS and the GA group. Three patients in the GA group had prolonged ICU stays and four had postoperative chest tightness with shortness of breath. Relative to the GA group, the NIVTAS group had significantly shorter hospital stay lengths at five days.
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Overview
This research presents a detailed protocol for performing non-intubated video-assisted thoracoscopic surgery (N-I-V-A-T-S) while preserving autonomic breathing. The approach emphasizes multimodal analgesia to enhance patient comfort during the procedure.
Key Study Components
Area of Science
- Thoracic surgery
- Anesthesia techniques
- Patient safety and comfort
Background
- Video-assisted thoracoscopic surgery is a minimally invasive surgical technique.
- Maintaining spontaneous breathing can reduce complications associated with intubation.
- Multimodal analgesia is crucial for effective pain management during surgery.
- Technical challenges exist in preserving breathing while performing thoracoscopic procedures.
Purpose of Study
- To provide a protocol for N-I-V-A-T-S that minimizes sedation.
- To enhance patient safety and comfort during thoracoscopic surgery.
- To effectively manage intraoperative pain and cough reflex.
Methods Used
- Ultrasound guided thoracic paravertebral blockade.
- Thoracoscopic vagal block.
- Proloinfiltration anesthesia.
- Sevoflurane inhalation anesthesia to reduce cough reflex.
Main Results
- Effective pain relief achieved through multimodal analgesia.
- Minimized cough reflex during the procedure.
- Maintained patient spontaneous breathing throughout surgery.
- Addressed technical challenges associated with the procedure.
Conclusions
- The N-I-V-A-T-S protocol enhances patient comfort and safety.
- Multimodal analgesia is effective in managing pain and reflexes.
- This approach can be beneficial for future thoracoscopic surgeries.
Frequently Asked Questions
Executive Industry Relevance
Non-intubated video-assisted thoracoscopic surgery (NIVATS) addresses a critical need for reducing perioperative pulmonary complications in thoracic procedures by preserving spontaneous breathing and minimizing anesthesia-related risks. This protocol enables more predictable patient recovery and operational efficiency, directly impacting early translational research and preclinical model development for respiratory interventions. The approach supports risk-adjusted decision-making at key inflection points in surgical innovation pipelines.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Enables mechanistic de-risking of anesthesia-related variables in thoracic disease models.
- Supports functional validation of respiratory targets by maintaining physiological breathing conditions.
- Improves predictive confidence in translational studies by reducing confounding procedural trauma.
Screening & Assay Development
- Facilitates preparation of validated in vivo models for downstream respiratory and surgical research.
- Standardizes perioperative conditions, enhancing reproducibility of quantitative endpoints.
- Enables reliable assessment of post-operative pulmonary function and biomarker outputs.
Translational & Preclinical Research
- Aligns with disease-relevant systems by minimizing artificial ventilation artifacts in preclinical studies.
- Supports continuity from surgical intervention models to clinical translation in respiratory therapeutics.
- Reduces late-stage biological risk by clarifying procedure-specific safety profiles.
Pipeline & Workflow Integration
NIVATS integrates into the discovery-to-preclinical continuum by providing a reproducible surgical model that preserves physiological respiratory function, supporting both mechanistic studies and translational biomarker validation.
- Discovery Biology: Enables hypothesis testing on respiratory outcomes without confounding intubation effects.
- Screening: Provides standardized, reproducible perioperative endpoints for comparative studies.
- Analytics: Delivers quantitative outputs such as blood loss, drainage, and complication rates for robust statistical analysis.
- Translational Research: Bridges preclinical and clinical workflows by modeling real-world surgical conditions.
- Enterprise Reuse: Establishes a protocol adaptable across thoracic disease models and intervention studies.
Operational & Enterprise Impact
- Scientific Value: Increases predictive confidence and reduces mechanistic ambiguity in respiratory intervention studies.
- Operational Value: Enhances standardization, reproducibility, and scalability of thoracic surgical models.
- Strategic Value: Improves go/no-go decision quality and capital efficiency by reducing post-operative risk.
- Portfolio Impact: Supports risk-adjusted prioritization of respiratory and surgical innovation programs.
Implementation Considerations
- Requires expertise in multimodal analgesia and intraoperative respiratory monitoring.
- Demands access to ultrasound guidance, bispectral index monitoring, and perioperative analytics infrastructure.
- Necessitates cross-team standardization of anesthesia and surgical protocols.
- Adaptation may be needed for different thoracic disease models or patient populations.
- Conversion criteria to intubated anesthesia must be clearly defined and operationalized.
