Anesthesiology of the spontaneous ventilation in thoracic surgery: a narrative review

Objective: Thanks to the growing experience and the improvement of video-assisted thoracoscopic surgery (VATS) technique most pulmonary resections can now be performed by minimally invasive techniques.The present and the future of the thoracic surgery should be associated with a combination of surgical and anaesthetic advancement and improvements to reduce the perioperative surgical stress on the patient.Background: Traditionally intubated, ventilated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections for all patients.An adequate analgesia technique (regional or epidural) allows VATS to be performed in anesthetized patients and the potential adverse effects related to general anaesthesia and mechanical one-lung ventilation (mOLV) can be avoided. Methods:A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the medical subject headings (MeSH)terms 'non intubated thoracic surgery', 'spontaneous breathing', 'regional blockade', 'cough reflex', 'mechanical ventilation' and 'pulmonary complications' screened according to the following inclusion criteria: availability as full text in English, categorization as original research, reviews or meta-analyses.Conclusions: The minimally invasive, non-intubated procedures try to minimize the adverse effects of general anesthesia, tracheal intubation, and mechanical ventilation.Furthermore, patients may have also benefited from preserved hypoxic pulmonary vasoconstriction from the efficient contraction of the dependent hemidiaphragm during surgically induced pneumothorax.The non-intubated anaesthesia combined with the uniportal surgical approach represents one step forward in the minimally invasive strategies of treatment and can be a reliable offer to an increasing number of patients.Therefore, educating and training programs in minimally invasive techniques for spontaneous breathing (SB) patients may be needed and the continuous evolution and findings of the better and better anesthetical and surgical methods are vital in reduction of the perioperative complications.