{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T06:11:59Z","timestamp":1793945519356,"version":"4.8.0"},"reference-count":54,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,10,26]],"date-time":"2021-10-26T00:00:00Z","timestamp":1635206400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Surg."],"abstract":"<jats:p>Traditionally, intubated general anesthesia with one-lung ventilation is standard in thoracoscopic surgery. However, in recent decades, non-intubated thoracoscopic surgery (NITS) has become an alternative method to minimize the adverse effects of intubated general anesthesia. Non-intubated procedures result in fewer adverse events than tracheal intubation and general anesthesia, such as intubation-related airway injury, ventilation-induced lung injury, prolonged hospital stay, and postoperative nausea and vomiting. Despite these benefits, surgeons must consider the possibility of converting to intubation during NITS as the conversion rate is between 2 and 11%, varying between regions and learning time. The conversion rate is also affected by race, body size, the learning curve, and the surgical team's preferred methods. There are surgical (e.g., significant respiratory movements, uncontrolled bleeding, hindered surgical fields, large tumor sizes, adhesions) and anesthetic (e.g., hypoxemia, hypercapnia, airway spasms) reasons for converting to intubation. When a conversion is deemed necessary by the surgical team, the members should be well-prepared and act rapidly. Anesthesiologists should also feel comfortable intubating patients in the lateral decubitus position with or without bronchoscopic guidance. Patient selection is the key factor for avoiding conversion into an intubated surgery. Patients with an American Society of Anesthesiologists grade 2 or less, a body mass index &amp;lt;25, and less surgical complexity may be good candidates for NITS. Careful monitoring, adequate anesthesia depth, an experienced surgical team, and sufficient preparation can also prevent conversion. Conversion from a non-intubated into intubated thoracic surgery is unwanted but not inevitable. Therefore, NITS can be successful when performed on select patients by a well-prepared and experienced surgical team and is worthy of recommendation owing to its non-invasiveness.<\/jats:p>","DOI":"10.3389\/fsurg.2021.769850","type":"journal-article","created":{"date-parts":[[2021,10,26]],"date-time":"2021-10-26T05:43:13Z","timestamp":1635226993000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":23,"title":["Converting to Intubation During Non-intubated Thoracic Surgery: Incidence, Indication, Technique, and Prevention"],"prefix":"10.3389","volume":"8","author":[{"given":"Xu-Heng","family":"Chiang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mong-Wei","family":"Lin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2021,10,26]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1097\/ACO.0b013e32835c4ea2","article-title":"Acute lung injury in thoracic surgery","volume":"26","author":"Della Rocca","year":"2013","journal-title":"Curr Opin Anaesthesiol."},{"key":"B2","doi-asserted-by":"publisher","first-page":"957","DOI":"10.1213\/01.ane.0000172112.02902.77","article-title":"The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery","volume":"101","author":"Schilling","year":"2005","journal-title":"Anesth Analg."},{"key":"B3","doi-asserted-by":"publisher","first-page":"350","DOI":"10.1055\/s-2006-948289","article-title":"The role of cytokines during the pathogenesis of ventilator-associated and ventilator-induced lung injury","volume":"27","author":"Belperio","year":"2006","journal-title":"Semin Respir Crit Care Med."},{"key":"B4","doi-asserted-by":"publisher","first-page":"R64","DOI":"10.1186\/cc5940","article-title":"Injurious mechanical ventilation in the normal lung causes a progressive pathologic change in dynamic alveolar mechanics","volume":"11","author":"Pavone","year":"2007","journal-title":"Crit Care."},{"key":"B5","doi-asserted-by":"publisher","first-page":"378","DOI":"10.1016\/j.jtcvs.2004.11.061","article-title":"Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial","volume":"130","author":"Zupancich","year":"2005","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B6","doi-asserted-by":"publisher","first-page":"5","DOI":"10.1097\/01.aco.0000192783.40021.c1","article-title":"Lung injury after thoracic surgery and one-lung ventilation","volume":"19","author":"Gothard","year":"2006","journal-title":"Curr Opin Anaesthesiol."},{"key":"B7","doi-asserted-by":"publisher","first-page":"322","DOI":"10.1016\/S1053-0770(99)90273-2","article-title":"Airway rupture from double-lumen tubes","volume":"13","author":"Fitzmaurice","year":"1999","journal-title":"J Cardiothorac Vasc Anesth."},{"key":"B8","doi-asserted-by":"publisher","first-page":"1485","DOI":"10.1213\/ANE.0000000000004669","article-title":"Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases","volume":"131","author":"Liu","year":"2020","journal-title":"Anesth Analg."},{"key":"B9","doi-asserted-by":"publisher","first-page":"1405","DOI":"10.1213\/ANE.0000000000000574","article-title":"Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications?","volume":"120","author":"Hausman","year":"2015","journal-title":"Anesth Analg."},{"key":"B10","doi-asserted-by":"publisher","first-page":"120","DOI":"10.1213\/ANE.0b013e3181da832d","article-title":"Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block","volume":"111","author":"Murphy","year":"2010","journal-title":"Anesth Analg."},{"key":"B11","doi-asserted-by":"publisher","first-page":"133","DOI":"10.1213\/ANE.0b013e3182742e75","article-title":"Postoperative residual neuromuscular blockade is associated with impaired clinical recovery","volume":"117","author":"Murphy","year":"2013","journal-title":"Anesth Analg."},{"key":"B12","doi-asserted-by":"publisher","first-page":"347","DOI":"10.2165\/00002512-200320050-00004","article-title":"Anaesthesia and postoperative analgesia in older patients with chronic obstructive pulmonary disease: special considerations","volume":"20","author":"Gruber","year":"2003","journal-title":"Drugs Aging."},{"key":"B13","doi-asserted-by":"publisher","first-page":"1038","DOI":"10.1097\/SLA.0b013e31822ed19b","article-title":"Nonintubated thoracoscopic lobectomy for lung cancer","volume":"254","author":"Chen","year":"2011","journal-title":"Ann Surg."},{"key":"B14","doi-asserted-by":"publisher","first-page":"4236","DOI":"10.21037\/jtd.2018.06.163","article-title":"Comparison of non-intubated versus intubated video-assisted thoracoscopic lobectomy for lung cancer","volume":"10","author":"AlGhamdi","year":"2018","journal-title":"J Thorac Dis."},{"key":"B15","doi-asserted-by":"publisher","first-page":"359","DOI":"10.21037\/jtd.2016.02.50","article-title":"Video-assisted thoracoscopic surgery segmentectomy by non-intubated or intubated anesthesia: a comparative analysis of short-term outcome","volume":"8","author":"Guo","year":"2016","journal-title":"J Thorac Dis."},{"key":"B16","doi-asserted-by":"publisher","first-page":"1703","DOI":"10.21037\/jtd.2018.02.10","article-title":"Non-intubated thoracoscopic bullectomy under sedation is safe and comfortable in the perioperative period","volume":"10","author":"Hwang","year":"2018","journal-title":"J Thorac Dis."},{"key":"B17","doi-asserted-by":"publisher","first-page":"1624","DOI":"10.21037\/jtd-20-3039","article-title":"A comparison of non-intubated video-assisted thoracic surgery with spontaneous ventilation and intubated video-assisted thoracic surgery: a meta-analysis based on 14 randomized controlled trials","volume":"13","author":"Zhang","year":"2021","journal-title":"J Thorac Dis."},{"key":"B18","first-page":"347","article-title":"Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution","volume":"4","author":"Chen","year":"2012","journal-title":"J Thorac Dis."},{"key":"B19","doi-asserted-by":"publisher","first-page":"1049","DOI":"10.1016\/j.athoracsur.2012.01.062","article-title":"Nonintubated needlescopic video-assisted thoracic surgery for management of peripheral lung nodules","volume":"93","author":"Tseng","year":"2012","journal-title":"Ann Thorac Surg."},{"key":"B20","doi-asserted-by":"publisher","first-page":"1186","DOI":"10.1213\/ANE.0000000000001117","article-title":"Ultrasound-guided thoracic paravertebral blockade: a retrospective study of the incidence of complications","volume":"122","author":"Pace","year":"2016","journal-title":"Anesth Analg."},{"key":"B21","doi-asserted-by":"publisher","first-page":"2061","DOI":"10.21037\/jtd-19-3830","article-title":"Conversion method to manage surgical difficulties in non-intubated uniportal video-assisted thoracic surgery for major lung resection: simple thoracotomy without intubation","volume":"12","author":"Furak","year":"2020","journal-title":"J Thorac Dis."},{"key":"B22","doi-asserted-by":"publisher","first-page":"e8645","DOI":"10.1590\/1414-431x20198645","article-title":"Feasibility of non-intubated anesthesia and regional block for thoracoscopic surgery under spontaneous respiration: a prospective cohort study","volume":"53","author":"Li","year":"2020","journal-title":"Braz J Med Biol Res."},{"key":"B23","doi-asserted-by":"publisher","first-page":"1607","DOI":"10.1016\/j.athoracsur.2019.01.013","article-title":"Nonintubated thoracoscopic surgery for lung tumor: seven years' experience with 1,025 patients","volume":"107","author":"Hung","year":"2019","journal-title":"Ann Thorac Surg."},{"key":"B24","doi-asserted-by":"publisher","first-page":"3490","DOI":"10.21037\/jtd.2018.05.147","article-title":"Non-intubated thoracoscopic surgery: initial experience at a single center","volume":"10","author":"Moon","year":"2018","journal-title":"J Thorac Dis."},{"key":"B25","doi-asserted-by":"publisher","first-page":"920","DOI":"10.1093\/ejcts\/ezw160","article-title":"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","volume":"50","author":"Liu","year":"2016","journal-title":"Eur J Cardiothorac Surg."},{"key":"B26","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1016\/j.ejcts.2007.04.029","article-title":"Awake anaesthesia for major thoracic surgical procedures: an observational study","volume":"32","author":"Al-Abdullatief","year":"2007","journal-title":"Eur J Cardiothorac Surg."},{"key":"B27","doi-asserted-by":"publisher","first-page":"620","DOI":"10.1093\/ejcts\/ezu054","article-title":"Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation","volume":"46","author":"Hung","year":"2014","journal-title":"Eur J Cardiothorac Surg."},{"key":"B28","doi-asserted-by":"publisher","first-page":"2587","DOI":"10.21037\/jtd.2017.08.96","article-title":"Non-intubated single-incision video-assisted thoracic surgery: a two-center cohort of 188 patients","volume":"9","author":"Wang","year":"2017","journal-title":"J Thorac Dis."},{"key":"B29","doi-asserted-by":"publisher","first-page":"1001","DOI":"10.1093\/ejcts\/ezx450","article-title":"Nasal high-flow oxygen therapy improves arterial oxygenation during one-lung ventilation in non-intubated thoracoscopic surgery","volume":"53","author":"Wang","year":"2018","journal-title":"Eur J Cardiothorac Surg."},{"key":"B30","doi-asserted-by":"publisher","first-page":"7202","DOI":"10.21037\/jtd-20-2122","article-title":"Developing a minimally-invasive anaesthesiological approach to non-intubated uniportal video-assisted thoracoscopic surgery in minor and major thoracic surgery","volume":"12","author":"Starke","year":"2020","journal-title":"J Thorac Dis."},{"key":"B31","doi-asserted-by":"publisher","first-page":"31","DOI":"10.1097\/00003643-201406001-00238","article-title":"Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation","volume":"6","author":"Chen","year":"2014","journal-title":"J Thorac Dis."},{"key":"B32","doi-asserted-by":"publisher","first-page":"1998","DOI":"10.1016\/j.athoracsur.2014.07.036","article-title":"Nonintubated uniportal thoracoscopic surgery for peripheral lung nodules","volume":"98","author":"Hung","year":"2014","journal-title":"Ann Thorac Surg."},{"key":"B33","doi-asserted-by":"publisher","first-page":"40","DOI":"10.21037\/atm.2018.11.58","article-title":"Non-intubated thoracoscopic surgery for lung cancer in patients with impaired pulmonary function","volume":"7","author":"Wang","year":"2019","journal-title":"Ann Transl Med."},{"key":"B34","doi-asserted-by":"publisher","first-page":"1209","DOI":"10.1016\/j.athoracsur.2013.05.065","article-title":"Nonintubated thoracoscopic anatomical segmentectomy for lung tumors","volume":"96","author":"Hung","year":"2013","journal-title":"Ann Thorac Surg."},{"key":"B35","doi-asserted-by":"publisher","first-page":"335","DOI":"10.2147\/IJGM.S11926","article-title":"Obesity and respiratory diseases","volume":"3","author":"Zammit","year":"2010","journal-title":"Int J Gen Med."},{"key":"B36","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1111\/j.1440-1843.2011.02096.x","article-title":"Impact of obesity on respiratory function","volume":"17","author":"Littleton","year":"2012","journal-title":"Respirology."},{"key":"B37","doi-asserted-by":"publisher","first-page":"123","DOI":"10.1177\/1553350614531662","article-title":"Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study","volume":"22","author":"Liu","year":"2015","journal-title":"Surg Innov."},{"key":"B38","doi-asserted-by":"publisher","first-page":"721","DOI":"10.1093\/ejcts\/ezv136","article-title":"Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?","volume":"49","author":"Gonzalez-Rivas","year":"2016","journal-title":"Eur J Cardiothorac Surg."},{"key":"B39","doi-asserted-by":"publisher","first-page":"27","DOI":"10.1016\/j.cryobiol.2020.03.003","article-title":"Feasibility, effectiveness, and safety of a novel cryo-balloon targeted lung denervation technique in an animal model","volume":"93","author":"Wang","year":"2020","journal-title":"Cryobiology."},{"key":"B40","doi-asserted-by":"publisher","first-page":"552","DOI":"10.1093\/icvts\/ivu209","article-title":"Single-port thoracoscopic lobectomy in a nonintubated patient: the least invasive procedure for major lung resection?","volume":"19","author":"Gonzalez-Rivas","year":"2014","journal-title":"Interact Cardiovasc Thorac Surg."},{"key":"B41","doi-asserted-by":"publisher","first-page":"755","DOI":"10.1016\/j.jtcvs.2014.04.042","article-title":"Reply to the editor","volume":"148","author":"Galvez","year":"2014","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B42","doi-asserted-by":"publisher","first-page":"471","DOI":"10.1097\/00000542-200609000-00009","article-title":"Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial","volume":"105","author":"Knoll","year":"2006","journal-title":"Anesthesiology."},{"key":"B43","doi-asserted-by":"publisher","first-page":"1761","DOI":"10.1016\/j.athoracsur.2004.05.083","article-title":"Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules","volume":"78","author":"Pompeo","year":"2004","journal-title":"Ann Thorac Surg."},{"key":"B44","doi-asserted-by":"publisher","first-page":"786","DOI":"10.1016\/j.jtcvs.2006.11.001","article-title":"The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax","volume":"133","author":"Pompeo","year":"2007","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B45","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1097\/imi.0000000000000075","article-title":"Nonintubated thoracoscopic pulmonary nodule resection under spontaneous breathing anesthesia with laryngeal mask","volume":"9","author":"Ambrogi","year":"2014","journal-title":"Innovations (Phila)."},{"key":"B46","doi-asserted-by":"publisher","first-page":"761","DOI":"10.1089\/jpm.2013.0617","article-title":"Quality of life and outcomes after nonintubated versus intubated video-thoracoscopic pleurodesis for malignant pleural effusion: comparison by a case-matched study","volume":"17","author":"Mineo","year":"2014","journal-title":"J Palliat Med."},{"key":"B47","first-page":"494","article-title":"de la Torre M, Bonome C. Uniportal video-assisted thoracoscopic left upper lobectomy under spontaneous ventilation","volume":"7","author":"Gonzalez-Rivas","year":"2015","journal-title":"J Thorac Dis."},{"key":"B48","doi-asserted-by":"publisher","first-page":"405","DOI":"10.1016\/j.athoracsur.2012.10.082","article-title":"Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients","volume":"95","author":"Wu","year":"2013","journal-title":"Ann Thorac Surg."},{"key":"B49","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1097\/01.sla.0000182917.39534.2c","article-title":"Awake nonresectional lung volume reduction surgery","volume":"243","author":"Mineo","year":"2006","journal-title":"Ann Surg."},{"key":"B50","doi-asserted-by":"publisher","first-page":"445","DOI":"10.1016\/j.athoracsur.2012.10.043","article-title":"Awake thoracoscopic biopsy of interstitial lung disease","volume":"95","author":"Pompeo","year":"2013","journal-title":"Ann Thorac Surg."},{"key":"B51","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1055\/s-2008-1038632","article-title":"Awake endoscopic thymectomy via an infrasternal approach using sternal lifting","volume":"56","author":"Matsumoto","year":"2008","journal-title":"Thorac Cardiovasc Surg."},{"key":"B52","doi-asserted-by":"publisher","first-page":"613","DOI":"10.1016\/j.jtcvs.2011.07.067","article-title":"Is there a benefit of awake thoracoscopic surgery in patients with secondary spontaneous pneumothorax?","volume":"143","author":"Noda","year":"2012","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B53","doi-asserted-by":"publisher","first-page":"47","DOI":"10.1016\/j.jtcvs.2011.09.050","article-title":"Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery","volume":"143","author":"Pompeo","year":"2012","journal-title":"J Thorac Cardiovasc Surg."},{"key":"B54","doi-asserted-by":"publisher","first-page":"126","DOI":"10.3978\/j.issn.2072-1439.2012.03.10","article-title":"Anesthesia with nontracheal intubation in thoracic surgery","volume":"4","author":"Dong","year":"2012","journal-title":"J Thorac Dis."}],"container-title":["Frontiers in Surgery"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2021.769850\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,10,26]],"date-time":"2021-10-26T05:43:18Z","timestamp":1635226998000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fsurg.2021.769850\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,10,26]]},"references-count":54,"alternative-id":["10.3389\/fsurg.2021.769850"],"URL":"https:\/\/doi.org\/10.3389\/fsurg.2021.769850","relation":{},"ISSN":["2296-875X"],"issn-type":[{"value":"2296-875X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,10,26]]},"article-number":"769850"}}