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Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia
Published on: May 26, 2023
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Intraoperative Ventilatory Strategies in Patients Undergoing Video-Assisted Thoracic Surgery: A Narrative Review
Silvia Coppola1,2, Bruno Pastene3, Isabella Fratti4
1Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudinì 9, Milan, Italy. silvia_coppola@libero.it.
Advances in Therapy
|September 19, 2025
Summary
Optimal mechanical ventilation settings for video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) remain unclear. Current evidence suggests protective lung ventilation may not reduce postoperative pulmonary complications, highlighting the need for further research.
Area of Science:
- Thoracic Surgery
- Anesthesiology
- Respiratory Medicine
Background:
- Video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) are prevalent surgical techniques.
- Postoperative pulmonary complications (PPCs) affect up to 10% of patients undergoing these procedures.
Purpose of the Study:
- To review current evidence on mechanical ventilation strategies for VATS and RATS.
- To evaluate the impact of positive end-expiratory pressure (PEEP), tidal volume (VT), and ventilation modes on patient outcomes.
- To assess the feasibility of two-lung ventilation in thoracic surgery.
Main Methods:
- A narrative review of studies published between January 2007 and February 2025.
- Searched MEDLINE/PubMed using terms 'VATS' or 'RATS' and 'ventilation'.
- Publications were screened by title or abstract and analyzed based on methodological quality.
Main Results:
- Protective lung ventilation (VT 5-8 mL/kg PBW, PEEP 5-8 cmH2O) during one-lung ventilation (OLV) did not lower PPC incidence.
- Titrating PEEP may improve oxygenation and reduce pneumonia, but evidence is limited.
- Two-lung ventilation shows recent positive evaluations for specific procedures without increased complications.
- The overall evidence level for ventilatory settings in VATS/RATS is low.
Conclusions:
- Current intraoperative ventilation strategies for VATS/RATS lack strong evidence for reducing PPCs.
- Further large randomized controlled trials (RCTs) are essential to establish optimal ventilatory settings.
- The feasibility of two-lung ventilation warrants continued investigation.
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