Recent advances in thoracic anesthesia: lung protection, airway management, and enhanced recovery-a narrative review

Thoracic anesthesia has recently made key progress in lung-protective ventilation, airway management, and perioperative care. This review synthesizes developments including electrical impedance tomography (EIT)-guided positive end-expiratory pressure (PEEP) optimization during one-lung ventilation (OLV), electromagnetic navigation bronchoscopy for bronchial blocker placement, enhanced recovery protocols with opioid-sparing approaches, and artificial intelligence (AI) applications in closed-loop anesthesia and airway assessment. Within these, we also discuss cross-cutting domains such as perioperative organ protection (neurocognitive dysfunction, immunological considerations, emerging technologies) as they underpin each major theme.

We searched PubMed and Web of Science for thoracic anesthesia, OLV, airway management, enhanced recovery, total intravenous anesthesia, and AI applications. The search covered January 2025 to May 2026 and was limited to English-language publications. Clinical trials, observational studies, systematic reviews, and consensus statements were included based on relevance. Study selection was performed by two authors independently, and disagreements were resolved by discussion. The thematic domains (lung-protective ventilation, airway management, enhanced recovery, AI-guided control, organ protection, emerging technologies) were predefined based on clinical relevance. A total of 71 references were included in this review.

Individualized lung-protective ventilation strategies, particularly EIT-guided PEEP titration, may improve ventilation distribution but remain limited by hemodynamic trade-offs. Advances in airway management include navigation-assisted bronchial blocker placement and AI-based difficult airway prediction, though external validation is limited. Enhanced recovery approaches emphasize opioid-sparing anesthesia, regional techniques, and selected non-intubated thoracoscopic surgery. AI-guided closed-loop anesthesia shows promise but faces regulatory and implementation barriers.

For the practicing thoracic anesthesiologist, key takeaways include: (I) individualized PEEP titration guided by EIT or dynamic compliance, where available, may improve ventilation distribution; (II) AI-assisted airway assessment should be viewed as an adjunct to clinical judgment, not a replacement; (III) non-intubated techniques and opioid-free anesthesia require careful patient selection and are not yet generalizable to routine practice. Clinical judgment and evidence-based tailoring remain essential.