The future of nonintubated thoracic surgery: from airway avoidance to preservation of respiratory function

Nonintubated thoracic surgery can be performed in selected patients and procedures, but its current role should be defined by comparative value rather than by absence of a tracheal tube alone. The early focus on feasibility and avoidance of tracheal intubation was appropriate; the next question is whether nonintubated approaches preserve respiratory function, maintain safety during rare complications, and improve recovery compared with contemporary video-assisted or robotic thoracic surgery embedded in enhanced recovery care. Future studies should report pathway fidelity, regional anaesthesia and sedation performance, conversion readiness, postoperative pulmonary complications, complication severity, quality of recovery, and pragmatic respiratory measurements including diaphragm ultrasound at standardised time points. Therefore, nonintubated thoracic surgery should be neither dismissed as a niche technique nor promoted as a universal alternative, but rather evaluated as a team-dependent, procedure-specific option requiring rigorous selection, training, rescue algorithms, and clinically meaningful endpoints.