Awake or intubated surgery in diagnosis of interstitial lung diseases? A prospective study

Abstract

BackgroundRisks associated with Video-Assisted Surgical Lung Biopsy (VASLB) for interstitial lung disease (ILD) with endotracheal intubation and mechanical ventilation are not nil. Awake Video-Assisted Surgical Lung Biopsy (Awake-VASLB) has been proposed as a method to obtain a precise diagnosis in several different thoracic diseases.ObjectivesTo compare clinical outcomes of Awake-VASLB and Intubated-VASLB in patients with suspected ILDs.MethodsFrom June 2016 to February 2020, all patients submitted to elective VASLB for suspected ILD were included. Differences in outcomes between Awake-VASLB and Intubated-VASLB were assessed through univariable, multivariable-adjusted, and a propensity score-matched (PS) analysis.Measurements and main resultsAwake-VASLB was performed in 66 out of 100 patients, while 34 underwent Intubated-VASLB. The Awake- VASLB resulted in a lower postoperative morbidity (OR 0.025; CI95% 0.001, 0.35; p=0.006), a less unexpected Intensive Care Unit (ICU) admission, a less need for rescue therapy for pain, a reduced surgical and anaesthesiologic time, a reduced chest drain duration, a lower postoperative length of stay.ConclusionAwake-VASLB in patients affected by ILD is feasible and seems safer than Intubated-VASLB.

Lung Biopsy With a Non-intubated VATS Approach in an Obese Population: Indications and Results

“…In addition, the diagnostic yield of NIVATS lung biopsy in obese patients was almost comparable to that in the normal-weight group, and the overall diagnostic rate of this procedure was similar to that reported by traditional surgical techniques under general anesthesia (88.2%; 95% CI, 86.9-89.4%) (12). To date, other Authors described the positive outcomes of NIVATS SLB when compared with mechanically ventilated VATS procedure, mainly for morbidity and pLOS without any significant decrease of the diagnostic yield in patients who underwent tubeless management (13). The negative association between locoregional anesthesia and surgical time could be explained by the extra time taken by the surgeon in performing the percutaneous intercostal block after skin incision.…”

The Anesthesiologist's Perspective Regarding Non-intubated Thoracic Surgery: A Scoping Review

“…Of the studies analyzed, 42.4% used intercostal nerve block, 40.7% thoracic epidural analgesia, 6.8% paravertebral block, 5.1% infiltration with local anesthetic of the wound, 3.4% erector spinae plane block, and 1.6% placed a catheter at the paravertebral site for continuous analgesia. Evaluating NITS vs. non-NITS cohort studies the postoperative pain was significantly lower in the NITS group in five studies ( 3 , 6 , 14 , 15 , 22 ), whereas the findings were not statistically significant in six studies ( 19 , 21 , 25 , 28 , 31 , 32 ).…”

“…Three hundred eighty-two and 234 were, respectively excluded following the first and second evaluation process bringing the number of studies included in the scoping review to 49. To these, four more articles ( 6 – 9 ) previously reported in systematic reviews were added leading the total number of articles included to 53, all published after 2011.…”

“…The NITS technique, accompanied by regional anesthesia, might be a good way to reduce postoperative pain in surgery at high risk of developing persistent postoperative pain and prone to high acute postoperative pain ( 66 , 67 ). Reducing opioid consumption in commonly frail patients, such as those undergoing NITS, could affect postoperative hospitalization and complication outcomes ( 6 ).…”

“…The choice of surgical procedure, as well as that of the patient, have not been well-defined in the literature yet. It is our opinion that frail patients have fewer complications during NITS than during intubated thoracic surgery ( 6 ). From a postoperative patient management perspective, the impact of NITS techniques on LOS remains unknown as the existing evidence available in the literature is conflicting.…”