Effect of the tubeless approach on the non-operative lung in thoracic surgery: a retrospective cohort study.

BACKGROUND

Postoperative pulmonary complications (PPCs) remain one of the common challenges in video-assisted thoracic surgeries. While tubeless anesthesia using laryngeal mask has emerged as a fast-track recovery approach, offering multiple advantages for both lungs, such as reduced anesthetic dosage, avoidance of airway injury, and facilitation of surgical manipulation, its impact on the non-operative lung remains unclear. We aim to conduct a retrospective study based on computed tomography (CT) imaging.

METHODS

We included lung surgery cases from January 2020 to March 2025 at The First Affiliated Hospital of Guangzhou Medical University. Pre- vs. postoperative CT reports were compared to identify novo contralateral lung abnormalities. Intraoperative respiratory parameters were collected and analyzed. Propensity score matching (PSM) was used to balance confounding factors between the tubeless anesthesia and intubated groups, followed by a conditional logistic regression model to analyze the incidence and severity of PPCs as the dependent variables, aiming to clarify the safety and efficacy of this anesthesia method.

RESULTS

After screening 140,036 surgeries, 1,294 cases were eligible. Following 2:1 PSM, 427 patients in the intubated group were matched with 234 patients in the tubeless group. The tubeless group showed lower average airway pressures (peak: 19.39 vs. 6.80 cmH2O, mean: 7.28 vs. 3.23 cmH2O, plateau: 17.88 vs. 8.03 cmH2O, all P<0.001) and ventilation parameters (tidal volume: 320.42 vs. 279.90 mL, P<0.001; minute ventilation: 4.65 vs. 3.47 L, P<0.001). For surgeries lasting 60-120 minutes, the tubeless group showed lower rates of overall CT changes (15.6% vs. 8.2% P=0.04) and consolidation (12.6% vs. 5.7% P=0.03). Postoperative hospital stay was shorter in the tubeless group (4.51 vs. 6.43 days, P<0.001). Average respiratory rate [odds ratio (OR) 1.36, 95% confidence interval (CI): 1.07-1.74, P=0.01] and minute ventilation (OR 1.32, 95% CI: 0.91-1.90, P=0.14) showed the strongest correlation with CT changes.

CONCLUSIONS

Tubeless approach is associated with lower mechanical ventilation pressures and less overall image abnormalities, potentially protecting the non-operative lung. These findings suggest that tubeless approach has protective effect on the non-operative lung, contributing to the enhanced recovery after thoracic surgery.