Non-intubated Video-Assisted Thoracoscopic Pleurodesis Under Paravertebral Block in a Patient With Fibrotic Hypersensitivity Pneumonitis and Chronic Respiratory Failure.

Non-intubated video-assisted thoracoscopic surgery (NIVATS) has increasingly been reported as an alternative to general anesthesia in patients at high risk of complications associated with mechanical ventilation. Fibrotic hypersensitivity pneumonitis (FHP) with chronic respiratory failure may pose an indication for this approach, given the risk of positive-pressure ventilation precipitating acute exacerbation of the underlying interstitial lung disease, even in patients with an otherwise uncomplicated intraoperative course. We report the anesthetic management of a 42-year-old woman with FHP and chronic respiratory failure on long-term home oxygen therapy, who developed a spontaneous pneumothorax refractory to conservative treatment and an initial surgical attempt via video-assisted thoracoscopic surgery (VATS) under general anesthesia. Due to persistent and worsening pneumothorax and given the potential risks of general anesthesia in this setting, she underwent NIVATS pleurodesis two months later under an ipsilateral multilevel thoracic paravertebral block (T2-T7) combined with dexmedetomidine-ketamine sedoanalgesia. This case demonstrates the feasibility of NIVATS pleurodesis under regional anesthesia, combining a multilevel thoracic paravertebral block with sedoanalgesia using agents with limited respiratory depressant effects in a frail patient with fibrotic interstitial lung disease and recurrent pneumothorax.