Non-intubated thoracic surgery (NITS) is a growing practice, alongside minimally invasive thoracic surgery. To date, only a consensus of experts provided opinions on NITS leaving a number of questions unresolved. We then conducted a scoping review to clarify the state of the art regarding NITS. The systematic review of all randomized and non-randomized clinical trials dealing with NITS, based on Pubmed, EMBASE, and Scopus, retrieved 665 articles. After the exclusion of ineligible studies, 53 were assessed examining: study type, Country of origin, surgical procedure, age, body mass index, American Society of Anesthesiologist's physical status, airway management device, conversion to orotracheal intubation and pulmonary complications rates and length of hospital stay. It emerged that NITS is a procedure performed predominantly in Asia, and certain European Countries. In China, NITS is more frequently performed for parenchymal resection surgery, whereas in Europe, it is mainly employed for pleural pathologies. The most commonly used device for airway management is the laryngeal mask. The conversion rate to orotracheal intubation is a~3%. The results of the scoping review seem to suggest that NITS procedures are becoming increasingly popular, but its role needs to be better defined. Further randomized clinical trials are needed to better define the role of the clinical variables possibly impacting on the technique effectiveness. Systematic Review Registration: https://osf.io/mfvp3/, identifier: 10.17605/OSF.IO/MFVP3.

Background Risks 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. Objectives To compare clinical outcomes of Awake-VASLB and Intubated-VASLB in patients with suspected ILDs. Methods From 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 results Awake-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. Conclusion Awake-VASLB in patients affected by ILD is feasible and seems safer than Intubated-VASLB.

Background: Several peripheral regional anaesthesia (RA) techniques are commonly used in thoracic surgery even in the absence of precise indications regarding their effectiveness on postoperative pain management. Objective: This systematic review and meta-analysis aims to describe and evaluate the relative effectiveness of different peripheral regional blocks and systemic analgesia in the context of video-assisted thoracoscopic surgery (VATS) or thoracotomy. Design: Systematic review of randomized controlled clinical trials (RCTs) with meta-analyses. Data sources: We searched PubMed and Embase for all RCTs comparing the 24 hour morphine equivalents (MMEs) consumption following peripheral regional blocks and systemic analgesia (SA). Eligibility criteria: We selected only RCTs including adult participants undergoing thoracic surgery, including esophagectomy and reporting on postoperative pain outcomes including 24 hour MMEs consumption. Results: Among the 28 randomized studies including adult participants undergoing thoracic surgery and reporting on 24 hour opioid consumption, 11 reporting a comparison of individual blocks with systemic analgesia were meta-analyzed. RA was effective for almost all peripheral blocks. Regarding intercostal block, its antalgic effect was not well evaluated SMD -1.57 (CI -3.88, 0.73). RA in VATS was more effective in reducing MMEs than thoracotomy SMD -1.10 (CI -1.78, -0.41). Conclusions: RA is a useful choice in thoracic surgery. However, it is still not possible to determine the most appropriate block in the individual surgical settings to be performed due to RCTs paucity.

Editorial Commentary Towards a universal, holistic, evidence-based consensus on difficult airway management: the new American Society of Anesthesiologists guidelines Giulio Luca Rosboch, Gerardo Cortese, Luca Neitzert, Luca Brazzi

The anesthesiologist perspective Giulio Luca Rosboch, Edoardo Ceraolo, Eleonora Balzani, Federico Piccioni, Luca Brazzi