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Introduction
General anaesthesia, mechanical ventilation with lung isolation using a double-lumen
endobronchial tube or bronchial blocker, has been the standard for lung management
during thoracic surgery for over 80 years. However, there has been increasing popularity
for avoiding lung isolation and maintaining spontaneous ventilation for video assisted
thoracoscopic surgery (VATS) both with patients conscious using regional anaesthesia
and unconscious using general anaesthesia. Many benefits of spontaneous ventilation
over the traditional approach have been proposed. We hypothesised that spontaneous
ventilation would be significantly more efficient that lung isolation for thoracic
surgery. The primary aim of this study was to compare the duration of hospital stay
in patients undergoing thoracic surgery with lung isolation or spontaneous ventilation
for lung management. Secondary aims were the durations of anaesthesia, global in-operating
room duration and overall hospital cost.
Methods
Systematic search of PubMed, OVID/Embase and Google Scholar from January 2000 - October
2020 was conducted using predetermined inclusion criteria. Bias was assessed using
the Cochrane screening method. Each lung management technique was segmented into randomised
controlled trials (RCTs) and observational studies and analysed both separately and
together. Meta-analysis using the Cochrane RevMan5 software was conducted and findings
summarised as forest plots. Mean and 95% confidence intervals were compared alongside
assessment of probability and heterogeneity.
Results
The literature search identified 649 studies, of which only 23 fulfilled the entry
criteria, and these included a total of 2,564 patients. The duration of hospital stay
was significantly shorter for spontaneous ventilation than lung isolation (mean: -0.78
days; 95% CI 1.17 - 0.38) in all studies and in RCTs (mean: -0.88 days; 95% CI 1.1
- 0.65). The duration of anaesthesia was significantly shorter in spontaneous ventilation
for all studies (mean: -10.87 minutes; 95% CI 9.3 - 12.43) and for RCTs (mean: -13.19
minutes; 95% CI 11.18 - 15.2). Similarly, global in operating room duration was shorter
using spontaneous ventilation for all studies (mean: -33.31 minutes; 95% CI 23.57
- 43.04) and for RCTs (mean: -31.77 minutes; 95% CI 28.49 - 35.05). No statistically
significant difference was found between hospital cost for the two techniques but
when only RCTs were analysed, spontaneous ventilation was associated with a lower
cost (mean: €990; 95% CI €760-1220).
Discussion
When compared to the traditional technique of lung isolation under general anaesthesia
for thoracic surgery, techniques using spontaneous ventilation either under regional
or general anaesthesia, were associated with shorter durations of hospital stay and
anaesthesia as well as time spent in the operating room. In addition, hospital costs
may also be less expensive using spontaneous ventilation.
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© 2021 Published by Elsevier Inc.
