Hemodynamic stability and rapid recovery
The early post-transplant period is characterized by hemodynamic instability and diminished pulmonary reserve. In this context, reinduction of anesthesia for urgent re-exploration for intrathoracic bleeding poses substantial risk and technical difficulty. These vulnerabilities make strategies that limit tracheal instrumentation and positive-pressure ventilation particularly appealing. Multiple high-quality studies demonstrate the safety of non-intubated VATS (NIVATS): a meta-analysis of 19 randomized trials (n = 2,222) showed shorter hospital stay, earlier feeding, shorter chest-tube duration, and lower risks of postoperative pulmonary complications (PPCs), postoperative nausea and vomiting, and sore throat versus intubated VATS, with comparable intraoperative safety [7]. A double-blind non-inferiority RCT likewise found NIVATS non-inferior for PPCs with similar hypoxemia, arrhythmia, and conversion rates [8]. Consistent with this evidence base, our patient maintained stable intraoperative hemodynamics and oxygenation throughout the procedure without requiring conversion to intubation and demonstrated rapid postoperative recovery.
Mitigating airway irritation
Ischemia-related necrosis, dehiscence, and anastomotic stenosis pose substantial morbidity in early post-lung transplantation [9,10,11]. NIVATS may mitigate stress on healing bronchial anastomoses by reducing airway reintubation, positive-pressure barotrauma, and ventilator-associated shear forces. Endotracheal intubation frequently causes direct airway trauma, resulting in postoperative complications including sore throat, hoarseness, airway hypersensitivity, and vocal cord injury, particularly when double-lumen tubes are employed [12, 13]. Additionally, one-lung ventilation (OLV) significantly increases the risk of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) through multiple mechanisms: hypoxemia, oxidative stress, ischemia-reperfusion injury, and mechanical overdistension of the ventilated lung [14]. By avoiding both endotracheal intubation and one-lung ventilation, mechanical and inflammatory airway injury may be substantially reduced—a hypothesis supported by randomized controlled trial evidence demonstrating significantly lower postoperative interleukin-6 levels at both 1 and 24 h in patients undergoing NIVATS compared to IVATS [15].
Cough reflex control without vagal block
Lung transplantation functionally denervates the donor lungs, interrupting autonomic (vagal and sympathetic) pathways at the pulmonary hilum [16]. In conventional, non-transplant non-intubated video-assisted thoracic surgery (NIVATS), intraoperative cough is typically attenuated by a combination of light-to-moderate sedation, topical lidocaine applied to the pleura/bronchi, and an intrathoracic vagal block. In the early post-transplant setting, manipulation of the distal lung parenchyma seldom provokes cough; thus, routine vagal blockade is often unnecessary. Nevertheless, stimulation of the trachea or the native proximal bronchus above the anastomosis can still elicit cough. Accordingly, selective topical anesthesia should remain available, while avoiding direct application to the fresh bronchial anastomosis. These considerations align with our NIVATS strategy to minimize airway instrumentation while maintaining preparedness for rescue measures.
Monitoring and intervention for severe hypercapnia
During non-intubated VATS (NIVATS), CO₂ retention is expected due to reduced alveolar ventilation from sedation and open pneumothorax, plus pendelluft and rebreathing between the operative and dependent lungs [17, 18]. Intraoperative hypercapnia is usually mild–moderate but can progress to acidosis; many programs predefine conversion criteria that include refractory hypoxemia or severe hypercapnia (PaCO₂ ≥70–80 mmHg) [18, 19].
Compared with intubated VATS, NIVATS cohorts often show higher peak ETCO₂/PaCO₂, underscoring the need for vigilant monitoring [20]. ETCO₂ with intermittent arterial blood gases is advisable to detect clinically relevant hypercapnia [21]. Practical mitigation centers on preserving respiratory drive with judicious sedation, optimizing positioning and supplemental oxygen, and maintaining a low threshold for conversion when gas exchange or exposure becomes unsafe [17, 19].
Although gas exchange remained acceptable (PaCO₂ 39–57 mmHg; ETCO₂ 41–51 mmHg) and well below predefined conversion thresholds for severe hypercapnia, the early post-transplant context—marked by immature graft function and limited respiratory reserve—warranted a fully prepared conversion plan. A senior anesthesiologist proficient in lateral-decubitus intubation stayed at the bedside, with rescue equipment immediately available (video laryngoscope and a visualized double-lumen endobronchial intubation set) to enable prompt conversion if oxygenation, ventilation, or surgical exposure deteriorated.
Strengths and limitations
As a single-patient case report, this study cannot establish causality or generalizability to broader post-transplant populations. Selection and performance biases are likely given the patient’s hemodynamic stability, favorable anatomy, and procedure performance by an experienced NIVATS team with immediate airway-rescue capabilities—conditions that may not be reproducible across centers. The absence of a contemporary IVATS comparator precludes direct assessment of differences in gas-exchange dynamics, surgical exposure, or complication rates. Brief follow-up focused on immediate postoperative outcomes prevents conclusions about medium- and long-term results, including anastomotic healing, airway stenosis, or graft function.