Thoracic: Pleura| Volume 163, ISSUE 5, P1702-1714.e7, May 2022

Spontaneous versus mechanical ventilation during video-assisted thoracoscopic surgery for spontaneous pneumothorax: A randomized trial

Published:February 02, 2021DOI:



      Spontaneous ventilation video-assisted thoracic surgery (SV-VATS) is reported to have superior or equal efficacy on postoperative recovery to mechanical ventilation VATS (MV-VATS). However, perioperative safety of the SV-VATS blebectomy is not entirely demonstrated.


      We performed a noninferiority, randomized controlled trial (No. NCT03016858) for primary spontaneous pneumothorax patients aged 16 to 50 years undergoing a SV-VATS and the MV-VATS procedure. The trial was conducted at 10 centers in China from April 2017 to January 2019. The primary outcome was the comparison of intra- and postoperative complications between SV-VATS and MV-VATS procedures. Secondary outcomes included total analgesia dose, change of vital sign during surgery, procedural duration, recovery time, postoperative visual analog pain scores, and hospitalization length.


      In this study, 335 patients were included. There was no significant difference between the SV-VATS group and the MV-VATS group in the intra- and postoperative complication rates (17.90% vs 22.09%; relative risk, 0.81; 95% confidence interval, 0.52-1.26; P = .346). The SV-VATS group was associated with significantly decreased total dose of intraoperative opioid agents; that is, sufentanil (11.37 μg vs 20.92 μg; P < .001) and remifentanil (269.78 μg vs 404.96 μg; P < .001). The SV-VATS procedure was also associated with shorter extubation time (12.28 minutes vs 17.30 minutes; P < .001), postanesthesia care unit recovery time (25.43 minutes vs 30.67 minutes; P = .02) and food intake time (346.07 minute vs 404.02 minutes; P = .002). Moreover, the SV-VATS procedure deceased the anesthesia cost compared with the MV-VATS ($297.81 vs $399.81; P < .001).


      SV-VATS was shown to be noninferior to MV-VATS in term of complication rate and in selected patients undergoing blebectomy for primary spontaneous pneumothorax.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      BIS (bispectral index), LMA (laryngeal mask airways), MV (mechanical ventilation), MV-VATS (mechanical ventilation video-assisted thoracoscopic surgery), NLR (neutrophil to lymphocyte ratio), OLV (1-lung ventilation), PACU (postanesthesia care unit), PaCO2 (arterial carbon dioxide tension), PetCO2 (end tidal carbon dioxide pressure), PLR (platelet to lymphocyte ratio), PSP (primary spontaneous pneumothorax), RCT (randomized controlled trial), SpO2 (pulse oxygen saturation), SV-VATS (non-intubated spontaneous ventilation video-assisted thoracoscopic surgery), TCI (target-controlled infusion), VAS (visual analog scale), VATS (video-assisted thoracoscopic surgery)
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      Linked Article

      • Commentary: Relax and breathe
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 5
        • Preview
          The multicenter randomized clinical trial reported by Liu and colleagues1 challenges the operative comfort zones of thoracic surgeons accustomed to selective positive pressure ventilation. For thoracic surgeons and anesthesiologists to relax enough to let their patients breathe spontaneously during minimally invasive surgery, sufficient equipoise and potential benefits are needed to stoke the desires for disruptive technologies.
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      • Commentary: Striving for higher level of evidence
        The Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 5
        • Preview
          As thoracic surgery has become less and less invasive, attention has also turned to minimizing complications from conventional mechanical ventilation during surgery, including intubation injury, ventilation-induced injury, and sequela of muscle relaxants and opioid analgesia. Spontaneous ventilation video-assisted thoracic surgery (SV-VATS) has emerged as a technique aimed to prevent these adverse effects of conventional mechanical ventilation video-assisted thoracic surgery.1 Liu and colleagues2 have performed a prospective randomized controlled trial to evaluate the perioperative safety and physiologic changes of these 2 ventilation strategies.
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