Non‐Intubated Video‐Assisted Thoracoscopic Surgery in a Pediatric Patient With Airway Obstruction

A five-year-old, 17-kg child with bilateral pulmonary metastases from high-grade renal sarcoma was scheduled for bilateral thoracoscopic lung resection. Imaging showed right main bronchus tumor involvement, preventing safe placement of a bronchial blocker [1, 2]. The anesthetic plan included: (1) selective endobronchial intubation, (2) spontaneous ventilation if lung isolation failed, and (3) ECMO as a backup. Induction was performed with propofol (100 mg), fentanyl (25 μg), and rocuronium (20 mg). A thoracic epidural was placed at T5 (0.2% ropivacaine, 0.2 mL/h). A 5.0 mm endotracheal tube was advanced into the left main bronchus; however, right lung isolation was not achievable due to tumor involvement [1, 2]. After lateral positioning, lung collapse remained inadequate. At this point, the endotracheal tube was removed, and spontaneous ventilation without an airway device was initiated. Sedation was maintained with dexmedetomidine (0.1 μg/kg/min), propofol (0.3 mg/kg/h), and remifentanil (0.3 μg/kg/min). The surgeons then induced a surgical pneumothorax, allowing effective collapse of the operative lung [3]. We ensured adequate anesthetic depth by combining regional anesthesia, targeted nerve blocks, and careful titration of intravenous sedation. A thoracic epidural provided baseline analgesia, and intraoperative vagal and phrenic nerve blocks were used to suppress cough and diaphragmatic movement. Sedative agents were titrated to maintain spontaneous ventilation while minimizing airway reactivity, with dosing adjusted according to the patient's weight. Adequacy of anesthetic depth was assessed clinically through respiratory pattern, hemodynamic stability, absence of movement or airway reflexes, and continuous capnography via nasal cannula. Surgical Course: Uniportal VATS was performed. To suppress cough and diaphragmatic movement while preserving spontaneous ventilation, 2 mL of ropivacaine were injected into the right vagus and phrenic nerves—a standard technique in non-intubated thoracic surgery to facilitate lung collapse without mechanical ventilation, as commonly reported in adults [4]. Right upper lobectomy and partial right main bronchus resection were completed, followed by a non-anatomical resection of the apical segment of the left lower lobe. The patient remained hemodynamically and respiratory stable throughout, and recovery was uneventful [3]. In the present case, we describe non-intubated, spontaneously ventilated VATS as a possible approach in a child with significant airway obstruction where conventional lung isolation was not achievable. Maintaining spontaneous ventilation avoided positive-pressure ventilation against a partially obstructed airway, potentially reducing the risk of barotrauma or airway collapse [3]. While non-intubated VATS has been increasingly reported in adults, with benefits such as shorter hospital stay and reduced chest tube duration, pediatric experience remains limited [5]. The main lesson is that spontaneous ventilation can be maintained with carefully titrated sedation, regional anesthesia, and targeted nerve blocks (5). This approach may be useful in other cases with partial airway obstruction or distorted anatomy, but should be reserved for selected patients in specialized centers, with continuous monitoring and clearly defined rescue strategies including readiness for emergent airway control or extracorporeal support. Non-intubated, spontaneously ventilated thoracoscopic surgery can be a viable alternative in small children when standard airway management is impossible. Success requires careful planning, experienced surgical and anesthetic teams, and continuous coordination. The authors have nothing to report. The authors declare no conflicts of interest. The data supporting the findings of this case report are included within the article. Additional de-identified clinical details may be available from the corresponding author upon reasonable request, in accordance with patient privacy regulations.