Sometimes Less Is Worse: A Recommendation Against Nonintubated Video-Assisted Thoracoscopy During the COVID-19 Pandemic

To the Editor:

In late 2019, a new virus, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in Wuhan, China, causing a severe flu-like illness named coronavirus disease 2019 (COVID-19).¹ The new virus has spread rapidly all over the world, and the World Health Organization declared it a pandemic on March 11, 2020.² COVID-19 causes a severe respiratory illness in 10% to 15% of patients, with an overall mortality rate as high as 12%.³

The virus is transmitted from person to person through droplets and contact routes. In the operating room, several procedures such as face mask ventilation, intubation, bronchoscopy, extubation, and in general all the aerosol-generating practices put healthcare providers at risk for transmission of the infection.

The impact of the COVID-19 outbreak on elective surgery is high and comprises several aspects, including the overall decrease of surgical activity and the subsequent need for prioritization of procedures, healthcare workers’ safety, optimization of resources, and the screening of patients for COVID-19 positivity.

Unlike other surgeries, thoracic oncologic surgery cannot be delayed for many patients to avoid catastrophic consequences on their prognosis. In the context of lung surgery, nonintubated video-assisted thoracoscopy (NIVATS) has grown in popularity in recent years.⁴ NIVATS is suitable for diagnostic procedures or resective surgery as well.⁴ There is no consensus on the best anesthetic care for NIVATS. Basically, it is performed avoiding intubation and using monitored anesthesia care combining sedatives, low-dose opioids, and loco-regional techniques.4, 5, 6 Given the importance of airway management during NIVATS, we advise against this kind of technique in light of the COVID-19 outbreak.

Some general considerations apply to thoracic surgery, especially to NIVATS, as well as to other surgeries in this pandemic emergency. First, anesthesiologists and surgeons must consider the priority of surgery. For instance, diagnostic procedure for benign tumor or chronic disease should be postponed whenever possible in favor of malignant tumor resection surgeries. Many NIVATS procedures belong to the first group of procedures and can be delayed. Second, all patients should be screened for COVID-19 positivity to avoid subjecting patients with the virus to surgery. This represents a risk for the patients themselves and for the staff of the operating room. Despite these reasonable considerations, there is no consensus on the best pathway for patients scheduled for elective surgery. Subjecting all patients to a swab test is costly both in terms of resources and organization. Moreover, the test can be false negative in about 30% of patients. Thus, a negative result does not rule out COVID-19 and should not be used as the sole basis for treatment or patient management decisions.⁷ If patients affected by the COVID-19 infection, even those who are asymptomatic, should not undergo elective surgery during the pandemic, all patients must be considered and managed as potentially infected to prevent virus diffusion. The best strategy for routine management of patients during this pandemic is beyond the scope of this manuscript, and the use of personal protective equipment should be based on national protocols.

In addition, NIVATS deserves specific considerations. To perform nonintubated thoracic procedures safely, the main goal is to avoid airway obstruction during sedation and the detrimental effect of chest opening or surgical manipulation. Most NIVATS cases are managed under light sedation with oxygen supply via nasal cannula or face mask.^{4 , 6} Conversely, some anesthesiologists perform deeper sedation using a supraglottic airway device.⁶

The risk for virus diffusion through aerosol and droplets must be considered high even during uneventful nonintubated procedures. This can be enhanced by oxygen delivery and, especially, by coughing, which is one of the main issues during NIVATS, usually at chest opening and during surgical manipulation. The risk for intraoperative intubation is another important question. Even if uncommon, anesthesiologists must always be prepared for urgent intubation during NIVATS.⁶ The use of a videolaryngoscope is advisable in such circumstances, but the maneuver can be challenging because the patient is usually in a lateral position.^{4 , 6} Furthermore, the need for double-lumen tube or bronchial blocker positioning to manage 1-lung ventilation makes the maneuver more complex and laborious. As a consequence, urgent intubation can increase the exposure of the surgical staff to droplet spread and aerosolization during facial mask ventilation, intubation, and bronchoscopy. Indeed, the importance of targeting a fast and easy intubation in diagnosed or suspected COVID patients is recommended by several scientific societies.8, 9, 10, 11

Furthermore, the current lack of strength of evidence supporting the advantage of NIVATS compared with standard thoracotomy or VATS procedures must be kept in mind before deciding to perform thoracic surgery without intubation.12, 13, 14 Thus, considering that airway management for thoracic surgery includes more aerosol-generating procedures than other surgeries (ie, intubation, bronchoscopy for double-lumen tube or bronchial blocker positioning, airway suction, or tube disconnection), we believe that procedures not yet completely based on evidence of effectiveness should be limited as much as possible during the COVID-19 pandemic.

Conflict of interest

The authors do not have any conflicts of interest to declare.