Multidisciplinary international expert consensus on perioperative airway management

Introduction

Perioperative airway management is critical for ensuring patient safety and optimizing surgical outcomes. Enhanced Recovery After Surgery (ERAS) protocols are now widely applied in clinical practice, with perioperative airway management being a crucial component of ERAS (1). Its clinical application can effectively reduce postoperative pulmonary complications, accelerate patient recovery, shorten the hospital length of stay (LOS), lower readmission and mortality rates, and reduce hospitalization costs. Previous consensus guidelines have strengthened surgeons’ understanding of airway management, lung function protection, and the reduction of pulmonary complications (2-4). This has facilitated a more effective and integrated approach to perioperative airway management and ERAS.

In recent years, new evidence in airway management has highlighted the need to update the multidisciplinary international expert consensus on perioperative airway management. This update integrates clinical practice experience with the latest research findings from both domestic and international studies to ensure more rational and standardized application of airway management in clinical practice.

Methods

A comprehensive search was conducted on PubMed. Original articles published in English before June 2024 were included. Combinations of the following terms were searched online: “airway management”, “multidiscipline”, “perioperative”, “preoperative”, “postoperative”, “lung function”, “rehabilitation”, “anesthesia”, “tubeless”, “surgery”, “asthma”, “obstructive sleep apnea syndrome”, “pulmonary fibrosis”, and “chronic obstructive pulmonary disease”. Furthermore, previous consensuses about airway management have also been scanned to avoid missing any qualified study.

To develop this consensus recommendation, we employed a modified Delphi method involving the following steps. A panel consisting of 62 domestic experts with relevant expertise in thoracic surgery, otolaryngology, general surgery, cardiac surgery, anesthesiology, and nursing fields were assembled to discuss and vote on preliminary recommendations. During an initial face-to-face meeting, all domestic experts engaged in discussions followed by a voting process to establish consensus on each recommendation. A minimum threshold of 70% agreement among participants was set to define consensus. Following the initial consensus-building phase, the draft recommendations were circulated to 18 international experts via email for their feedback and suggestions. This step ensured that the recommendations were informed by diverse perspectives and expertise. The titles of all discussed topics along with the rate of agreement for each are listed in Table 1. Personal points of view of different experts is included in the Appendix 1.

Consensus 1: preoperative airway preparation

• In which cases do you recommend that pulmonary ventilation and diffusion tests be routinely indicated? Preoperative pulmonary ventilation and diffusion function tests are recommended for elderly patients and those with pulmonary comorbidities. For patients undergoing pulmonary surgery, these tests are routinely required as they can not only predict the risk of perioperative complications and long-term quality of life, but also provide an objective basis for surgical decision-making (agreement rate 90%).
• For which patients are preoperative exercise tests necessary? Preoperative exercise tests are recommended for elderly patients and those with cardiopulmonary diseases. Exercise tests are recommended for pulmonary surgery when either the predicted postoperative forced expiratory volume in the first second (ppoFEV1) or the predicted postoperative diffusion capacity of carbon monoxide (ppoDLco) is below 60% (agreement rate 85%).
• Under what circumstances is arterial blood gas analysis advised? Arterial blood gas analysis is recommended for patients with symptoms of respiratory failure, severe respiratory comorbidities, or when pulmonary function tests are difficult to perform (agreement rate 97.5%).
• How should a patient be managed if airway hyperresponsiveness (AHR), unstable asthma or chronic obstructive pulmonary disease (COPD) surgery be delayed in favor of using inhaled corticosteroids (ICS) with bronchodilators? If a patient is found to have AHR, unstable asthma or COPD during preoperative evaluation, the use of ICS in combination with bronchodilators, such as ICS + long-acting beta-agonists (LABA) or ICS + LABA + long-acting muscarinic antagonists (LAMA), is recommended and surgery should be temporarily delayed until a new evaluation is obtained, if possible (agreement rate 75%).
• Who should receive preoperative breathing and aerobic training? Preoperative breathing and aerobic training are recommended, especially for patients at high risk of postoperative complications, as they benefit more from prehabilitation (agreement rate 85%).
• How should smoking cessation be managed prior to surgery? Smoking cessation at least 2 weeks before surgery is recommended. Patients should still be encouraged to quit smoking for as long as possible if they cannot follow a 2-week smoking cessation plan (agreement rate 75%).
• For which patients is preoperative weight management and obstructive sleep apnea syndrome (OSAS) screening advised? Preoperative weight management is recommended for patients who are malnourished or obese before elective surgery. High-risk obese patients should also undergo screening for OSAS (agreement rate 75%).
• What should be done if airway obstruction is found on preoperative computed tomography (CT)? Bronchoscopy is advised for patients with airway stenosis seen on chest CT scan (agreement rate 100%).

Preoperative pulmonary function assessment plays a critical role in predicting surgical outcomes and postoperative complications, as well as guiding the selection of surgical type and scope. Pulmonary ventilation and diffusion function tests are routine preoperative examinations in pulmonary surgery. For non-thoracic surgery patients, these tests are recommended for elderly patients and those with heart or lung diseases. Due to significant individual differences, relying solely on the absolute value of forced expiratory volume in the first second (FEV1) for screening may be biased. By considering factors such as gender, height, weight, and age, the use of ppoFEV1 as a percentage of the expected value better addresses individual variability (5). The diffusion function is primarily measured through the diffusion capacity of carbon monoxide (DLco) (6). Both FEV1 and DLco are independent factors in predicting postoperative complications and mortality following pulmonary resection. When both ppoFEV1 and ppoDLco are greater than 60%, surgery is considered low risk (7). Puente-Maestú et al. (8) show that postoperative complications significantly increase when ppoFEV1 or ppoDLco is as low as 30% to 40%. Ferguson et al. (9) show that when ppoFEV1 or ppoDLco is <30%, the all-cause mortality rate rises significantly. When both ppoDLco and ppoFEV1 are greater than or equal to 40% but either or both are less than 60%, a low-technology cardiopulmonary exercise test (CPET) like a stair-climbing test (SCT) or a shuttle walk test (SWT) is required. If either ppoFEV1 or ppoDLco is less than 40%, a comprehensive CPET is necessary, and a multidisciplinary consultation with anesthesiology and pulmonology is recommended to assess surgical risk (10). Preoperative pulmonary function tests can also help detect undiagnosed chronic respiratory diseases, such as COPD (11). If preoperative pulmonary function show airflow limitation, such as FEV1/FVC <0.7, bronchodilator test is advised and a respiratory consultation should be requested to determine whether there is COPD or asthma (12,13).

Preoperative exercise tests, including CPET and low technology exercise tests, help assess cardiopulmonary capacity. For non-pulmonary surgery, exercise tests are recommended for elderly patients and those with underlying cardiopulmonary diseases. Preoperative exercise tests are recommended for patients whose ppoFEV1 or ppoDLco is less than 60% for pulmonary surgery. SCT or SWT can be considered when ppoFEV1 and ppoDLco are both greater than or equal to 40% but either is less than 60% (14,15). A meta-analysis from Boujibar et al. (16) demonstrated that an SCT distance of less than 10 meters was associated with a high risk for surgery, with a relative risk (RR) of 2.34 [95% confidence interval (CI): 1.59–3.43]. Win et al. (17) suggested SWT <400 meters indicates high surgical risk. CPET is recommended when either ppoFEV1% or ppoDLco% is less than 40% or SCT or SWT indicates high risk. A meta-analysis from Arbee-Kalidas et al. (18), including 37 studies with 6,450 patients, suggested that a higher maximum oxygen consumption (VO₂max) was significantly associated with a lower risk of mortality [mean difference (MD) =3.66; 95% CI: 0.88–6.43] and fewer complications (MD =2.06; 95% CI: 1.12–3.00). Patients with a VO₂max greater than 20 mL/(kg·min) are considered relatively safe for surgery (19). When VO₂max is between 10–20 mL/(kg·min), the extent of surgical resection should be calculated based on the patient’s specific condition. VO₂max less than 10 mL/(kg·min) is associated with high postoperative mortality and complication rates (15,20). For patients with exercise tests, previous history of coronary disease, as well as active symptoms indicating high risk, further cardiology assessment with cardiac coronary CT or coronary angiography is necessary to evaluate coronary artery status. Additionally, a multidisciplinary consultation involving cardiology, pulmonology, and anesthesiology is recommended to assess the surgical risk thoroughly (21).

Arterial blood gas analysis can be performed on patients with symptoms of respiratory failure, severe respiratory diseases, or when pulmonary function tests cannot be obtained. This test can reveal conditions such as hypoxemia or hypercapnia (22). Routine blood gas analysis is unnecessary for younger patients in good physical condition, as arterial blood gas sampling is painful and offers limited clinical benefit.

Patients with AHR are at an increased risk of experiencing bronchospasm during and after surgery. If the preoperative evaluation reveals that a patient has AHR, unstable asthma or COPD, pre-treatment with ICS combined with bronchodilators, such as ICS + LABA or ICS + LABA + LAMA, is recommended. This pre-treatment strategy helps to stabilize the airway, reduce inflammation, and minimize the risk of perioperative respiratory complications.

Preoperative exercises like breathing exercises and aerobic training are beneficial. A meta-analysis from Xu et al. (23) found that preoperative interventions significantly reduced the risk of postoperative pulmonary complications [odds ratio (OR) =0.32; 95% CI: 0.22–0.47] and shortened the LOS [weighted mean difference (WMD) =−1.68 days; 95% CI: −2.23 to −1.13]. A meta-analysis from Gravier et al. (24), including 14 studies with involvement of 791 participants, reported that preoperative exercise could reduce postoperative complications (RR =0.58; 95% CI: 0.45–0.75) and recommended prehabilitation programs of no less than 2 weeks to improve preoperative criteria and reduce postoperative complications effectively. We also support the effectiveness of such short-term exercise programs, as they are unlikely to delay surgery and show good patient compliance. It is important to note that a previous study suggested that the benefits of preoperative exercise may be insignificant for low-risk patients (25). However, high-risk patients, particularly those with poor preoperative lung function or concomitant lung diseases, are more likely to benefit from preoperative exercise (26).

Several studies have shown that active smoking increases the risk of postoperative complications. A meta-analysis from Mills et al. (27), including 6 randomized controlled trials (RCTs) and 15 observational studies, indicated that smoking abstinence for at least 4 weeks or longer may be associated with reduced perioperative respiratory complications. However, the included RCTs did not specifically study the impact of smoking cessation on lung surgery. Fukui et al. (28) suggested that smoking cessation at any time before surgery benefits postoperative outcomes for lung resection. Kadomatsu et al. (29) did not find a definitive relationship between the duration of smoking cessation and the incidence of postoperative complications, suggesting that it is unnecessary to delay surgery for the sake of smoking cessation duration. Considering that the previously recommended 4-week cessation period might delay surgery, we recommend at least 2 weeks of smoking cessation before surgery (27). If the patients are unable or do not have the time to follow a 2-week smoking cessation plan, such as those with large central tumor, they should still be encouraged to quit smoking for whatever duration possible. The smoking cessation of 2 weeks should not be treated as an “all or none” rule.

Studies have reported more significant morbidity and longer LOS in underweight patients compared to obese or overweight patients (30-32). Obesity itself is not a contraindication for lung resection, but it may be associated with increased difficulties with intubation and longer surgery times (32). The previous study also indicates that obese patients may have increased airway inflammation and a higher risk for OSAS (31). Therefore, it is recommended that underweight patients improve their nutritional status. Obese patients, especially those undergoing neoadjuvant therapy or elective surgeries, should aim for weight reduction. Additionally, they should undergo OSAS screening using tools like the Nutritional Risk Score (NRS), the Malnutrition Universal Screening Tool (MUST), and the Subjective Global Assessment.

Second-time thoracic surgery brings its own technical challenges. Second-time surgery on the same side is associated with significant intrapleural adhesions, longer operative duration and a greater likelihood of needing to perform surgery via thoracotomy. Second-time surgery performed on the opposite side to the first operation means that single lung ventilation is a particular challenge, as the ventilated lung may only consist of a single lobe. For patients undergoing a second-time lung surgery, blood flow and ventilation redistribution can result in disproportionate lobe function. Pulmonary imaging with ventilation-perfusion is recommended to assess the function of each lobe (33,34). This helps determine the ventilation and perfusion status of each lobe, guiding the surgical plan and avoiding severe pulmonary function impairment. Bronchoscopy is advised for patients with airway obstruction seen on a chest CT scan as this may add specific information about the airway involvement, the need for preoperative rigid endoscopy to recover the bronchial canalization and accurately evaluate the base implant of the tumor.

Consensus 2: anesthesia management

• For which procedures is a laryngeal mask airway recommended to reduce airway epithelial damage? Using a laryngeal mask airway for airway management can be applied in various types of surgical procedures to reduce airway epithelial damage caused by endotracheal intubation. For thoracic surgery, patients who are suitable for non-intubated spontaneous breathing anesthesia [tubeless video-assisted thoracoscopic surgery (VATS) technique] should be taken to consideration (agreement rate 95%).
• How should endotracheal intubation be performed to follow lung-protective principles? When performing endotracheal intubation, select the appropriate tube size and use a video laryngoscope for guidance. During ventilation, follow lung-protective ventilation principles (agreement rate 100%).
• Which anesthesia maintenance strategy is recommended for faster postoperative extubation? Intravenous propofol, combined with volatile anesthesia, is recommended as the primary maintenance drug. Short-acting anesthetics should be used to facilitate faster postoperative extubation (agreement rate 100%).
• How should a muscle relaxant be selected? The use of a steroid muscular relaxant is recommended because the antagonist sugammadex can rapidly and completely reversed it, facilitating faster extubation (agreement rate 90%).
• How should intraoperative bronchospasm be managed? Intraoperative bronchospasm should be relieved with bronchodilators and intravenous corticosteroids or aminophylline (agreement rate 100%).
• What should be considered in fluid management during anesthesia? Fluid management during anesthesia is crucial to prevent postoperative pulmonary edema or sputum retention caused by airway dryness (agreement rate 100%).

The primary goals of intraoperative anesthesia management include minimizing pulmonary and systemic inflammatory responses and facilitating early extubation. A laryngeal mask is a supraglottic airway device that does not require insertion into the trachea, theoretically reducing damage to the airway epithelium. It can be easily and safely used for laryngotracheal surgery, in particular for the airway management during laryngotracheal and cervical trachea resection and reconstruction (35). Many disciplines have conducted RCTs to verify the feasibility of laryngeal mask airway management (36-39). For selected patients, the tubeless VATS technique is the optimal choice for ERAS in experienced centers. Compared to the tracheal intubation method, the tubeless VATS technique uses a laryngeal mask, which avoids damage to the airway mucosa and vocal cords caused by intubation, thereby reducing the incidence of postoperative coughing (40,41). The tubeless VATS technique minimizes the use of muscle relaxants, enhancing postoperative tracheal ciliary movement and sputum clearance. Additionally, it can shorten the LOS and benefit postoperative cognitive function (41,42). The tubeless VATS technique uses a laryngeal mask to assist in airway management, maintaining low tidal volume ventilation to ensure adequate oxygenation (43,44). Reasons for converting from tubeless VATS technique to intubation include persistent hypoxemia (PaO₂ <60 mmHg or SpO₂ <90%), severe hypoxemia (PaO₂ <55 mmHg or SpO₂ <85%), severe hypercapnia (PaCO₂ >70–80 mmHg), and acidosis (pH <7.1) (45,46). For safety reasons, a single-lumen endotracheal tube should always be prepared for emergencies, and a bronchoscope should be available to ensure safe access to the bronchial system (47). Anesthesiologists should be skilled in intubating patients in the lateral decubitus position. Tubeless VATS is not yet fully implemented worldwide, but it is being actively promoted globally. In China, its adoption is progressing very rapidly. Further research is needed to better highlight its clinical utility and support its broader application in clinical practice.

If tubeless VATS surgery is not possible or safety conditions are not met, double lumen tube placement continues to be the preferred option in most thoracic surgery centers.

The selection of an appropriately sized endotracheal tube is paramount to minimizing airway damage during endotracheal intubation. Applying lidocaine or beclomethasone spray during intubation can increase patient comfort with the tube and effectively reduce postoperative coughing (48,49). Using a video laryngoscope for intubation guidance helps the speed and success of positioning and reduces mal-positioning rates (50,51). In thoracic surgery, a double-lumen tube (DLT) is preferred for single-lung ventilation. A tidal volume of 6–8 mL/kg ideal body weight should be used during double-lung ventilation, along with appropriate positive end-expiratory pressure (PEEP) and lung recruitment maneuvers. Before one-lung ventilation, preoxygenation with pure oxygen can accelerate the collapse of the surgical side lung (1). During one-lung ventilation, a tidal volume of ≤6 mL/kg ideal body weight should be set, along with PEEP of 5–10 cmH₂O, and the lowest fraction of inspired oxygen (FiO₂) necessary to maintain satisfactory arterial oxygen saturation (52). Peak airway pressure should not exceed 35 cmH₂O, and plateau pressure should not exceed 25 cmH₂O, PaCO₂ is usually maintained at 35–45 mmHg (53). Both volume-controlled and pressure-controlled ventilation modes can be used, but pressure-controlled ventilation is recommended first if there are high-risk factors for lung injury (53).

Intravenous anesthesia with propofol and remifentanil, combined with inhalational anesthesia using sevoflurane or desflurane, can be used to maintain anesthesia in thoracic surgery (54). Using short-acting anesthetics as much as possible can shorten postoperative extubation time and reduce complications (1). Volatile anesthesia can reduce systemic and local inflammatory responses, but only subgroup analyses suggest that patients with severe surgical injuries benefit from the anti-inflammatory effects of volatile anesthetics (55). This anti-inflammatory effect does not show clinical significance in less severe cases. Tubeless VATS technique using vagal nerve blockade, intercostal nerve blockade, and pleural surface local anesthetic spraying to anesthetize specific nerves or regions, can lead to lower amounts of anesthetics used (56-58).

We recommend using steroid muscular relaxants, such as rocuronium (59,60). As non-steroid muscular relaxants cannot be completely reversed, whereas steroid muscular relaxants can be fully antagonized by sugammadex (61). Sugammadex is significantly faster than neostigmine in reversing neuromuscular blockade, with 2 mg/kg of sugammadex reversing moderate blockade 10.22 minutes (6.6 times) quicker than neostigmine 0.05 mg/kg, and 4 mg/kg reversing deep blockade 45.78 minutes (16.8 times) faster than neostigmine 0.07 mg/kg (62). In addition, sugammadex appears to have a better safety profile than neostigmine, with 40% fewer adverse events (62).

In the event of intraoperative bronchospasm, it should be promptly managed to ensure airway patency. Continuous oxygen inhalation should be maintained to provide adequate ventilation. The first choice for inhaled bronchodilators is terbutaline spray, administered repeatedly through the mouth or endotracheal tube, in combination with intravenous corticosteroids or aminophylline to relieve bronchospasm (63). These measures can quickly alleviate bronchospasm and ensure the smooth progression of the surgery.

Controlling the speed and volume of fluid administration during anesthesia is essential. Excessive or rapid infusion can lead to pulmonary edema and diffusion impairment (64). Insufficient fluid administration or excessive diuresis can cause dehydration, airway dryness, weakened mucociliary clearance, sputum retention, and even atelectasis. Additionally, if the anesthesia duration is prolonged or if there are excessive airway secretions, intermittent bronchoscopic suctioning should be performed promptly to maintain airway patency.

Consensus 3: surgical approach

• How important is preoperative surgical path planning for improving surgical outcomes? Preoperative surgical path planning is essential to shorten the operation time and preserve normal structures that do not need to be damaged (agreement rate 100%).
• How should lung tissue be handled during pulmonary surgery to ensure both tumor resection and preservation? For pulmonary surgery, it is recommended to preserve as much lung tissue as possible while ensuring radical tumor resection. Sleeve resection is recommended even in case of patient with good functional status and after neoadjuvant therapy (agreement rate 90%).
• What precautions should be taken during laryngotracheal surgery to protect the airway? For laryngotracheal surgery, it is essential to prevent foreign objects from entering the airway and to protect the airway from damage by surgical instruments. Airway management should be crucial even during tracheal resection by cross-field intubation (agreement rate 100%).

Preoperative surgical planning is crucial. Shortening surgery time can reduce anesthesia duration and airway intubation time, thereby lowering the risk of postoperative airway complications. Ideally, surgical techniques should employ minimally invasive methods and instrumention to minimize injury of tissue. If conditions permit, it is advisable to perform preoperative three-dimensional reconstruction to clarify the surgical approach (65). Preserving typical structures in the surgical area as much as possible, such as branches of the vagal nerve and bronchial arteries during lung surgery, can reduce intraoperative and postoperative airway injury and inflammatory responses, helping to minimize postoperative cough (66,67).

For pulmonary surgery it is recommended that as much lung tissue is preserved as possible while meeting the oncological requirement (68). Minimizing lung tissue loss and avoiding excessive lymph node dissection are crucial to reducing postoperative respiratory complications. The JCOG0802 multi-center study (69) found that anatomical segmentectomy improved overall survival compared to lobectomy for peripheral stage IA non-small cell lung cancer (NSCLC), although it nearly doubled the local recurrence rate. Similarly, the CALGB 140503 study (70) showed no significant differences in overall survival or disease-free survival between sublobar resection and lobectomy for node-negative, peripheral stage IA NSCLC. These large, rigorous studies suggest that sublobar resection may be non-inferior in survival for patients with small, peripheral tumors. Moreover, less extensive resection implies less surgical trauma, which helps reduce airway complications caused by inflammation (41). Sleeve resection (bronchial and/or vascular) can avoid pneumonectomy in many cases of centrally-located lung cancer. It is recommended even in case of patient with good functional status and after neoadjuvant therapy (71). In case of laryngotracheal resection and reconstruction a laryngeal mask can be safely and easily used, moreover is recommended the use of cross-field ventilation of the distal tracheal stump after tracheal resection, and during the end-to-end reconstruction phase (35).

For otolaryngology surgeries, particularly those involving the use of a suspension laryngoscope within the airway, it is essential to ensure that the endotracheal tube cuff fully seals the airway to prevent blood, secretions, or foreign objects from entering the trachea during the procedure. Additionally, precautions must be taken in order to avoiding the ignition of flammable gases by laser or other thermal devices, which could damage the airway. Care should also be taken to prevent excessive airway pressure caused by surgical instruments’ compression of the endotracheal tube by surgical instruments, as this can lead to CO₂ retention.

Consensus 4: postoperative airway management

• How can persistent cough after pulmonary resection be managed? Postoperative ICS + LABA + LAMA can help alleviate persistent cough after pulmonary resection (agreement rate 80%).
• When should early mobilization be initiated post-surgery, and what measures should be taken for patients who cannot mobilize? Patients who are able to walk should begin early mobilization. For those who cannot mobilize, healthcare personnel should assist with frequent repositioning to prevent hypostatic pneumonia (agreement rate 100%).
• What strategies are recommended to prevent postoperative sputum retention? Preventing postoperative sputum retention is crucial. Effective early postoperative cough, combined with mechanical sputum clearance and the use of intravenous ambroxol or oral acetylcysteine to reduce sputum viscosity, are recommended (agreement rate 100%).
• Should postoperative rehabilitation exercise be implemented after thoracic surgery? Postoperative individualized rehabilitation exercise is recommended for thoracic surgery, even though it is controversial if it reduces postoperative complications or shortens LOS. However, it can improve activity levels and quality of life after surgery (agreement rate 100%).
• When can continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) be considered post-surgery? CPAP or NIV can be considered for acute respiratory failure but are not used routinely (agreement rate 85%).
• What is the impact of postoperative pain and how can it be controlled? Postoperative pain can limit adequate sputum clearance, especially after chest and abdominal surgeries. Effective postoperative pain relief facilitates sputum clearance and reduces pulmonary complications. We recommend a multimodal analgesia regimen based on nonsteroidal anti-inflammatory drugs (NSAIDs), while minimizing the use of opioid analgesics (agreement rate 95%).
• When should a postoperative chest drainage tube be removed? If there is no lung air leak, the postoperative chest drainage tube should be removed promptly. Be vigilant for pleural effusion following major upper abdominal surgery (agreement rate 95%).

The incidence of postoperative persistent coughing is relatively high and significantly impacts quality of life. Sawada et al. (72) reported that ICS and bronchodilators can alleviate postoperative coughing. A recent RCT that was presented at the American Association of Thoracic Surgery demonstrated that postoperative use of the ICS + LABA + LAMA significantly reduced the incidence of persistent postoperative cough (13.73% vs. 40.38%, P<0.05) (73). This may be explained by the fact that surgical trauma can induce airway inflammatory responses, leading to AHR and bronchospasm (74). The combination of ICS and bronchodilators reduces inflammation and airway spasms, thereby decreasing the occurrence of postoperative cough.

Patients who are able to walk should begin early mobilization as soon as possible. Early mobilization is beneficial because it helps improve circulation, reduces the risk of blood clots, and promotes faster recovery (75). Additionally, it can enhance muscle strength and prevent muscle atrophy, thereby improving overall physical function. For patients who are intubated or unable to ambulate, healthcare personnel should assist with frequent repositioning. Repositioning is crucial in preventing hypostatic pneumonia, which can occur when patients remain in one position for too long (76). By regularly changing positions, the lungs are encouraged to fully expand, which helps in clearing secretions and maintaining respiratory function. Additionally, repositioning helps prevent pressure ulcers and other complications associated with prolonged immobility, contributing to a quicker recovery process.

Promoting clearance of airway secretions is critical to postoperative airway management, as poor secretion clearance can lead to inadequate lung re-expansion and an increased risk of pulmonary infection (77). Mechanical airway clearance can effectively promote secretion removal (78). Intravenous ambroxol or oral acetylcysteine can encourage the clearance of sputum (79,80). Effective active coughing postoperatively also aids in secretion removal (81).

Wang et al. (82) suggested that postoperative exercise training could significantly improve the quality of life of patients undergoing pulmonary surgery, as measured using short form 36 healthy survey (SF-36) physical and mental domain scores. Additionally, postoperative exercise may improve physical activity and cough symptoms after pulmonary resection (83,84). However, a meta-analysis from Xu et al. (23) suggested interventions delivered during the immediate postoperative period did not have any significant effects on either postoperative pulmonary complication (OR =0.85; 95% CI: 0.56 to 1.29) or LOS (WMD =−0.23 days; 95% CI: −1.08 to 0.63). Taken together, based on current evidence, postoperative exercise may or may not reduce the occurrence of postoperative complications or shorten LOS, but it probably improves the quality of life, postoperative activity level and cough symptoms.

A multicenter RCT conducted by Abrard et al. (85) where the most patients underwent cardiac and pulmonary surgeries demonstrated that prophylactic NIV does not reduce the incidence of acute respiratory failure. Lorut et al. (86) suggested prophylactic postoperative NIV did not reduce the rate of adverse events in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of intensive care unit (ICU) and hospital stay. A meta-analysis by Lockstone et al. (87), which included 17 studies, confirmed that prophylactic postoperative CPAP or NIV did not reduce postoperative pulmonary complications. Although these patients would seem to be the ones most likely to benefit with postoperative non-invasive ventilatory support, yet well-designed RCTs have confirmed its ineffectiveness. Thus, the routine use of CPAP or NIV to prevent postoperative complications has yet to be proven effective to date. However, for patients with postoperative acute respiratory failure, CPAP and NIV are still valuable as they help reduce the reintubation rate and improve perioperative outcomes (88,89). High-flow nasal cannula (HFNC) offers several advantages, including improved oxygenation, better patient comfort, and reduced airway resistance compared to traditional oxygen therapy methods. Post hoc analysis of an RCT (90) showed HFNC is not inferior to NIV in terms of treatment failure rates (13.3% vs. 15.4%, respectively, P=0.62), ICU mortality (2.2% vs. 5.9%, P=0.22), length of ICU stay (median 5.0 vs. 4.0 days, P=0.63), or length of hospital stay (median 10.0 vs. 11.1 days, P=0.71). However, skin breakdown at 24 hours was significantly more common with NIV than with HFNC (9.2% vs. 1.6%, respectively, P=0.01). Furthermore, when acute respiratory failure does occur, HFNC can be an effective treatment modality either on its own or in conjunction with CPAP or NIV (91).

Postoperative pain can limit effective coughing, leading to inadequate clearance of sputum and airway secretions. This increases the risk of atelectasis and pulmonary infections. Therefore, individualized pain management should be emphasized, and preventive and multimodal analgesia should be advocated. Using NSAIDs as the foundation of a multimodal pain management approach can reduce the need for opioids (92). This can be combined with various methods to enhance pain control, such as patient-controlled analgesia (PCA) pumps, local wound infiltration, intercostal nerve blocks, and paravertebral blocks (93-95).

For thoracic surgery, the drainage tube should be removed as soon as possible if there is no pulmonary air leak. A meta-analysis conducted by Zhang et al. (96) suggests that it is generally safe to remove the drainage tube when the 24-hour drainage volume is less than 300 mL, provided that bleeding and chylothorax are excluded. Additionally, other prospective studies have demonstrated that the removal of the drainage tube is safe when the volume is less than 450–500 mL (97,98).

Consensus 5: management of coexisting respiratory diseases

• What should be considered during the perioperative period for patients with asthma? It is recommended that patients with asthma control their symptoms as much as possible before surgery. Perioperative bronchospasm should be closely monitored (agreement rate 95%).
• What should be considered during the perioperative period for patients with COPD? ICS + LABA + LAMA perioperatively is recommended for patients with COPD. Be vigilant for postoperative respiratory failure and provide respiratory support promptly if needed (agreement rate 90%).
• What should be considered during the perioperative period for patients with OSAS? Monitor for perioperative hypoxemia in patients with OSAS. Tracheal intubation is recommended for surgery, and postoperative care should avoid the supine position to prevent airway obstruction (agreement rate 85%).
• What should be considered during the perioperative period for patients with pulmonary fibrosis? For patients with pulmonary fibrosis, there are higher postoperative complications and long-term mortality rates. A sub-lobar resection may help reduce acute exacerbation of postoperative pulmonary fibrosis (agreement rate 95%).
• When should a multidisciplinary consultation be considered for patients with complex respiratory conditions? A multidisciplinary consultation is recommended for patients with multiple respiratory diseases or complex respiratory conditions to evaluate surgical risk (agreement rate 100%).

Patients with a recent history of acute exacerbation of asthma or who have experienced acute exacerbations have a higher likelihood of bronchospasm during and after surgery (99). Therefore, it is crucial to assess asthma control preoperatively. Patients with well-controlled asthma should maintain their current medication regimen before surgery. Patients with poorly controlled asthma should upgrade their regimens to ICS + LABA, ICS + LABA + LAMA, or even add systemic corticosteroids. Ideally, surgery should be performed after achieving complete asthma control. If asthma cannot be controlled in the short term or if the patient has a history of acute exacerbation within the past 6 months, a reevaluation of surgical and anesthetic risk is required. Preoperative use of short-term systemic corticosteroids for 3–5 days may reduce the likelihood of intraoperative bronchospasm (100). During intubation, gentle technique is essential as it can trigger bronchospasm. Postoperative NIV or CPAP may benefit patients with persistent airway spasms after extubation.

The perioperative administration of ICS + LABA + LAMA can effectively improve airflow limitation in COPD, suppress inflammatory responses, reduce airway spasms, and alleviate lung hyperinflation and respiratory symptoms. Mucolytics should be used preoperatively for patients with excessive airway secretions (101). Protective ventilation strategies during surgery are recommended. It is essential to monitor closely for signs of respiratory distress after extubation. If such symptoms arise, prompt use of CPAP or NIV is necessary to ensure perioperative safety. Perioperative combined use of ICS and bronchodilators can effectively improve patients’ respiratory function (102). Using ICS + LABA + LAMA is better than LABA + LAMA in improving lung function and postoperative outcomes in patients with lung cancer combined with COPD (103).

Patients with OSAS are prone to airway obstruction and hypoxemia during the perioperative period. If hypoxemia is present preoperatively, NIV or CPAP is recommended. During anesthesia, tracheal intubation is preferred for airway management. It is advisable to perform the extubation when the patient is awake and in a lateral or semi-upright position to prevent airway obstruction. Maintaining a semi-upright position is essential to post-extubation, and continuing to use of NIV or CPAP, if used preoperatively is crucial. Continuous monitoring of blood oxygen saturation is crucial.

Patients with pulmonary fibrosis who undergo pulmonary surgery have higher rates of complications and long-term mortality (104-106). Preoperative ventilatory function is usually normal, so the evaluation of diffusion capacity is crucial. Nintedanib, an antifibrotic agent, is used in the treatment of pulmonary fibrosis; however, its perioperative use to mitigate acute exacerbations remains controversial due to concerns regarding its potential to delay wound healing while it has been shown to slow the progression of fibrosis (107). A smaller resection extent may reduce postoperative complications, and the tubeless VATS technique might be suitable for these patients (108,109).

A multidisciplinary consultation with departments such as pulmonology, cardiology, radiology, and anesthesiology is recommended for patients with multiple respiratory diseases or complex respiratory conditions. A comprehensive assessment by the multidisciplinary team can provide a better understanding of surgical risks and potential complications, helping to develop a safer and more personalized anesthetic and surgical plan. This approach maximizes surgical success and improves postoperative recovery outcomes.

Discussion

This consensus updates some previously established practices and introduces several new vital aspects. We want to emphasize the importance of perioperative medication management and minimizing unnecessary intubations.

For patients with preoperative uncontrollable asthma, AHR, and COPD, ICS + LABA + LAMA can be used perioperatively. ICS + LABA + LAMA is a helpful treatment option for the maintenance treatment of COPD (110). Its components help reduce airway inflammation, thereby alleviating AHR and bronchospasm. Postoperative early decline in lung function, persistent cough, and shortness of breath may be associated with AHR and bronchospasm (74). ICS + LABA + LAMA has been shown to reduce persistent postoperative cough in single-center study (73). Further multicenter clinical trials are needed to validate its efficacy in postoperative airway management.

With the continuous improvement of laryngeal mask devices, clinical research across various disciplines has indicated that the ventilation provided by laryngeal masks can meet the requirements of many types of surgical procedures (36,37,39,111). For example, in thoracic surgery, the tubeless VATS technique reduces airway damage caused by intubation and requires fewer opioids and muscle relaxants. Additionally, it results in shorter operation times, earlier mobilization, and a reduced postoperative LOS (112). Currently, this technique can be safely applied to minor procedures like wedge resections and complex thoracic surgeries such as tracheal operations and extensive mediastinal tumor resections (43,113). Despite the potential advantages of tubeless VATS technology, its adoption has been limited to only a few high specialized centers. This may be attributed to the need for close cooperation between surgeons and anesthesiologists. To maximize patient benefits, anesthesiologists and surgeons must learn and master this technique actively.

Conclusions

In conclusion, this consensus highlights the critical importance of airway management, emphasizing the need for advanced techniques and early interventions. Moving forward, it is crucial to place even greater emphasis on optimizing airway management to improve patient outcomes.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-273/prf

Funding: Supported by R&D Program of Guangzhou National Laboratory (Grant No. SRPG22-017).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-2025-273/coif). Maria Rodriguez reports consulting fees and payment for lectures/activities from AstraZeneca, Abex/Intuitive and Johnson and Johnson. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019;55:91-115. [Crossref] [PubMed]
2. Piccioni F, Droghetti A, Bertani A, et al. Recommendations from the Italian intersociety consensus on Perioperative Anesthesia Care in Thoracic surgery (PACTS) part 1: preadmission and preoperative care. Perioper Med (Lond) 2020;9:37. [Crossref] [PubMed]
3. Piccioni F, Droghetti A, Bertani A, et al. Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care. Perioper Med (Lond) 2020;9:31. [Crossref] [PubMed]
4. Zhi XY, Liu LXWriting Committee of Chinese Guidelines for Perioperative Airway Management in Thoracic Surgery. (2020 edition). Chinese Guidelines for Perioperative Airway Management in Thoracic Surgery (2020 edition). Chinese Journal of Clinical Thoracic and Cardiovascular Surgery 2021;28:251-62.
5. Bolliger CT, Jordan P, Solèr M, et al. Exercise capacity as a predictor of postoperative complications in lung resection candidates. Am J Respir Crit Care Med 1995;151:1472-80. [Crossref] [PubMed]
6. Ferguson MK, Little L, Rizzo L, et al. Diffusing capacity predicts morbidity and mortality after pulmonary resection. J Thorac Cardiovasc Surg 1988;96:894-900. [Crossref] [PubMed]
7. Licker MJ, Widikker I, Robert J, et al. Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg 2006;81:1830-7. [Crossref] [PubMed]
8. Puente-Maestú L, Villar F, González-Casurrán G, et al. Early and long-term validation of an algorithm assessing fitness for surgery in patients with postoperative FEV₁ and diffusing capacity of the lung for carbon monoxide < 40%. Chest 2011;139:1430-8. [Crossref] [PubMed]
9. Ferguson MK, Watson S, Johnson E, et al. Predicted postoperative lung function is associated with all-cause long-term mortality after major lung resection for cancer. Eur J Cardiothorac Surg 2014;45:660-4. [Crossref] [PubMed]
10. Brunelli A, Kim AW, Berger KI, et al. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e166S-90S.
11. Liang BM, Lam DC, Feng YL. Clinical applications of lung function tests: a revisit. Respirology 2012;17:611-9. [Crossref] [PubMed]
12. Johannessen A, Lehmann S, Omenaas ER, et al. Post-bronchodilator spirometry reference values in adults and implications for disease management. Am J Respir Crit Care Med 2006;173:1316-25. [Crossref] [PubMed]
13. Annangi S, Coz-Yataco AO. Clinical Implications of Bronchodilator Testing: Diagnosing and Differentiating COPD and Asthma-COPD Overlap. Respir Care 2022;67:440-7. [Crossref] [PubMed]
14. Novoa NM, Esteban P, Rodriguez M, et al. Functional evaluation before lung resection: searching for a low technology test in a safer environment for the patient: a pilot study. Eur J Cardiothorac Surg 2017;51:856-60. [Crossref] [PubMed]
15. Holden DA, Rice TW, Stelmach K, et al. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest 1992;102:1774-9. [Crossref] [PubMed]
16. Boujibar F, Gillibert A, Gravier FE, et al. Performance at stair-climbing test is associated with postoperative complications after lung resection: a systematic review and meta-analysis. Thorax 2020;75:791-7. [Crossref] [PubMed]
17. Win T, Jackson A, Groves AM, et al. Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer. Thorax 2006;61:57-60. [Crossref] [PubMed]
18. Arbee-Kalidas N, Moutlana HJ, Moodley Y, et al. The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis. PLoS One 2023;18:e0295430. [Crossref] [PubMed]
19. Brunelli A, Belardinelli R, Refai M, et al. Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection. Chest 2009;135:1260-7. [Crossref] [PubMed]
20. Bechard D, Wetstein L. Assessment of exercise oxygen consumption as preoperative criterion for lung resection. Ann Thorac Surg 1987;44:344-9. [Crossref] [PubMed]
21. Nwaejike N, Elbur E, Malagon I, et al. Is there a role for the high-risk multidisciplinary team meeting in thoracic surgery? Interact Cardiovasc Thorac Surg 2016;22:397-400. [Crossref] [PubMed]
22. Markou NK, Myrianthefs PM, Baltopoulos GJ. Respiratory failure: an overview. Crit Care Nurs Q 2004;27:353-79. [Crossref] [PubMed]
23. Xu X, Cheung DST, Smith R, et al. The effectiveness of pre- and post-operative rehabilitation for lung cancer: A systematic review and meta-analysis on postoperative pulmonary complications and length of hospital stay. Clin Rehabil 2022;36:172-89. [Crossref] [PubMed]
24. Gravier FE, Smondack P, Prieur G, et al. Effects of exercise training in people with non-small cell lung cancer before lung resection: a systematic review and meta-analysis. Thorax 2022;77:486-96. [Crossref] [PubMed]
25. Karenovics W, Licker M, Ellenberger C, et al. Short-term preoperative exercise therapy does not improve long-term outcome after lung cancer surgery: a randomized controlled study. Eur J Cardiothorac Surg 2017;52:47-54. [Crossref] [PubMed]
26. Pu CY, Batarseh H, Zafron ML, et al. Effects of Preoperative Breathing Exercise on Postoperative Outcomes for Patients With Lung Cancer Undergoing Curative Intent Lung Resection: A Meta-analysis. Arch Phys Med Rehabil 2021;102:2416-2427.e4. [Crossref] [PubMed]
27. Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011;124:144-154.e8. [Crossref] [PubMed]
28. Fukui M, Suzuki K, Matsunaga T, et al. Importance of Smoking Cessation on Surgical Outcome in Primary Lung Cancer. Ann Thorac Surg 2019;107:1005-9. [Crossref] [PubMed]
29. Kadomatsu Y, Sugiyama T, Sato K, et al. Relationship of smoking cessation period with the incidence of complications in lung cancer surgery. Eur J Cardiothorac Surg 2022;62:ezac163. [Crossref] [PubMed]
30. Wang C, Guo M, Zhang N, et al. Association of body mass index and outcomes following lobectomy for non-small-cell lung cancer. World J Surg Oncol 2018;16:90. [Crossref] [PubMed]
31. Petrini F, Di Giacinto I, Cataldo R, et al. Perioperative and periprocedural airway management and respiratory safety for the obese patient: 2016 SIAARTI Consensus. Minerva Anestesiol 2016;82:1314-35. [PubMed]
32. Paul S, Andrews W, Osakwe NC, et al. Perioperative Outcomes after Lung Resection in Obese Patients. Thorac Cardiovasc Surg 2015;63:544-50. [PubMed]
33. Tulchinsky M, Fotos JS, Wechalekar K, et al. Applications of Ventilation-Perfusion Scintigraphy in Surgical Management of Chronic Obstructive Lung Disease and Cancer. Semin Nucl Med 2017;47:671-9. [Crossref] [PubMed]
34. Bourhis D, Robin P, Essayan M, et al. V/Q SPECT for the Assessment of Regional Lung Function: Generation of Normal Mean and Standard Deviation 3-D Maps. Front Med (Lausanne) 2020;7:143. [Crossref] [PubMed]
35. Maurizi G, Vanni C, Rendina EA, et al. Surgery for laryngotracheal stenosis: Improved results. J Thorac Cardiovasc Surg 2021;161:845-52. [Crossref] [PubMed]
36. Fabregat-López J, Garcia-Rojo B, Cook TM. A case series of the use of the ProSeal laryngeal mask airway in emergency lower abdominal surgery. Anaesthesia 2008;63:967-71. [Crossref] [PubMed]
37. Kang F, Li J, Chai X, et al. Comparison of the I-gel laryngeal mask airway with the LMA-supreme for airway management in patients undergoing elective lumbar vertebral surgery. J Neurosurg Anesthesiol 2015;27:37-41. [Crossref] [PubMed]
38. Kim DH, Park JY, Yu J, et al. Positive end-expiratory pressure increases arterial oxygenation in elderly patients undergoing urological surgery using laryngeal mask airway in lithotomy position. J Clin Monit Comput 2020;34:161-9. [Crossref] [PubMed]
39. Zhang Q, Sun Y, Wang B, et al. Comparative study of the Ambu® AuraOnce™ laryngeal mask and endotracheal intubation in anesthesia airway management during neurosurgery. J Int Med Res 2020;48: [Crossref] [PubMed]
40. Xia Z, Qiao K, He J. Recent advances in the management of pulmonary tuberculoma with focus on the use of tubeless video-assisted thoracoscopic surgery. J Thorac Dis 2017;9:3307-12. [Crossref] [PubMed]
41. Chen Z, Dong Q, Liang L. Effect of different thoracic anesthesia on postoperative cough. J Thorac Dis 2018;10:3539-47. [Crossref] [PubMed]
42. Hung MH, Chen JS, Cheng YJ. Precise anesthesia in thoracoscopic operations. Curr Opin Anaesthesiol 2019;32:39-43. [Crossref] [PubMed]
43. Caronia FP, Loizzi D, Nicolosi T, et al. Tubeless tracheal resection and reconstruction for management of benign stenosis. Head Neck 2017;39:E114-7. [Crossref] [PubMed]
44. Li S, Ai Q, Liang H, et al. Nonintubated Robotic-assisted Thoracic Surgery for Tracheal/Airway Resection and Reconstruction: Technique Description and Preliminary Results. Ann Surg 2022;275:e534-6. [Crossref] [PubMed]
45. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721-31. [Crossref] [PubMed]
46. Chen JS, Cheng YJ, Hung MH, et al. Nonintubated thoracoscopic lobectomy for lung cancer. Ann Surg 2011;254:1038-43. [Crossref] [PubMed]
47. Liu J, Cui F, Pompeo E, et al. The impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: a propensity score matching analysis. Eur J Cardiothorac Surg 2016;50:920-5. [Crossref] [PubMed]
48. Banihashem N, Alijanpour E, Hasannasab B, et al. Prophylactic Effects of Lidocaine or Beclomethasone Spray on Post-Operative Sore Throat and Cough after Orotracheal Intubation. Iran J Otorhinolaryngol 2015;27:179-84. [PubMed]
49. Sumathi PA, Shenoy T, Ambareesha M, et al. Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth 2008;100:215-8. [Crossref] [PubMed]
50. Lin W, Li H, Liu W, et al. A randomised trial comparing the CEL-100 videolaryngoscope(TM) with the Macintosh laryngoscope blade for insertion of double-lumen tubes. Anaesthesia 2012;67:771-6. [Crossref] [PubMed]
51. Purugganan RV, Jackson TA, Heir JS, et al. Video laryngoscopy versus direct laryngoscopy for double-lumen endotracheal tube intubation: a retrospective analysis. J Cardiothorac Vasc Anesth 2012;26:845-8. [Crossref] [PubMed]
52. Blank RS, Colquhoun DA, Durieux ME, et al. Management of One-lung Ventilation: Impact of Tidal Volume on Complications after Thoracic Surgery. Anesthesiology 2016;124:1286-95. [Crossref] [PubMed]
53. Brassard CL, Lohser J, Donati F, et al. Step-by-step clinical management of one-lung ventilation: continuing professional development. Can J Anaesth 2014;61:1103-21. [Crossref] [PubMed]
54. Sun B, Wang J, Bo L, et al. Effects of volatile vs. propofol-based intravenous anesthetics on the alveolar inflammatory responses to one-lung ventilation: a meta-analysis of randomized controlled trials. J Anesth 2015;29:570-9. [Crossref] [PubMed]
55. Beck-Schimmer B, Bonvini JM, Braun J, et al. Which Anesthesia Regimen Is Best to Reduce Morbidity and Mortality in Lung Surgery?: A Multicenter Randomized Controlled Trial. Anesthesiology 2016;125:313-21. [Crossref] [PubMed]
56. Fabo C, Oszlanyi A, Lantos J, et al. Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review. Front Surg 2021;8:818456. [Crossref] [PubMed]
57. Hung MH, Chan KC, Liu YJ, et al. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: a retrospective cohort study of 238 cases. Medicine (Baltimore) 2015;94:e727. [Crossref] [PubMed]
58. Hsiung PY, Shih PY, Wu YL, et al. Effects of nonintubated thoracoscopic surgery on postoperative neurocognitive function: a randomized controlled trial. Eur J Cardiothorac Surg 2024;65:ezad434. [Crossref] [PubMed]
59. Umari M, Falini S, Segat M, et al. Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice. J Thorac Dis 2018;10:S542-54. [Crossref] [PubMed]
60. Granell M, Parra MJ, Jiménez MJ, et al. Review of difficult airway management in thoracic surgery. Rev Esp Anestesiol Reanim (Engl Ed) 2018;65:31-40. [Crossref] [PubMed]
61. Carron M, Zarantonello F, Lazzarotto N, et al. Role of sugammadex in accelerating postoperative discharge: A meta-analysis. J Clin Anesth 2017;39:38-44. [Crossref] [PubMed]
62. Hristovska AM, Duch P, Allingstrup M, et al. Efficacy and safety of sugammadex versus neostigmine in reversing neuromuscular blockade in adults. Cochrane Database Syst Rev 2017;8:CD012763. [Crossref] [PubMed]
63. Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth 2009;103:i57-65. [Crossref] [PubMed]
64. Kim JH, Kim Y, Yoo K, et al. Prediction of Postoperative Pulmonary Edema Risk Using Machine Learning. J Clin Med 2023;12:1804. [Crossref] [PubMed]
65. Vervoorn MT, Wulfse M, Mohamed Hoesein FAA, et al. Application of three-dimensional computed tomography imaging and reconstructive techniques in lung surgery: A mini-review. Front Surg 2022;9:1079857. [Crossref] [PubMed]
66. Pan L, Zhou X, Xu C, et al. Effects of preserving the bronchial artery on cough after thoracoscopic lobectomy. Thorac Cancer 2021;12:2151-60. [Crossref] [PubMed]
67. Gu S, Wang W, Wang X, et al. Effects of Preserving the Pulmonary Vagus Nerve Branches on Cough After Pneumonectomy During Video-Assisted Thoracic Surgery. Front Oncol 2022;12:837413. [Crossref] [PubMed]
68. Sarna L, Evangelista L, Tashkin D, et al. Impact of respiratory symptoms and pulmonary function on quality of life of long-term survivors of non-small cell lung cancer. Chest 2004;125:439-45. [Crossref] [PubMed]
69. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet 2022;399:1607-17. [Crossref] [PubMed]
70. Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:489-98. [Crossref] [PubMed]
71. Maurizi G, D'Andrilli A, Anile M, et al. Sleeve lobectomy compared with pneumonectomy after induction therapy for non-small-cell lung cancer. J Thorac Oncol 2013;8:637-43. [Crossref] [PubMed]
72. Sawada S, Suehisa H, Yamashita M. Inhalation of corticosteroid and β-agonist for persistent cough following pulmonary resection. Gen Thorac Cardiovasc Surg 2012;60:285-8. [Crossref] [PubMed]
73. Dong J. The Efficacy And Safety Of Budesonide/Glycopyrronium/Formoterol Fumarate Co-suspension Metered Dose Inhaler For Cough After Lobectomy: A Single-Center, Open-Label, Randomized Clinical Trial. AATS Conference 2024.
74. Okamoto K, Hayashi K, Kaku R, et al. Airway inflammation and lung function recovery after lobectomy in patients with primary lung cancer. Gen Thorac Cardiovasc Surg 2021;69:297-302. [Crossref] [PubMed]
75. Hodgson CL, Capell E, Tipping CJ. Early Mobilization of Patients in Intensive Care: Organization, Communication and Safety Factors that Influence Translation into Clinical Practice. Crit Care 2018;22:77. [Crossref] [PubMed]
76. Kazaure HS, Martin M, Yoon JK, et al. Long-term results of a postoperative pneumonia prevention program for the inpatient surgical ward. JAMA Surg 2014;149:914-8. [Crossref] [PubMed]
77. Shin SH, Shin S, Im Y, et al. Effect of perioperative bronchodilator therapy on postoperative pulmonary function among lung cancer patients with COPD. Sci Rep 2021;11:8359. [Crossref] [PubMed]
78. Chinese Thoracic Society. Respiratory Care Group of Chinese Association of Chest Physicians Respiratory Career Development Committee, et al. Expert consensus on clinical application of mechanical airway clearance techniques. Zhonghua Jie He He Hu Xi Za Zhi 2023;46:866-79.
79. Wang S, Huang D, Ma Q, et al. Does ambroxol confer a protective effect on the lungs in patients undergoing cardiac surgery or having lung resection? Interact Cardiovasc Thorac Surg 2014;18:830-4. [Crossref] [PubMed]
80. Bastin AJ, Davies N, Lim E, et al. Systemic inflammation and oxidative stress post-lung resection: Effect of pretreatment with N-acetylcysteine. Respirology 2016;21:180-7. [Crossref] [PubMed]
81. de Sousa VE, Lopes MV, da Silva VM. Systematic review and meta-analysis of the accuracy of clinical indicators for ineffective airway clearance. J Adv Nurs 2015;71:498-513. [Crossref] [PubMed]
82. Wang J, Dong Y, Su J, et al. Postoperative exercise training improves the quality of life in patients receiving pulmonary resection: A systematic review and meta-analysis based on randomized controlled trials. Respir Med 2022;192:106721. [Crossref] [PubMed]
83. Luo N, Dai F, Wang X, et al. Pulmonary Rehabilitation Exercises Effectively Improve Chronic Cough After Surgery for Non-small Cell Lung Cancer. Cancer Control 2024;31: [Crossref] [PubMed]
84. Brocki BC, Andreasen JJ, Westerdahl E. Inspiratory Muscle Training in High-Risk Patients Following Lung Resection May Prevent a Postoperative Decline in Physical Activity Level. Integr Cancer Ther 2018;17:1095-102. [Crossref] [PubMed]
85. Abrard S, Rineau E, Seegers V, et al. Postoperative prophylactic intermittent noninvasive ventilation versus usual postoperative care for patients at high risk of pulmonary complications: a multicentre randomised trial. Br J Anaesth 2023;130:e160-8. [Crossref] [PubMed]
86. Lorut C, Lefebvre A, Planquette B, et al. Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial. Intensive Care Med 2014;40:220-7. [Crossref] [PubMed]
87. Lockstone J, Denehy L, Truong D, et al. Prophylactic Postoperative Noninvasive Ventilation in Adults Undergoing Upper Abdominal Surgery: A Systematic Review and Meta-Analysis. Crit Care Med 2022;50:1522-32. [Crossref] [PubMed]
88. Auriant I, Jallot A, Hervé P, et al. Noninvasive ventilation reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med 2001;164:1231-5. [Crossref] [PubMed]
89. Zhu GF, Wang DJ, Liu S, et al. Efficacy and safety of noninvasive positive pressure ventilation in the treatment of acute respiratory failure after cardiac surgery. Chin Med J (Engl) 2013;126:4463-9. [Crossref] [PubMed]
90. Stéphan F, Bérard L, Rézaiguia-Delclaux S, et al. High-Flow Nasal Cannula Therapy Versus Intermittent Noninvasive Ventilation in Obese Subjects After Cardiothoracic Surgery. Respir Care 2017;62:1193-202. [Crossref] [PubMed]
91. Longhini F, Pisani L, Lungu R, et al. High-Flow Oxygen Therapy After Noninvasive Ventilation Interruption in Patients Recovering From Hypercapnic Acute Respiratory Failure: A Physiological Crossover Trial. Crit Care Med 2019;47:e506-11. [Crossref] [PubMed]
92. Turner KM, Delman AM, Griffith A, et al. The Impact of Enhanced Recovery After Surgery on Persistent Opioid Use Following Pulmonary Resection. Ann Thorac Surg 2023;115:249-55. [Crossref] [PubMed]
93. Pehora C, Pearson AM, Kaushal A, et al. Dexamethasone as an adjuvant to peripheral nerve block. Cochrane Database Syst Rev 2017;11:CD011770. [Crossref] [PubMed]
94. Barak M, Ziser A, Katz Y. Thoracic epidural local anesthetics are ineffective in alleviating post-thoracotomy ipsilateral shoulder pain. J Cardiothorac Vasc Anesth 2004;18:458-60. [Crossref] [PubMed]
95. Ong CK, Seymour RA, Lirk P, et al. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110:1170-9. [Crossref] [PubMed]
96. Zhang TX, Zhang Y, Liu ZD, et al. The volume threshold of 300 versus 100 ml/day for chest tube removal after pulmonary lobectomy: a meta-analysis. Interact Cardiovasc Thorac Surg 2018;27:695-702. [Crossref] [PubMed]
97. Bjerregaard LS, Jensen K, Petersen RH, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg 2014;45:241-6. [Crossref] [PubMed]
98. Cerfolio RJ, Bryant AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output. J Thorac Cardiovasc Surg 2008;135:269-73. [Crossref] [PubMed]
99. Warner DO, Warner MA, Barnes RD, et al. Perioperative respiratory complications in patients with asthma. Anesthesiology 1996;85:460-7. [Crossref] [PubMed]
100. Silvanus MT, Groeben H, Peters J. Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation. Anesthesiology 2004;100:1052-7. [Crossref] [PubMed]
101. Odor PM, Bampoe S, Gilhooly D, et al. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ 2020;368:m540. [Crossref] [PubMed]
102. Yu ZB, Lu X, Wang JS, et al. Protective effect of budesonide and ipratropium bromide inhalation during perioperative period in lung canc-er patients complicated with COPD. Journal of Clinical Pulmonary Medicine 2019;24:1851-4.
103. Bölükbas S, Eberlein M, Eckhoff J, et al. Short-term effects of inhalative tiotropium/formoterol/budenoside versus tiotropium/formoterol in patients with newly diagnosed chronic obstructive pulmonary disease requiring surgery for lung cancer: a prospective randomized trial. Eur J Cardiothorac Surg 2011;39:995-1000. [Crossref] [PubMed]
104. Goto T. Measuring Surgery Outcomes of Lung Cancer Patients with Concomitant Pulmonary Fibrosis: A Review of the Literature. Cancers (Basel) 2018;10:223. [Crossref] [PubMed]
105. Kewalramani N, Machahua C, Poletti V, et al. Lung cancer in patients with fibrosing interstitial lung diseases: an overview of current knowledge and challenges. ERJ Open Res 2022;8:00115-2022. [Crossref] [PubMed]
106. Garner M, Taylor M, Smith M, et al. Pre-existing pulmonary fibrosis is associated with adverse outcomes after lung resection. Respir Med 2022;205:107037. [Crossref] [PubMed]
107. Sekihara K, Aokage K, Miyoshi T, et al. Perioperative pirfenidone treatment as prophylaxis against acute exacerbation of idiopathic pulmonary fibrosis: a single-center analysis. Surg Today 2020;50:905-11. [Crossref] [PubMed]
108. Patel AJ, Walters GI, Watkins S, et al. Lung cancer resection in patients with underlying usual interstitial pneumonia: a meta-analysis. BMJ Open Respir Res 2023;10:e001529. [Crossref] [PubMed]
109. Sato T, Teramukai S, Kondo H, et al. Impact and predictors of acute exacerbation of interstitial lung diseases after pulmonary resection for lung cancer. J Thorac Cardiovasc Surg 2014;147:1604-1611.e3. [Crossref] [PubMed]
110. Heo YA. Budesonide/Glycopyrronium/Formoterol: A Review in COPD. Drugs 2021;81:1411-22. [Crossref] [PubMed]
111. Yoon SW, Kang H, Choi GJ, et al. Comparison of supraglottic airway devices in laparoscopic surgeries: A network meta-analysis. J Clin Anesth 2019;55:52-66. [Crossref] [PubMed]
112. Ali JM, Volpi S, Kaul P, et al. Does the 'non-intubated' anaesthetic technique offer any advantage for patients undergoing pulmonary lobectomy? Interact Cardiovasc Thorac Surg 2019;28:555-8. [Crossref] [PubMed]
113. Cui W, Huang D, Liang H, et al. Tubeless video-assisted thoracoscopic surgery in mediastinal tumor resection. Gland Surg 2021;10:1387-96. [Crossref] [PubMed]

(English Language Editor: L. Huleatt)