HE Breathing: A new ventilation mode in airway surgery

Complex airway surgery, particularly tracheal/carinal resection and reconstruction, is still considered as the “crown jewel” of video-assisted thoracoscopic surgery (VATS). Notably, during these procedures, maintaining adequate oxygenation and preventing hypercapnia, while simultaneously ensuring optimal surgical conditions, remains a formidable challenge. Drawing on prior clinical experience, successful airway surgery hinges on close collaboration with a skilled anesthesia team, where the choice of ventilation mode—intubated or non-intubated (tubeless)—plays a critical role in achieving optimal procedural outcomes.

In a comparative study, Prof. He’s team successfully performed thoracoscopic carinal (4 patients) and tracheal (14 patients) resections under the HE Breathing ventilation mode, achieving shorter anastomosis times (22.5–40 vs. 45–86 minutes), operative duration (162.5 vs. 260 minutes) and potentially postoperative hospital stays (11.5±4.3 vs. 13.2±6.3 days), compared with the conventional intubated ventilation method. These results underscore the significant advantages of HE Breathing ventilation mode in enhancing surgical safety, reducing perioperative mortality and promoting faster recovery. Key contributing factors include:

• Spontaneous breathing minimizes lung injury and infection risks associated with mechanical ventilation. The naturally regulated rhythm and depth of spontaneous breathing may enhance respiratory efficiency and oxygenation. Although it is known that hypercapnia may occur, permissive hypercapnia can improve hemodynamics, enhance ventilation-perfusion matching, and provide protective effects against inflammatory responses.
• Using a laryngeal mask instead of an endotracheal tube avoids intubation-related injuries (e.g., throat pain, mucosal ulceration and airway rupture). The associated reduction in reflexive coughing may also help prevent early anastomotic rupture.
• The absence of a tube within the surgical area optimizes visualization and precision during resection and anastomosis, vastly simplifying this technically demanding procedure. Accordingly, the ischemia-reperfusion time of the airway is reduced, facilitating more efficient anastomotic reapproximation and recovery.
• The combination of local anesthesia (e.g., infiltration of the vagus nerve, extensive intercostal nerves and lung surface) and mild intravenous anesthesia, rather than general deep anesthesia, reduced postoperative adverse effects related to muscle relaxants, as well as heavy sedatives and analgesics, particularly in the prolonged airway surgeries.

With the collaborative efforts of surgeons and anesthesiologists, HE Breathing ventilation mode has emerged as an innovative technique in airway surgery, offering significant advantages. Further investigations into its respiratory dynamics and other underlying mechanisms are warranted. Prof. He’s team has successfully extended its application to robotic-assisted VATS, and it is anticipated that this technique will achieve broader adoption and benefit a wider range of patients in the future.