Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Endotracheal intubation is considered standard practice during general anesthesia to support airway patency and oxygenation. It is necessary for patients under neuromuscular blockade, who are medically paralyzed for the duration of surgery and unable to breathe on their own. However, some cases involve deep sedation and general anesthesia without endotracheal intubation. Clinical studies evaluating gastrointestinal endoscopy, thoracic surgery, orthopedic trauma, and outpatient gynecologic procedures suggest that carefully selected patients can safely undergo airway management without an endotracheal tube, often resulting in fewer hemodynamic disturbances, reduced postoperative complications, and faster recovery.
In advanced endoscopy, Barnett and colleagues prospectively compared deep sedation without intubation to general endotracheal anesthesia (GET) in nearly 450 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), most performed prone (Barnett et al., 2013). Almost 90% of cases were completed successfully with non-intubated deep sedation alone, and although intraoperative events such as transient desaturation were relatively common in both groups, few led to serious complications. Only 3.7% of non-intubated cases required conversion to GET, most often in patients with higher ASA classification, obesity, or chronic obstructive pulmonary disease. The authors concluded that deep sedation without intubation is feasible for non-obese, healthier patients, provided capnography and experienced staff are available.
Non-intubated thoracoscopic procedures are also being performed more frequently—including minor wedge resections, major lobectomies, and even airway reconstruction—using regional techniques such as thoracic epidural anesthesia, paravertebral blocks, and vagal blockade combined with sedation (Okuda & Nakanishi, 2016). Non-intubated approaches were associated with shorter operating room time, lower rates of postoperative respiratory complications, and reduced mortality compared with single-lung ventilation under general anesthesia in several of the cited series. However, the authors caution that non-intubated major resection and airway reconstruction remain technically demanding, with unresolved challenges in managing hypoxia, hypercapnia, and intraoperative bleeding, and that strict patient selection criteria—good cardiopulmonary reserve, body mass index under 25, and anticipated operative time under three hours—are essential.
In orthopedic anesthesia, a study retrospectively compared general anesthesia with intubation, combined spinal-epidural anesthesia, and general anesthesia using a laryngeal mask airway (LMA) with nerve block in elderly patients undergoing intertrochanteric fracture surgery (Liu et al., 2019). The LMA nerve block group demonstrated the smallest intraoperative hemodynamic swings, the lowest postoperative pain scores, and the best-preserved cognitive function on serial Mini-Mental State Examination testing, suggesting that avoiding tracheal intubation may be particularly advantageous in frail, elderly populations vulnerable to postoperative cognitive dysfunction.
Deep intravenous sedation with propofol without intubation has also proven safe in surgical abortion, according to a study of over 62,000 cases (Dean et al., 2011). Only a single patient required endotracheal intubation, and no cases of perioperative pulmonary aspiration occurred.
Taken together, these studies suggest that inducing general anesthesia and deep sedation without intubation is a viable strategy across a range of procedures when patients are appropriately selected, monitoring is rigorous, and the anesthesia team maintains readiness to convert to a secured airway if needed. The consistent caveat across all four studies is that these benefits are procedure- and patient-dependent, and obesity, advanced ASA class, pulmonary comorbidity, and anticipated procedural complexity remain important considerations for proceeding with an intubated approach.
References
- Barnett, S. R., Berzin, T., Sanaka, S., Pleskow, D., Sawhney, M., & Chuttani, R. (2013). Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients. Digestive Diseases and Sciences. https://doi.org/10.1007/s10620-013-2783-x
- Dean, G., Jacobs, A. R., Goldstein, R. C., Gevirtz, C. M., & Paul, M. E. (2011). The safety of deep sedation without intubation for abortion in the outpatient setting. Journal of Clinical Anesthesia, 23, 437–442. https://doi.org/10.1016/j.jclinane.2011.05.001
- Liu, Y., Su, M., Li, W., Yuan, H., & Yang, C. (2019). Comparison of general anesthesia with endotracheal intubation, combined spinal-epidural anesthesia, and general anesthesia with laryngeal mask airway and nerve block for intertrochanteric fracture surgeries in elderly patients: A retrospective cohort study. BMC Anesthesiology, 19, 230. https://doi.org/10.1186/s12871-019-0908-2
- Okuda, K., & Nakanishi, R. (2016). The non-intubated anesthesia for airway surgery. Journal of Thoracic Disease, 8(11), 3414–3419. https://doi.org/10.21037/jtd.2016.11.101
