TIVA Without Endotracheal Intubation: Clinical Feasibility and Protocol
Yes, Total Intravenous Anesthesia (TIVA) can be safely administered without endotracheal tube insertion for carefully selected patients and specific procedures, using spontaneous ventilation techniques with appropriate monitoring and backup airway management plans. 1, 2
Evidence-Based Applications
Established Clinical Uses
Laryngeal and airway procedures represent the most robust evidence base for tubeless TIVA, where maintaining spontaneous ventilation provides uninterrupted surgical access without airway obstruction from an endotracheal tube. 1, 2
Suspension microlaryngoscopy has been successfully performed using continuous propofol and remifentanil infusions in 66 cases, with only 12% requiring supplemental ventilation and just 3% requiring conversion to alternative ventilation methods. 1
Laryngeal framework surgery benefits specifically from tubeless TIVA because it allows intraoperative voice monitoring while patients remain in light sedation (BIS around 60), with patients able to phonate on command within approximately 234 seconds after propofol cessation. 2
Thoracoscopic procedures including major lung resections have been performed using non-intubated TIVA with regional or epidural analgesia, though this requires spontaneous ventilation with an open hemithorax. 3, 4
Critical Technical Requirements
Anesthetic Management Protocol
Continuous intravenous infusion is mandatory—any interruption of propofol or other anesthetic agents may result in awareness, making equipment checks the most important step in reducing awareness risk. 5
Anti-reflux/non-return valves must always be used on the IV fluid infusion line when administering TIVA to prevent backflow and ensure continuous drug delivery. 5
Visible IV sites are required so infusions can be monitored for disconnection, leaks, or subcutaneous infiltration. 5
Propofol and remifentanil combination is the most commonly used regimen (57.6% of cases), providing adequate sedation while maintaining respiratory drive. 1
BIS monitoring should be used to measure anesthetic depth, typically maintaining values around 60 during the procedure. 2
Airway Management Safeguards
Superior laryngeal nerve block can be used in approximately half of cases to reduce airway reactivity and improve tolerance of the procedure. 1
Backup ventilation capability must be immediately available—mask ventilation, endotracheal intubation equipment, and jet ventilation should be prepared before starting, as 9% of cases may require transient supplemental ventilation. 1
Continuous monitoring with pulse oximetry and capnography is essential to detect hypoventilation or desaturation early, allowing rapid intervention before critical hypoxemia develops. 5
Patient Selection Criteria
Suitable Candidates
Low-risk patients without difficult airway anatomy, aspiration risk, or obesity are appropriate for tubeless TIVA techniques. 6
Patients requiring avoidance of airway stimulation such as those with reactive airway disease may benefit from avoiding endotracheal intubation. 6
Procedures requiring intraoperative patient cooperation (such as voice monitoring during laryngeal surgery) are ideal indications where tubeless TIVA provides unique advantages over traditional intubation. 2
Absolute Contraindications
Difficult airway patients should never undergo tubeless TIVA due to the risk of inability to rescue the airway if complications occur. 6
Aspiration risk patients require definitive airway protection with a cuffed endotracheal tube. 6
Obese patients and those with severe emphysema are poor candidates because hypercapnia is more difficult to manage without controlled ventilation. 3
Problematic oropharyngeal anatomy (high Mallampati score) creates an emergent situation if urgent intubation becomes necessary during the procedure. 3
Critical Pitfalls and Risk Mitigation
Hypercapnia Management
Spontaneous ventilation limitations mean hypercapnia can develop during tubeless TIVA, which is easier to manage with controlled ventilation through an endotracheal tube. 3
Shorter operative times (average 73 minutes in published series) reduce the risk of progressive respiratory acidosis from inadequate ventilation. 1
Emergency Conversion Protocol
Immediate intubation capability must be available—if hypoventilation or desaturation occurs, endotracheal ventilation, mask ventilation, or jet ventilation can effectively recover oxygenation. 1
Equipment familiarity is essential—anesthetists using TIVA must be thoroughly familiar with the drugs, technique, and all equipment being used. 5
Clearly labeled equipment including IV connectors and valves prevents confusion during crisis management. 5
Comparison with Intubated Techniques
Advantages of Tubeless TIVA
Unobstructed surgical access is the primary advantage for laryngeal procedures, eliminating the physical presence of an endotracheal tube in the surgical field. 1, 2
Reduced intubation-related complications including airway trauma, residual neuromuscular blockade, ventilation-induced lung injury, and postoperative nausea are avoided. 3
Lower intraocular pressure is maintained—neither LMA insertion nor endotracheal intubation increases IOP during TIVA without muscle relaxants, though extubation does increase IOP significantly. 7
Limitations Compared to Intubated Anesthesia
Modern intubated techniques using optical intubation cannulas, TIVA, BIS monitoring, and relaxometry provide safe anesthesia with minimal airway injury risk, minimal residual curarization, and rapid recovery allowing mobilization within hours. 3
ERAS protocols with intubated uniportal VATS show shortened hospitalization and better outcomes comparable to non-intubated techniques, suggesting the benefits may relate more to overall perioperative management than intubation status alone. 3