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Application for ESRA Abstract Prizes : I apply as an Anesthesiologist (Aged 35 years old or less)Background and Aims Video-assisted thoracoscopic surgery (VATS) without tracheal intubation —performed under sedation and regional anesthesia— has gained popularity as a lung-protective strategy in selected patients. We present the anesthetic management of a patient with severe COPD undergoing lung volume reduction surgery (LVRS) under sedation and dual-level retrolaminar block (RLB).Methods A 58-year-old male with advanced bullous emphysema, predominantly in the left lung, was scheduled for LVRS. He had no comorbidities apart from COPD and was on inhaled salbutamol. Given the compromised status of the contralateral lung, the multidisciplinary team opted for a non-intubated approach to reduce the risk of postoperative pulmonary complications. Following preoperative salbutamol inhalation, monitoring per ASA standards revealed SpO 2 99%, EtCO2 42 mmHg, HR 70 bpm, and BP 130/80 mmHg. A dexmedetomidine infusion (0.2 mcg/kg/h) was initiated after a loading dose and titrated as needed. An arterial catheter was placed for continuous BP monitoring and blood gas sampling. After positioning in the right lateral decubitus, RLB was performed at T6 and T8 with 10 mL of local anesthetic mixture at each level (20 mg bupivacaine, 40 mg lidocaine, and 6 mL saline). Surgery commenced at the T5 level. During the procedure, EtCO2 rose to 60 mmHg. Arterial blood gas revealed PaCO2 of 88 mmHg and pH 7.17. Assisted mask ventilation was initiated. Although intubation was considered, the surgical team proceeded due to near completion. As the lower lobe resection and the bullous part of upper lobe was finalized, respiratory parameters improved. Postoperatively, the patient was awake, pain-free, and stable with PaCO2 58 mmHg and pH 7.34. He was monitored in PACU for 24 hours before transfer to the surgical ward.Abstract P064 Figure 1Advanced bullous CT imaging of the patientConclusions Non-intubated VATS may be a viable anesthetic strategy for carefully selected COPD patients undergoing LVRS, provided that both surgical and anesthetic teams are experienced in managing intraoperative ventilatory challenges.