The use of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) in one hundred and five upper airway endoscopies. A case series

Waters, Eleanor; Kellner, Maximiliane; Milligan, Pamela; Adamson, Richard; Nixon, Iain J.; McNarry, Alistair F.

doi:10.1111/coa.13408

Cited by 31 publications

(43 citation statements)

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“…Our rate of rise in end tidal CO 2 at 0.844 mmHg per minute or 0.11 kPa per minute is very similar to that found in other studies 1,9,10 . Using capnography measurements, however, is limited to only beginning and end of case measurements.…”

Section: Discussionsupporting

confidence: 89%

“…Of the 13 patients in our cohort who had a BMI >30, four required rescue intubation. Waters et al found that patients with a BMI >25 desaturated sooner, although most patients maintained high oxygen saturations up to 20 minutes 10 . In our cohort, only one case of the aforementioned 12 patients exceeded 20 minutes of apneic time, which may explain the relative paucity of adverse events.…”

Section: Discussionmentioning

confidence: 45%

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Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

et al. 2020

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Objective Microlaryngeal surgery typically requires oxygenation and ventilation via either an endotracheal tube (ETT), jet ventilation (JV), or intermittent apnea with an ETT. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) delivered by high flow nasal cannula has been reported as an alternative technique. This method of apneic oxygenation and ventilation allows for stable, unobstructed visualization of immobile laryngeal structures. We aim to describe the technique and characterize intraoperative parameters related to its safety. Study Design Case Series. Methods The electronic medical record was reviewed for patients who underwent microlaryngoscopy using THRIVE technique. Patient demographics, procedural details, operative parameters, and anesthesia records were reviewed. Descriptive statistics were reported. Results A total of 53 patients underwent microlaryngoscopy using THRIVE as the sole method of ventilation, with 62% female. Median age was 51 years, and median BMI was 25 kg/m2. Most patients were ASA class 2, and most had a Mallampati score of 2. The most common surgical indications were subglottic stenosis, vocal fold lesions, and vocal fold paralysis. Median apnea time was 16 minutes. At the end of case, median end tidal CO2 was 50 mmHg, and median minimum SpO2 was 95. Six cases required supplementation of THRIVE with JV or tracheal intubation for sustained oxygen desaturation. There was an increase in end tidal CO2 of 0.844 mmHg/min of apneic time. Conclusions THRIVE is a safe and effective technique for oxygenation and ventilation in microlaryngeal, non‐laser surgery in appropriately selected patients. To ensure safety, back‐up plans such as jet ventilation and microlaryngeal ETT should be available. Level of Evidence 4 Laryngoscope, 131:587–591, 2021

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Section: Discussionsupporting

confidence: 89%

Section: Discussionmentioning

confidence: 45%

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

et al. 2020

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“…However, regardless of the airway pressure generated, HFNT allows extension of the safe apnoea period, and it is used clinically with increasing popularity; also to maintain constant oxygenation in surgical procedures with shared airways [12, 13, 31]. The question arises, however, whether the clinically negligible airway pressure increase measured with an open mouth helps to prevent atelectasis formation, which may be formed while using high oxygen concentrations, [32–34] which in turn is necessary to maintain oxygenation during apnoeic oxygenation [11].…”

Section: Discussionmentioning

confidence: 99%

Measurement of airway pressure during high‐flow nasal therapy in apnoeic oxygenation: a randomised controlled crossover trial^*

et al. 2020

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It is recognised that high-flow nasal therapy can prevent desaturation during airway management. Studies in spontaneously breathing patients show an almost linear relationship between flow rate and positive airway pressure in the nasopharynx. Positive airway pressure has been suggested as one of the possible mechanisms explaining how high-flow nasal therapy works. However, data on pressures generated by high-flow nasal therapy in apnoeic adults under general anaesthesia are absent. This randomised controlled crossover trial investigated airway pressures generated by different flow rates during high-flow nasal therapy in anaesthetised and paralysed apnoeic patients, comparing pressures with closed and open mouths. Following induction of anaesthesia and neuromuscular blockade, a continuous jaw thrust was used to enable airway patency. Airway pressure was measured in the right main bronchus, the middle of the trachea and the pharynx, using a fibreoptically-placed catheter connected to a pressure transducer. Each measurement was randomised with respect to closed or open mouth and different flow rates. Twenty patients undergoing elective surgery were included (mean (SD) age 38 (18) years, BMI 25.0 (3.3) kg.m-2 , nine women, ASA physical status 1 (35%), 2 (55%), 3 (10%). While closed mouths and increasing flow rates demonstrated non-linear increases in pressure, the pressure increase was negligible with an open mouth. Airway pressures remained below 10 cmH 2 O even with closed mouths and flow rates up to 80 l.min À1 ; they were not influenced by catheter position. This study shows an increase in airway pressures with closed mouths that depends on flow rate. The generated pressure is negligible with an open mouth. These data question positive airway pressure as an important mechanism for maintenance of oxygenation during apnoea.

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“…Hypercapnia is well known to induce several cardiovascular effects, including increased mean pulmonary artery pressure, pulmonary vascular resistance and heart rate 23,24 . No previous case reports or studies have reported haemodynamic instability during THRIVE, 25,26 despite the increasing hypercapnia, as high as ETCO 2 of 16 kPa in one case series 27 . Notably, only a few THRIVE trials report arterial CO 2 levels and haemodynamic parameters; 2,17,28 therefore, the haemodynamic effects of hypercapnia during THRIVE are difficult to assess.…”

Section: Discussionmentioning

confidence: 96%

Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study

Forsberg

Mkrtchian

Ebberyd

et al. 2021

Acta Anaesthesiol Scand

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Background Apnoeic oxygenation using Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) during general anaesthesia prolongs the safe apnoeic period. However, there is a gap of knowledge how THRIVE‐induced hyperoxia and hypercapnia impact vital organs. The primary aim of this randomised controlled trial was to characterise oxidative stress and, secondary, vital organ function biomarkers during THRIVE compared to mechanical ventilation (MV). Methods Thirty adult patients, American Society of Anesthesiologists (ASA) 1–2, undergoing short laryngeal surgery under general anaesthesia were randomised to THRIVE, FIO2 1.0, 70 L min−1 during apnoea or MV. Blood biomarkers for oxidative stress, malondialdehyde and TAC and vital organ function were collected (A) preoperatively, (B) at procedure completion and (C) at PACU discharge. Results Mean apnoea time was 17.9 (4.8) min and intubation to end‐of‐surgery time was 28.1 (12.8) min in the THRIVE and MV group, respectively. Malondialdehyde increased from 11.2 (3.1) to 12.7 (3.1) µM (P = .02) and from 9.5 (2.2) to 11.6 (2.6) µM (P = .003) (A to C) in the THRIVE and MV group, respectively. S100B increased from 0.05 (0.02) to 0.06 (0.02) µg L−1 (P = .005) (A to C) in the THRIVE group. No increase in TAC, CRP, leukocyte count, troponin‐T, NTproBNP, creatinine, eGFRcrea or NSE was demonstrated during THRIVE. Conclusion While THRIVE and MV was associated with increased oxidative stress, we found no change in cardiac, inflammation or kidney biomarkers during THRIVE. Further evaluation of stress and inflammatory response and cerebral and cardiac function during THRIVE is needed.

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The use of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) in one hundred and five upper airway endoscopies. A case series

Cited by 31 publications

References 6 publications

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

Measurement of airway pressure during high‐flow nasal therapy in apnoeic oxygenation: a randomised controlled crossover trial^*

Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study

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The use of Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) in one hundred and five upper airway endoscopies. A case series

Cited by 31 publications

References 6 publications

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

Utility of Transnasal Humidified Rapid Insufflation Ventilatory Exchange for Microlaryngeal Surgery

Measurement of airway pressure during high‐flow nasal therapy in apnoeic oxygenation: a randomised controlled crossover trial*

Biomarkers for oxidative stress and organ injury during Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange compared to mechanical ventilation in adults undergoing microlaryngoscopy: A randomised controlled study

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Measurement of airway pressure during high‐flow nasal therapy in apnoeic oxygenation: a randomised controlled crossover trial^*