The Use of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) for Pre-Oxygenation in Neurosurgical Patients: A Randomised Controlled Trial

Abstract

This study explored the use of high-flow nasal oxygen (HFNO) in both pre-oxygenation and apnoeic oxygenation in adults who were intubated following a non-rapid sequence induction. Fifty patients were randomised to receive pre-oxygenation via a standard facemask or the Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) device. After five minutes of pre-oxygenation, induction and muscle relaxant agents were given. While waiting for complete paralysis, patients in the standard facemask group received bag-mask ventilation (BMV), whereas patients in the HFNO group received apnoeic oxygenation via the THRIVE device. Serial blood samples for arterial blood gas analysis were taken. Baseline patient and airway characteristics were similar. The median PaO 2 after pre-oxygenation was 357 (interquartile range [IQR] 324-450 [range 183-550]) mmHg in the facemask group, compared to 471 (IQR 429-516 [range 185-550]) mmHg in the HFNO group (P=0.01). The median arterial partial pressure of oxygen (PaO 2) in the HFNO group decreased after a period of apnoeic oxygenation, and was significantly lower when compared to patients who received BMV in facemask group. The arterial carbon dioxide partial pressure (PaCO 2) level after complete paralysis was significantly higher in the HFNO group when compared to the facemask group (median 52 [IQR 48-55 {range 40-65}] versus median 43 [IQR 40-48 {range 35-63}] mmHg, P=0.0005 and P=0.004 respectively). There were no differences in the time to muscle paralysis and time to intubation. Seven patients required use of airway adjuncts during BMV in the facemask group, compared to none in the HFNO group (P=0.004). No complications were observed in either group. HFNO produces a higher PaO 2 after pre-oxygenation and safe PaO 2 during intubation. However, the subsequent fall in PaO 2 and rise in PaCO 2 indicates that it is not as effective as BMV in maintaining oxygenation and ventilation following neuromuscular blockade.

Lung volume changes in Apnoeic Oxygenation using Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) compared to mechanical ventilation in adults undergoing laryngeal surgery

“…[3][4][5]22,23 This study confirms an increasing alveolar-arterial CO 2 difference over time, as previously described, indicating an increased ventilation/perfusion mismatch. [2][3][4] However, the present study does not support the hypothesis that the progressive alveolar-ar- [24][25][26] No difference in S p O 2 or P a O 2 was seen over time between the groups.…”

The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline

“…Ten trials [39][40][41][42][43][44][45][46][47][48] compared HFNC to COT (face mask and/or bag mask ventilation) or NIPPV in the peri-intubation period. Half of these trials enrolled non-hypoxemic patients undergoing intubation during induction of general anaesthesia before surgery and the remaining trials examined critically ill hypoxemic patients who required intubation [39−41, 43, 45].…”

“…Half of these trials enrolled non-hypoxemic patients undergoing intubation during induction of general anaesthesia before surgery and the remaining trials examined critically ill hypoxemic patients who required intubation [39−41, 43, 45]. Of the peri-operative trials, two trials included patients undergoing emergency surgery [42,47], one trial each included patients undergoing bariatric surgery [35], any surgery, [48] and neurosurgery [46]. See the supplementary material to review the evidence profiles (Suppl material 1) and for a discussion of physiologic mechanisms (Suppl material 2).…”

High-flow humidified nasal preoxygenation in pregnant women: a prospective observational study

“…8e10 Pillai and colleagues 8 have shown that etO 2 after 3 min of high-flow humidified nasal preoxygenation in healthy volunteers breathing with closed mouths were noninferior to face mask preoxygenation. Ng and colleagues 9 and Heinrich and colleagues 10 reported comparable arterial partial pressure of oxygen values after high-flow humidified nasal preoxygenation in neurosurgical and bariatric patients, respectively. Other studies investigating the use of high-flow nasal oxygen for preoxygenation and apnoeic oxygenation in rapid sequence induction have shown longer safe apnoea times when high-flow nasal oxygen was used.…”