THRIVE? The answer, my friend, is blowing in the (high flow) wind!

Transnasal Humidified Rapid Insufflation Ventilatory Exchange With Nasopharyngeal Airway Facilitates Apneic Oxygenation: A Randomized Clinical Noninferiority Trial

Background: Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) was used to extend the safe apnea time. However, THRIVE is only effective in patients with airway opening. Nasopharyngeal airway (NPA) is a simple device that can help to keep airway opening. This study aimed to investigate the noninferiority of NPA to jaw thrust for airway opening during anesthesia-induced apnea. Methods: This was a prospective randomized single-blinded noninferiority clinical trial on the use of THRIVE in patients with anesthesia-induced apnea. The participants were randomly allocated to receive NPA or jaw thrust. The primary outcomes were PaO₂ and PaCO₂ at 20 min after apnea, with noninferiority margin criteria of -6.67 and 0.67 kPa, respectively. Results: A total of 123 patients completed the trial: 61 in the NPA group and 62 in the jaw thrust group. PaO₂ at 20 min after apnea was 42.9 ± 14.0 kPa in the NPA group and 42.7 ± 13.6 kPa in the jaw thrust group. The difference between these two means was 0.25 kPa (95% CI, -3.87 to 4.37 kPa). Since the lower boundary of the 95% CI was > -6.67 kPa, noninferiority was established because higher PO₂ is better. PaCO₂ at 20 min after apnea was 10.74 ± 1.09 kPa in the NPA group and 10.54 ± 1.18 kPa in the jaw thrust group. The difference between the two means was 0.19 kPa (95% CI, -0.14 to 0.53 kPa). Since the upper boundary of the 95% CI was <0.67 kPa, noninferiority was established because lower PCO₂ is better. No patient had a SpO₂ < 90% during apnea. Conclusion: When THRIVE was applied during anesthesia-induced apnea, NPA placement kept airway opening and was noninferior to jaw thrust in terms of its effects on PaO₂ and PaCO₂ at 20 min after apnea. Clinical Trial Registration: ClinicalTrials.gov (NCT03741998).