High flow versus conventional nasal cannula for oxygenation and ventilation maintenance during surgery with intravenous deep sedation by propofol: a randomized controlled study

Place of high-flow nasal oxygen in nonoperating room anesthesia

PURPOSE OF REVIEW

This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings.

RECENT FINDINGS

The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact.

SUMMARY

HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) in neuroanesthesia practice: A review

Respiratory management is an important aspect of care in neuroanesthesia practice for neurosurgical patients. A wide variety of procedures are performed under sedation in the neurosurgical population, and maintaining oxygenation is of paramount importance during these procedures. The high-flow oxygen devices improve arterial oxygenation by providing higher inspiratory oxygen concentration and maintaining higher dynamic positive airway pressure. These devices have gained importance during the recent years with regard to enhancing patient safety. This narrative review focuses on the role of trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) and high-flow nasal oxygenation (HFNO) techniques in the neuroanesthesia practice and electroconvulsive therapy.

Airway Management of an Infant With Giant Neck Macro-Cystic Hygroma Utilizing a High-Flow Nasal Cannula

BACKGROUND

 Cystic hygroma is a congenital lymphatic malformation. It may present as a huge mass in the neck, jeopardizing airway patency and prolonging intubation time, resulting in hypoventilation and hypoxemia. We used a high-flow nasal cannula to decrease the risk of hypoxemia and provide anesthesiologists sufficient time to perform tracheal intubation in young infants.

CASE PRESENTATION

A 33-day-old infant (height, 55 cm; weight, 5.05 kg) was diagnosed with macro-cystic hygroma of the right neck. Considering the progressive enlargement of the macrocystic hygroma and its impact on the airway, urgent intervention becomes imperative. Among the available treatment modalities, percutaneous cyst aspiration and sclerotherapy performed under ultrasound guidance represent the most commonly chosen approach. During the induction of general anesthesia, the otolaryngologists were on standby and prepared for emergency tracheotomy. The anesthesiologists chose total intravenous anesthesia induction while maintaining spontaneous breathing. A high-flow nasal cannula was used to keep the infant oxygenated, and endotracheal intubation was successfully performed using a C-MAC video laryngoscope and fiber-optic bronchoscope.

CONCLUSIONS

Airway management is the biggest challenge for anesthesiologists when delivering general anesthesia to infants with neck macro-cystic hygroma. Total intravenous anesthesia could be a choice for induction without considering compromised respiration and the side effects of inhalational anesthetics. A high-flow nasal cannula can be used in young infants to maintain oxygenation and allow anesthesiologists a longer time to perform intubation.

Negative pressure pulmonary edema due to upper airway obstruction after general anesthesia in a patient with Parkinson's disease: A case report

In a patient with Parkinson's disease (PD) who underwent spine surgery 13 h after the last anti-Parkinson medications, negative pressure pulmonary edema from upper airway obstruction developed immediately after extubation. Although oxygenation improved with high-flow nasal cannula therapy, such complications might develop due to abrupt discontinuation of medication for PD.

Respiratory support with nasal high flow without supplemental oxygen in patients undergoing endoscopic retrograde cholangiopancreatography under moderate sedation: a prospective, randomized, single-center clinical trial

BACKGROUND

Nasal high flow (NHF) may reduce hypoxia and hypercapnia during an endoscopic retrograde cholangiopancreatography (ERCP) procedure under sedation. The authors tested a hypothesis that NHF with room air during ERCP may prevent intraoperative hypercapnia and hypoxemia.

METHODS

In the prospective, open-label, single-center, clinical trial, 75 patients undergoing ERCP performed with moderate sedation were randomized to receive NHF with room air (40 to 60 L/min, n = 37) or low-flow O₂ via a nasal cannula (1 to 2 L/min, n = 38) during the procedure. Transcutaneous CO₂, peripheral arterial O₂ saturation, a dose of administered sedative and analgesics were measured.

RESULTS

The primary outcome was the incidence of marked hypercapnia during an ERCP procedure under sedation observed in 1 patient (2.7%) in the NHF group and in 7 patients (18.4%) in the LFO group; statistical significance was found in the risk difference (-15.7%, 95% CI -29.1 - -2.4, p = 0.021) but not in the risk ratio (0.15, 95% CI 0.02 - 1.13, p = 0.066). In secondary outcome analysis, the mean time-weighted total PtcCO₂ was 47.2 mmHg in the NHF group and 48.2 mmHg in the LFO group, with no significant difference (-0.97, 95% CI -3.35 - 1.41, p = 0.421). The duration of hypercapnia did not differ markedly between the two groups either [median (range) in the NHF group: 7 (0 - 99); median (range) in the LFO group: 14.5 (0 - 206); p = 0.313] and the occurrence of hypoxemia during an ERCP procedure under sedation was observed in 3 patients (8.1%) in the NHF group and 2 patients (5.3%) in the LFO group, with no significant difference (p = 0.674).

CONCLUSIONS

Respiratory support by NHF with room air did not reduce marked hypercapnia during ERCP under sedation relative to LFO. There was no significant difference in the occurrence of hypoxemia between the groups that may indicate an improvement of gas exchanges by NHF.

TRIAL REGISTRATION

jRCTs072190021 . The full date of first registration on jRCT: August 26, 2019.

Effect of high-flow nasal oxygen on hypoxaemia during procedural sedation: a systematic review and meta-analysis

We conducted a systematic review to evaluate the effect of high-flow nasal oxygen and conventional oxygen therapy during procedural sedation amongst adults and children. We searched MEDLINE, EMBASE and CINAHL for randomised controlled trials that reported the effects of high-flow nasal oxygen during procedural sedation. The primary outcome measure was hypoxaemia and the secondary outcomes were minimum oxygen saturation; hypercarbia; requirement for airway manoeuvres; and procedure interruptions. The quality of evidence was assessed using the revised Cochrane risk-of bias tool and grading of recommendations, assessment, development and evaluation (GRADE). Nineteen randomised controlled trials (4121 patients) including three in children were included. Administration of high-flow nasal oxygen reduced hypoxaemia, risk ratio (95%CI) 0.37 (0.24-0.56), p < 0.001; minor airway manoeuvre requirements, risk ratio (95%CI) 0.26 (0.11-0.59), p < 0.001; procedural interruptions, risk ratio (95%CI) 0.17 (0.05-0.53), p = 0.002; and increased minimum oxygen saturation, mean difference (95%CI) 4.1 (2.70-5.50), p < 0.001; as compared with the control group. High-flow nasal oxygen had no impact on hypercarbia, risk ratio (95%CI) 1.24 (0.97-1.58), p = 0.09, I²  = 0%. High-flow nasal oxygen reduced the incidence of hypoxaemia regardless of the procedure involved, degree of fractional inspired oxygen, risk-profile of patients and mode of propofol administration. The evidence was ascertained as moderate for all outcomes except for procedure interruptions. In summary, high-flow nasal oxygen compared with conventional oxygenation techniques reduced the risk of hypoxaemia, increased minimum oxygen saturation and reduced the requirement for airway manoeuvres. High-flow nasal oxygen should be considered in patients at risk of hypoxaemia during procedural sedation.