Effectiveness of transnasal humidified rapid-insufflation ventilatory exchange versus traditional preoxygenation followed by apnoeic oxygenation in delaying desaturation during apnoea: A preliminary study

Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

Comparison of hands-free Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) with conventional facemask ventilation technique for oxygenation in patients undergoing electroconvulsive therapy - A cross over study

OBJECTIVES

Modified ECT is routinely conducted using face mask (FM) and bag ventilation technique. Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) is a novel hands-free insufflation technique that provides oxygenation and prolongs apnoea time. There is limited literature comparing the two techniques. Primary objective of this study was to compare oxygen desaturation between THRIVE and FM techniques during ECT while secondary objective was to compare hemodynamics and complications.

METHODS

Patients aged 18-50 years undergoing 3rd-5th ECT treatments were enrolled. First ECT was with FM technique followed by THRIVE (with LUBO collar) in the next ECT. Except for the oxygenation technique, the protocol for ECT administration was similar with both techniques. SpO2 values were recorded every minute for 10 min while hemodynamic parameters were measured at 2 min and 5 min following administration of electrical stimulus. Any drop in SpO2 below 92 % was considered as a desaturation event.

RESULTS

A total of 201 patients underwent ECTs, one each with FM and THRIVE technique. Median age of patients was 28 years. There was no difference in SpO2 between the techniques (main effect P = 0.324, interaction P = 0.14). Only one patient had desaturation with THRIVE requiring intervention with FM. None of the patients had any airway complications in terms of nasal injury, hoarseness, or pneumothorax with THRIVE.

CONCLUSION

THRIVE is a safe alternative option for hands-free oxygenation while administering ECT. However, considering patient safety, an anaesthesiologist competent in airway management must be readily available.

Effect of trans-nasal humidified rapid insufflation ventilatory exchange on reflux and microaspiration in patients undergoing laparoscopic cholecystectomy during induction of general anesthesia: a randomized controlled trial

Background

Reflux aspiration is a rare but serious complication during induction of anesthesia. The primary aim of this study is to compare the incidence of reflux and microaspiration in patients undergoing laparoscopic cholecystectomy during induction of general anesthesia using either a facemask or trans-nasal humidified rapid insufflation ventilatory exchange.

Methods

We conducted a single-center, randomized, controlled trial. Thirty patients were allocated to either a facemask or a trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) group. Pre-oxygenation for 5 min with a facemask or THRIVE, positive pressure ventilation for 2 min or THRIVE for 2 min after anesthesia induction was followed. Before endotracheal intubation, the secretion above and below the glottis was collected to measure pepsin content and analyze blood gas. The ELISA assay for supra- and subglottic human pepsin content was used to detect the presence of reflux and microaspiration. The primary outcome was the incidence of reflux and microaspiration. Secondary outcomes were apnea time, PaO2 before tracheal intubation, and the end-expiratory carbon dioxide partial pressure.

Results

Patients in the THRIVE group had a significantly longer apnea time (379.55 ± 94.12 s) compared to patients in the facemask group (172.96 ± 58.87 s; p < 0.001). There were no differences observed in PaO2 between the groups. A significant difference in gastric insufflation, reflux, and microaspiration was observed between the groups. Gastric insufflation was 6.9% in the THRIVE group vs. 28.57% kPa in the facemask group (p = 0.041); reflux was 10.34% in the THRIVE group vs. 32.14% kPa in the facemask group (p = 0.044); and microaspiration was 0% in the THRIVE group vs. 17.86% kPa in the facemask group (p = 0.023).

Conclusion

The application of THRIVE during induction of general anesthesia reduced the incidence of reflux and microaspiration while ensuring oxygenation and prolonged apnea time in laparoscopic cholecystectomy patients. THRIVE may be an optimal way to administer oxygen during the induction of general anesthesia in laparoscopic cholecystectomy patients.

Clinical trial registration

Chinese Clinical Trial Registry, No: ChiCTR2100054086, https://www.chictr.org.cn/indexEN.html.

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments

BACKGROUND

Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality.

OBJECTIVES

To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8.

MORTALITY

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange Versus Conventional Facemask Breathing for Preoxygenation During Rapid Sequence Induction

INTRODUCTION

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE), if used for pre-oxygenation and apnoeic oxygenation, has the propensity to extend the safe apnoea time and thereby decrease the incidence of desaturation during rapid sequence induction (RSI) for emergency surgeries. Hence, we proposed to evaluate the comparative efficacy of pre-oxygenation with the use of conventional facemask breathing versus THRIVE during RSI in patients undergoing general anaesthesia (GA) for emergency surgeries.

MATERIALS AND METHODS

Eighty patients undergoing RSI under GA for emergency abdominopelvic surgery were divided randomly into two groups. Patients were preoxygenated for three minutes with 100% oxygen via either a high-flow nasal cannula at a flow of 60 L/minute using THRIVE or a tightly-held, snuggly-fitting facemask at a flow of 12L/minute using a circle system. RSI was administered followed by laryngoscopy and endotracheal intubation. Arterial partial pressure of oxygen (PaO2) measured immediately after successful endotracheal intubation was our primary outcome. The lowest peripheral oxygen saturation (SpO2), apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and any adverse event were also recorded. Data thus collected were statistically analysed.

RESULTS

No statistically significant difference in PaO2 value was observed after successful intubation, lowest SpO2, apnoea time, number of attempts at laryngoscopy, use of any rescue manoeuvres, and adverse event between both the groups (p>0.05).

CONCLUSION

We conclude that though not superior to conventional facemasks, THRIVE is a safe, practicable, and efficient pre-oxygenation tool during RSI of GA for patients undergoing emergency surgeries.

Effect of transnasal humidified rapid-insufflation ventilatory exchange on gastric insufflation during anaesthesia induction: A randomised controlled trial and multivariate analysis

BACKGROUND

Mask ventilation during anaesthesia induction is generally used to provide adequate oxygenation but improper mask ventilation can result in gastric insufflation. It has been reported that oxygen administered by transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) during anaesthesia induction can maintain oxygenation but its effect on gastric insufflation is unknown.

OBJECTIVES

The primary aim of this study was to evaluate whether THRIVE provided adequate oxygenation without gastric insufflation. The secondary aim was to explore the change in cross-sectional area of the antrum (CSAa) during anaesthesia induction. Other potential risk factors of gastric insufflation were also explored.

DESIGN

A prospective, randomised, double-blind study.

SETTING

Single centre, Department of Anaesthesiology, 1 st Affiliated Hospital, Wenzhou Medical University, China, from May 2022 to September 2022.

PATIENTS

A total of 210 patients (age >18 years, ASA classification I to III) scheduled to undergo general anaesthesia were enrolled.

INTERVENTIONS

For induction of general anaesthesia, patients were randomised into two groups: THRIVE and pressure-controlled facemask ventilation (PCFV). The THRIVE group received high-flow nasal oxygen with no additional ventilation. The PCFV group had pressure-controlled positive pressure ventilation from the anaesthesia machine via a tight fitting facemask. Gastric insufflation was detected using real-time ultrasonography. The CSAa was measured from ultrasonography images obtained before anaesthesia induction and at 0, 1, 2 and 3 min after loss of consciousness.

MAIN OUTCOME MEASURES

The incidence of gastric insufflation during the period from loss of consciousness until intubation.

RESULTS

The THRIVE group had a lower incidence of gastric insufflation during anaesthesia induction than the PCFV group (13.0 vs. 35.3%, odds ratio (OR) = 0.27, 95% confidence interval (CI), 0.14 to 0.56, P  < 0.001). Increase in the CSA after anaesthesia induction was significantly correlated with gastric insufflation (OR = 5.35, 95% CI, 2.90 to 9.89, P  < 0.001). Multivariate logistic regression analysis showed that advancing age (OR = 1.04, 95% CI, 1.01 to 1.07), obstructive sleep apnoea syndrome (OR = 2.43, 95% CI, 1.24 to 4.76), higher Mallampati score (OR = 2.66, 95% CI, 1.21 to 5.85) and PCFV (OR = 4.78, 95% CI, 2.06 to 11.06) were important independent risk factors for gastric insufflation.

CONCLUSION

During anaesthesia induction, the THRIVE technique provided adequate oxygenation with a reduced incidence of gastric insufflation. PCFV, advancing age, obstructive sleep apnoea syndrome and the Mallampati score were found to be independent risk factors for gastric insufflation during anaesthesia induction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR200059555.

High-flow Nasal Cannula versus Conventional Ventilation in Laryngeal Surgery: A Systematic Review and Meta-analysis

High-flow nasal cannula (HFNC) is an emerging option for maintaining oxygenation in patients undergoing laryngeal surgery, as an alternative to traditional tracheal ventilation and jet ventilation (JV). However, the data on its safety and efficacy is sparse. This study aims to aggregate the current data and compares the use of HFNC with tracheal intubation and jet ventilation in adult patients undergoing laryngeal surgery. We searched PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), Embase (Excerpta Medica Database), Google Scholar, Cochrane Library, and Web of Science. Both observational studies and prospective comparative studies were included. Risk of bias was appraised with the Cochrane Collaboration Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) or RoB2 tools and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for case series. Data were extracted and tabulated as a systematic review. Summary statistics were performed. Meta-analyses and trial sequential analyses of the comparative studies were performed. Forty-three studies (14 HFNC, 22 JV, and seven comparative studies) with 8064 patients were included. In the meta-analysis of comparative studies, the duration of surgery was significantly reduced in the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) group, but the number of desaturations, need for rescue intervention, and peak end-tidal CO₂ were significantly increased compared to the conventional ventilation group. The evidence was of moderate certainty and there was no evidence of publication bias. In conclusion, HFNC may be as effective as tracheal intubation in oxygenation during laryngeal surgery in selected adult patients and reduces the duration of surgery but conventional ventilation with tracheal intubation may be safer. The safety of JV was comparable to HFNC.

Apneic anesthesia with THRIVE for pediatric bronchial foreign body removal: A case series

Anesthesia for impacted tracheobronchial foreign body (FB) removal in pediatrics is challenging owing to shared airway, need of tubeless apneic anesthesia, and higher risk of airway complications. Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) has unique applications for apneic anesthesia. The authors describe two pediatric cases of impacted lower bronchial FB that were difficult to retrieve and required long procedure time. They were done successfully under apneic anesthesia using THRIVE that provided intermittent total apnea of 58 and 62 min, respectively, with single-continuous apnea time of 13-18 min. THRIVE facilitated the procedure by providing a safe long apnea time without desaturation and with permissible increase in PaCo2 while maintaining hemodynamic parameters and oxygenation.

High-flow nasal cannula (HFNC) oxygenation for sclerotherapy of facial and upper airway vascular malformations in pediatric patients: Case series

We report anesthesia management of sclerotherapy for vascular malformations (VMs) of the upper airway and face of pediatric patients conducted under sedation using a high-flow nasal cannula (HFNC) oxygen delivery system. Sclerotherapy procedures were carried out in six patients (five males, one female; age group: 5-12 years). The patients were sedated with midazolam, fentanyl, ketamine, and graded doses of propofol along with continuous oxygen delivery using HFNC. There were no episodes of oxygen desaturation, tongue fall or obstruction of the airway, interruption of procedure for assisted ventilation, and postoperative nausea and vomiting (PONV). Only two patients showed transient apnea for 10 and 15 s but did not require ventilatory assistance. HFNC provides effective oxygenation in pediatric patients undergoing sclerotherapy of VMs of the upper airway and face under sedation.

Comparison of the Effectiveness of Transnasal Humidified Rapid Insufflation Ventilator Exchange (THRIVE) with Facemask Pre-Oxygenation in 40 Patients ≥65 Years of Age Undergoing General Anaesthesia During Gastrointestinal Surgery for Intestinal Obstruction

BACKGROUND In this study, we aimed to compare the effectiveness of transnasal humidified rapid insufflation ventilator exchange (THRIVE) with facemask pre-oxygenation in 40 patients ≥65 years of age undergoing general anesthesia during gastrointestinal surgery for intestinal obstruction. MATERIAL AND METHODS Patients with gastrointestinal obstruction were randomized to either a facemask group (group M, n=20) or THRIVE group (group T, n=20). During pre-oxygenation, the 2 groups used a facemask (100% oxygen, 6 L/min) and THRIVE (100% oxygen, 40 L/min) to supply oxygen, respectively. Induction of anesthesia was performed in both groups using facemasks and without mechanical or assisted ventilation. The intubation occurred after myorelaxant action began. When the peripheral oxygen saturation (SpO₂) dropped below 95%, or 480 s after administration of muscle relaxants, mechanical ventilation was initiated immediately. The primary outcome was arterial partial pressure of oxygen (PaO₂) at 5 min after pre-oxygenation. A secondary outcome was time to SpO₂ of 95% during apnea, with a cut-off time of 480 s. RESULTS PaO₂ at 5 min after pre-oxygenation was (261.5±30.9) mmHg for group M and (446.1±84.4) mmHg for group T (P<0.001). Based on survival analysis, the median time-to-event in group T was 480 s (95% CI 415.7 s - upper limit unknown) and 240 s (95% CI 225.9-254.1 s) in group M (P<0.001). CONCLUSIONS In elderly patients undergoing rapid sequence induction, pre-oxygenation with THRIVE could improve oxygenation and extend safe apnea time, compared with facemask pre-oxygenation.

Ease and comfort of pre-oxygenation with high-flow nasal oxygen cannulae vs. facemask: a randomised controlled trial

The Difficult Airway Society recommends that all patients should be pre-oxygenated before the induction of general anaesthesia, but this may not always be easy or comfortable and anaesthesia may often be induced without full pre-oxygenation. We tested the hypothesis that high-flow nasal oxygen cannulae would be easier and more comfortable than facemasks for pre-oxygenation. We randomly allocated 199 patients undergoing elective surgery aged ≥ 10 years to pre-oxygenation using either high-flow nasal oxygen or facemask. Ease and comfort were assessed by anaesthetists and patients on 10-cm visual analogue scale and six-point smiley face scale, respectively. Secondary endpoints included end-tidal oxygen fraction after securing a definitive airway and time to secure an airway. A mean difference (95%CI) between groups in ratings of -0.76 (-1.25 to -0.27) cm for ease of use (p = 0.003) and -0.45 (-0.75 to -0.13) points for comfort (p = 0.006), both favoured high-flow nasal oxygen. A mean difference (95%CI) between groups in end-tidal oxygen fraction of 3.89% (2.41-5.37%) after securing a definitive airway also favoured high-flow nasal oxygen (p < 0.001). There was no significant difference between groups in the number of patients with hypoxaemia (S_p O₂  < 90%) or severe hypoxaemia (S_p O₂  < 85%) lasting ≥ 1 min or ≥ 2 min; in the proportion of patients with an end-tidal oxygen fraction < 87% in the first 5 min after tracheal intubation (52.2% vs. 58.9% in facemask and high-flow nasal oxygen groups, respectively; p = 0.31); or in time taken to secure an airway (11.6 vs. 12.2 min in facemask and high-flow nasal oxygen groups, respectively; p = 0.65). In conclusion, we found pre-oxygenation with high-flow nasal oxygen to be easier for anaesthetists and more comfortable for patients than pre-oxygenation with a facemask, with no clinically relevant differences in end-tidal oxygen fraction after securing a definitive airway or time to secure an airway. The differences in ease and comfort were modest.

The clinical advantage of nasal high-flow in respiratory management during procedural sedation: A scoping review on the application of nasal high-flow during dental procedures with sedation

Structured summary

Rationale: Nasal high-flow (NHF), a new method for respiratory management during procedural sedation, has greater advantages than conventional nasal therapy with oxygen. However, its clinical relevance for patients undergoing oral maxillofacial surgery and/or dental treatment remains uncertain and controversial, due to a paucity of studies. This scoping review compared and evaluated NHF and conventional nasal therapy with oxygen in patients undergoing oral maxillofacial surgery and/or dental treatment.

Materials and methods

A literature search of two public electronic databases was conducted, and English writing randomized controlled trials (RCTs) of nasal high flow during dental procedure with sedation reviewed. The primary and secondary outcomes of interest were the incidence of hypoxemia and hypercapnia during sedation and the need for intervention to relieve upper airway obstruction, respectively.

Results

The search strategy yielded 7 studies, of which three RCTs met our eligibility criteria, with a total of 78 patients. Compared with conventional nasal therapy with oxygen, NHF significantly reduced the incidence of hypoxemia and hypercapnia during procedural sedation.

Conclusion

NHF can maintain oxygenation and possibly prevent hypercapnia in patients undergoing dental treatment. Additional RCTs are needed to clarify and confirm these findings.

A comparison of high-flow nasal cannula and standard facemask as pre-oxygenation technique for general anesthesia: A PRISMA-compliant systemic review and meta-analysis

BACKGROUND

Current practice guidelines recommend the use of nasal cannula as an alternative pre-oxygenation method for tracheal intubation. However, the efficacy of high-flow nasal oxygenation versus standard facemask oxygenation has not been fully evaluated.

METHODS

We searched PubMed, Cochrane Library, and ClinicalTrials.gov for English-language studies published from January 1, 2000 to November 30, 2021. We included randomized controlled trials which compared high-flow nasal oxygenation and facemask oxygenation as the pre-oxygenation maneuver. Primary outcome was arterial partial pressure of oxygen (PaO2) after pre-oxygenation. Secondary outcomes were safe apnea time, arterial desaturation during intubation, lowest peripheral capillary oxygen saturation during intubation, and patient comfort score. Random-effects models and Mantel-Haenszel method were used for data synthesis.

RESULTS

A total of 16 randomized controlled trials and 1148 patients were included. High-flow nasal oxygenation achieved a higher PaO2 compared with facemask, mean difference: 64.86 mm Hg (95% confidence interval [CI]: 32.33-97.40, P < .0001). Safe apnea time was longer in high-flow nasal oxygenation, mean difference: 131.03 seconds (95% CI: 59.39-202.66, P < .0001). There was no difference in the risk of peri-intubation desaturation or lowest peripheral capillary oxygen saturation between groups. Patient comfort score was higher in high-flow nasal oxygenation, mean difference: 1.00 (95% CI: 0.46-1.54, P = .0003).

CONCLUSION

High-flow nasal oxygenation better enhanced PaO2 and extended safe apnea time and is not inferior to facemask oxygenation in preventing desaturation during tracheal intubation. High-flow nasal oxygenation may be considered as an alternative method, especially for patients with a potential difficult airway.

Humidified rapid-insufflation ventilatory exchange is a means of oxygenation during rigid bronchoscopy: A case series

Humidified rapid-insufflation ventilatory exchange (HRIVE) is an option for maintenance of oxygenation. This technique allows for oxygenation while the patient is apnoeic due to continuous positive airway pressure and gas exchange through flow-dependent dead space flushing. There is no study about the usage of HRIVE during rigid bronchoscopy. This retrospective study looked at rigid bronchoscopy cases utilizing HRIVE. Data points assessing adequacy of oxygenation and ventilation were recorded at time points: oxygen saturation (SpO2), partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2). Our nine cases had an average baseline SpO2 of 99.26%, 95.56% at 10 min into HRIVE and 95.27% at the end of HRIVE. The average baseline PaO2 was 309.01 mmHg, 124.99 mmHg at 10 min into HRIVE and 128.17 mmHg at the end of HRIVE. The average baseline PaCO2 was 43.26 mmHg, 68.76 mmHg at 10 min into HRIVE and 75.52 mmHg at the end of HRIVE. The average pre-HRIVE end-tidal CO2 (ETCO2) was 38.56 mmHg and the average post-HRIVE ETCO2 was 61.22 mmHg. The average baseline pH was 7.36, 7.22 at 10 min into HRIVE and 7.19 at the end of HRIVE. In this small cohort study, HRIVE was able to maintain adequate oxygenation via the rigid bronchoscope in a select group of patients. Hypercapnia and respiratory acidosis did result after 10 min, which may predispose certain patient populations to complications. HRIVE potentially offers an additional option of oxygenation via the rigid bronchoscope.

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

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, F_I O₂ 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.

Tubeless Anesthesia in Subglottic Stenosis: Comparative Review of Apneic Low-Flow Oxygenation With THRIVE

OBJECTIVE

Managing the shared airway in subglottic stenosis presents a unique challenge. Tubeless anesthesia with apneic oxygenation is increasingly being adopted as it overcomes the limitations of access to and visualization of the narrowed subglottis. Low-flow oxygenation (LFO) and transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) are two delivery techniques. We sought to compare their utility in this patient cohort.

STUDY DESIGN

Retrospective cohort study.

METHODS

Thirty-five cases of endoscopic debridement of subglottic stenosis were retrospectively studied. Operative technique was consistent among the cases. Oxygen was delivered at low-flow rates at the laryngeal inlet with LFO (n = 23) or high-flow rates at the nares with THRIVE (n = 12). Data regarding apnea time, the need for rescue ventilation, and relevant patient and disease factors were recorded for analysis.

RESULTS

Median apnea time for LFO and THRIVE were 34 and 25 minutes, respectively. Rescue with intermittent supraglottic jet ventilation was required more often with LFO than THRIVE (61% vs 33%) and was sufficient for the case to be completed in all but one instance. Elevated BMI was the sole significant predictor of early oxygen desaturation (24.8 vs 37.95 kg/m² , P = .002) with LFO. Median stenosis diameter was 6 mm (range 2-14).

CONCLUSION

Apneic techniques are safe and feasible for the endoscopic management of subglottic stenosis of all severities. Elevated BMI is the only significant predictor for early oxygen desaturation. In the many healthcare settings where THRIVE is not available, LFO is a valid alterative in the nonobese patient. Laryngoscope, 2021.

Comparison of High-flow Nasal Cannula (HFNC) and Conventional Oxygen Therapy in Obese Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis

BACKGROUND/AIM

High-flow nasal cannula (HFNC), a new method for postoperative oxygenation, has increasingly received attention during postoperative care. However, its importance for obese patients undergoing cardiac surgery remains controversial. This systematic review and meta-analysis compared and evaluated HFNC and conventional oxygen therapy (COT) in this patient group.

MATERIALS AND METHODS

Literature was retrieved by searching eight public databases. Randomized controlled trials (RCTs) were selected. RevMan 5.3 was used to analyze the results and any potential bias. The primary outcome included atelectasis score at 24 h postoperatively. The secondary outcomes included PaO2/FiO2 (ratio), dyspnea score at 24 h postoperatively, intensive care unit (ICU) length of stay, and reintubation.

RESULTS

The search strategy yielded 382 studies after duplicates were removed. Finally, 3 RCTs with a total of 526 patients were included in the present study. Compared with COT, there was no significant difference in atelectasis score, dyspnea score, reintubation, and ICU length of stay.

CONCLUSION

For obese patients undergoing cardiac surgery, postoperative use of HFNC can maintain patient's oxygenation. Additional clinical studies are needed to investigate the role of HFNC in this patient group.

Rapid sequence induction: An international survey

BACKGROUND

Rapid sequence induction (RSI) is a standard procedure, which should be implemented in all patients with a risk of aspiration/regurgitation during anaesthesia induction.

OBJECTIVE

The primary aim was to evaluate clinical practice in RSI, both in adult and paediatric populations.

DESIGN

Online survey.

SETTINGS

A total of 56 countries.

PARTICIPANTS

Members of the European Society of Anaesthesiology.

MAIN OUTCOME MEASURES

The aim was to identify and describe the actual clinical practice of RSI related to general anaesthesia.

RESULTS

From the 1921 respondents, 76.5% (n=1469) were qualified anaesthesiologists. When anaesthetising adults, the majority (61.7%, n=1081) of the respondents preoxygenated patients with 100% O₂ for 3 min and 65.9% (n=1155) administered opioids during RSI. The Sellick manoeuvre was used by 38.5% (n=675) and was not used by 37.4% (n=656) of respondents. First-line medications for a haemodynamically stable adult patient were propofol (90.6%, n=1571) and suxamethonium (56.0%, n=932). Manual ventilation (inspiratory pressure <12 cmH₂O) was used in 35.5% (n=622) of respondents. In the majority of paediatric patients, 3 min of preoxygenation (56.6%, n=817) and opioids (54.9%, n=797) were administered. The Sellick manoeuvre and manual ventilation (inspiratory pressure <12 cmH₂O) in children were used by 23.5% (n=340) and 35.9% (n=517) of respondents, respectively. First-line induction drugs for a haemodynamically stable child were propofol (82.8%, n=1153) and rocuronium (54.7%, n=741).

CONCLUSION

We found significant heterogeneity in the daily clinical practice of RSI. For patient safety, our findings emphasise the need for international RSI guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03694860

New Visionary in Upper Airway Surgeries-THRIVE, a Tubeless Ventilation

THRIVE stands for Transnasal Humidified Rapid Insufflation Ventilatory Exchange. Usage of THRIVE technique is common in emergency settings and of late its usage in upper airway surgeries is gaining popularity. (1) To determine the operative time, total anaesthesia time, safety and efficacy of THRIVE in patients undergoing upper airway surgeries for varied pathologies. (2) To assess the surgeon's satisfaction and patients post-operative comfort. An observational study was from May 2019 to Oct 2020. Study was conducted through a detailed proforma which consists of patient demographic details, physical status, co-morbidities and various domains to assess the safety and efficacy of THRIVE. A total of 32 patients were divided into four groups depending on the type of surgery. We had 18 patients in microlaryngeal excision, six in direct laryngoscopy and biopsy, four in tracheostomy and four in balloon dilatation for subglottic stenosis groups. The mean operation time was 16 ± 2 min in the first three groups and 29 ± 0.8 in the fourth group. All the patients underwent successful surgeries without any episodes of desaturation, without complications and with good surgical satisfaction. THRIVE with appropriate safety precautions can be tried in patients undergoing various upper airway surgeries of short duration. All the patients in our study maintained stable vital parameters throughout the surgery. Initial results with the use of THRIVE as per our study and other studies are definitely encouraging to use THRIVE in upper airway surgeries with varied pathologies.

Supraglottic jet oxygenation and ventilation reduces desaturation during bronchoscopy under moderate to deep sedation with propofol and remifentanil: A randomised controlled clinical trial

BACKGROUND

Hypoxaemia is frequently seen during flexible bronchoscopies that are done with a nasal approach under the traditional sedation with propofol. This study investigated the potential benefits of supraglottic jet oxygenation and ventilation (SJOV) using the Wei nasal jet tube (WNJ) in reducing hypoxaemia in patients undergoing bronchoscopy under moderate to deep intravenous sedation using a propofol, lidocaine and remifentanil cocktail.

OBJECTIVES

Our primary objective was to evaluate the efficacy and complications of SJOV via the WNJ during flexible bronchoscopy under moderate to heavy sedation with propofol and remifentanil.

DESIGN

A randomised controlled clinical trial.

SETTING

The 180th Hospital of People's Liberation Army, Quanzhou, China, from 1 June to 1 November 2019.

PATIENTS

A total of 280 patients aged ≥18 years with American Society of Anesthesiologists' physical status 1 to 3 undergoing flexible bronchoscopy were studied.

INTERVENTIONS

Patients were assigned randomly into one of two groups, a nasal cannula oxygenation (NCO) group (n = 140) using a nasal cannula to deliver oxygen (4 l min-1) or the SJOV group (n = 140) using a WNJ connected to a manual jet ventilator to provide SJOV at a driving pressure of 103 kPa, respiratory rate 20 min-1, FiO2 1.0 and inspiratory:expiratory (I:E) ratio 1:2.

MAIN OUTCOME MEASURES

The primary outcome was an incidence of desaturation (defined as SpO2 < 90%) during the procedure. Other adverse events related to the sedation or SJOV were also recorded.

RESULTS

Compared with the NCO group, the incidence of desaturation in the SJOV group was lower (NCO 37.0% vs. SJOV 13.1%) (P < 0.001). Patients in the SJOV group had a higher incidence of a dry mouth at 1 min (13.1% vs. 1.5%, P < 0.001) than at 30 min (1.5% vs. 0%, P = 0.159) or at 24 h (0% vs. 0%). There was no significant difference between the groups in respect of sore throat, subcutaneous emphysema or nasal bleeding.

CONCLUSIONS

SJOV via a WNJ during flexible bronchoscopy under moderate to deep sedation with propofol and remifentanil significantly reduces the incidence of desaturation when compared with regular oxygen supplementation via a nasal cannula. Patients in the SJOV group had an increased incidence of transient dry mouth.

TRIAL REGISTRATION

Registered at www.chictr.org.cn (ChiCTR1900023514).

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.

The Effectiveness of High-Flow Nasal Oxygen During the Intraoperative Period: A Systematic Review and Meta-analysis

BACKGROUND

High-flow nasal oxygen (HFNO) is increasingly being used in intensive care units for management of hypoxemia and respiratory failure. However, the effectiveness of HFNO for preventing hypoxemia in the intraoperative period is unclear. The purpose of this systematic review was to compare patient oxygenation and end-tidal CO2 (EtCO2), between HFNO and conventional oxygenation, during the intraoperative period in surgical patients.

METHODS

Standard databases were searched from inception to February 2020. Studies involving intraoperative use of HFNO with 1 of the 4 outcomes: (1) oxygen (O2) desaturation, (2) minimum O2 saturation, (3) safe apnea time, or (4) EtCO2 were included. Intraoperative period was divided into 2 phases: at induction with general anesthesia and during surgical procedure under sedation without tracheal intubation.

RESULTS

Eight randomized controlled trials (RCTs; 4 induction, 4 procedure, 2314 patients) were included for systematic review and meta-analyses. We found the risk of intraoperative O2 desaturation was lower in HFNO versus conventional oxygenation control group; at induction with an odds ratio (OR; 95% confidence interval [CI]) of 0.06 (0.01-0.59, P = .02), and during procedure, OR (95% CI) of 0.09 (0.05-0.18; P < .001). The minimum O2 saturation was higher in HFNO versus conventional oxygenation; at induction by a mean difference (MD) (95% CI) of 5.1% (3.3-6.9; P < .001), and during procedure, by a MD (95% CI) of 4.0% (1.8-6.2; P < .001). Safe apnea time at induction was longer in HFNO versus conventional oxygenation by a MD (95% CI) of 33.4 seconds (16.8-50.1; P < .001). EtCO2 at induction was not significantly different between HFNO and conventional oxygenation groups.

CONCLUSIONS

This systematic review and meta-analysis show that, in the intraoperative setting, HFNO compared to conventional oxygenation reduces the risk of O2 desaturation, increases minimum O2 saturation, and safe apnea time. HFNO should be considered for anesthesia induction and during surgical procedures under sedation without tracheal intubation in patients at higher risk of hypoxemia.

Supraglottic jet oxygenation and ventilation - A novel ventilation technique

Supraglottic jet oxygenation and ventilation (SJOV) is a novel minimally invasive supraglottic technique of jet ventilation which has shown superior results in maintaining oxygenation without any major complications. Theoretically, it could maintain PaO₂ and PaCO₂ within physiological limits for as long as required, the maximum duration reported till now is 45 min. The distinct advantage of SJOV over techniques of nasal oxygenation is its ability to record EtCO₂ during the periods of ventilation. In addition, it also provides reliable airway access by the blind passage of the endotracheal tube into the trachea with a high success rate even in Cormack-Lehane-III (CLIII) grading patients. Potential complications seen with SJOV include nasal bleed and sore throat. No studies have shown to cause severe barotrauma. In this article, we review the evidence regarding oxygenation, ventilation, indications, airway patency and complications of SJOV in comparison to other more commonly used supraglottic oxygenation and ventilation devices.