Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) is no longer just a tool to help anaesthetists secure a difficult airway. Thanks to the work of authors like Yang and colleagues, it is being revolutionised to provide apnoeic oxygenation during endoscopic oesophageal surgery (EOS), thereby unshackling patients from the proverbial cuff of traditional endotracheal intubation. THRIVE can administer up to 90L/min of humidified oxygen via a non-invasive nasal cannula. It can provide adequate oxygenation with relatively unremarkable increases in EtCO2 for the entire period of general anaesthesia in certain short procedures without the need for mechanical ventilation. This study retrospectively analysed 14 patients who underwent EOS with total intravenous anaesthesia and neuromuscular paralysis using THRIVE. Patients were preoxygenated at 50L/min and subsequently maintained on 70ml/min following induction. Thirteen patients successfully sustained a mean SpO2 of 99% (range 94–100%) throughout the procedure after a mean apnoeic time of 17.9 minutes (maximum 32 minutes). One patient required uncomplicated ‘rescue’ intubation following five minutes of THRIVE after desaturating to 88% SpO2. Excluding this THRIVE failure, linear regression found EtCO2 increased by 0.127 kPa/min, correlating with a weighted average of 0.13 kPa/min found in four similar studies. This highlights THRIVE’s ability to eliminate CO2 non-invasively in comparison to increases of 0.35 to 0.45 kPa/min noted by different authors in control apnoeic patients. Removing the need for an endotracheal tube allows for greater visualisation during EOS and grants greater access in patients with posterior glottic or subglottic stenosis. However, we must further investigate whether intranasal anatomical variation, degree of pulmonary reserve, and lack of continuous EtCO2 monitoring can adversely affect the future feasibility of THRIVE. Perhaps, with THRIVE leading the charge, it’s time to ditch the tube and crank up the oxygen for a breath of fresh air in endoscopic oesophageal surgery.
THRIVE: redefining airway management in endoscopic oesophageal surgery
Reviewed by Thomas William Binnersley and Lucy Dalton
Transnasal Humidified Rapid Insufflation Ventilatory Exchange in Endoscopic Esophageal Surgery.
