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TRANSCRIPT
THRIVETransnasal Humidified Rapid- Insufflation Ventilatory Exchange
A physiological method of increasing apnoea time in patients with difficult airways
Anaesthesia, 2014. Patel & NouraeiJoanna Gordon, ST7
Mechanisms of action
• Warmth & humidification allows higher flows
• Flush dead space in nasopharynx CO2
• Mechanical splinting supraglottic resistance
• Warmed, humidified – less constriction, more compliance
• Distending pressure – up to 6cm H2O pharyngeal pressure
• Apnoeic oxygenation
• Reducing rates of intubation in resp failure
• Reducing rates of re-intubation on ITU and PACU
• Home device as alternative to CPAP/BiPAP for OSA
& CLD
• Areas of increasing interest:
– Pre-oxygenation in high risk pts (adults)
– Oxygenation during difficult airway management
Uses
Sample
• Case series• 25 adult patients• Difficult airways - anatomical or rapid SpO2 likely• Stenosis, vocal fold pathology, OSA,
hypopharyngeal obstruction
Methods
• 40 degrees head up tilt• Optiflow at 70L/min, 10 minutes• Prop 2-3mg/kg, Fent 1-2μg/kg, Roc 0.5mg/kg
• TIVA maintenance, propofol 0.2-0.3mg/kg/min
• Jaw thrust on LOC• BMV confirmed then discontinued
1. MAC laryngoscopy2. VL 3. VL difficult blade
• Apnoea time = NMB to PPV or jet vent or SV
Results
• 15M, 10F• Mean age 49 (25-81)• Median BMI 30 (18-52)• 10 benign larynx, 2 OSA, 4 head & neck masses• 9 had stridor• Median MP = 3• Median C&L = 3• Mean apnoea time = 17mins (5 – 65)
Results
• Airway management:–14 suspension laryngoscopy with jet vent–4 ETT–4 LMA–2 THRIVE only–1 Tracheostomy
No SpO2 <90%
THRIVE
Limitations
• Observational & cross sectional – routine clinical care
• Optiflow only until definitive airway secured• Airway expert management ? generalisable• Techniques not far from our practice• Conclusion – can extend safe apnoeic window
THRIVE To change difficult airway management?