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      Laryngeal microsurgery under Transnasal Humidified Rapid Insufflation Ventilatory Exchange


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          Since 2015, Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) has been used in general anesthesia for preoxygenation or difficult exposure airway management. Its use offers new opportunities in laryngology. THRIVE increases apnea time and frees the access to the upper airway. However, its use may be less stable than orotracheal intubation. The main objective of this work was to evaluate the feasibility of laryngeal microsurgery under THRIVE including using Laser.

          Study Design



          A total of N = 99 patients with laryngeal microsurgery (with or without CO 2 laser) under THRIVE were included successively from January 1, 2020 to January 30, 2022.


          Medical history, comorbidities, clinical and surgical data were extracted and analyzed. Two groups were constituted regarding the “success” (use of THRIVE along all the procedure) or the “failure” (need for an endotracheal tube) of the use of THRIVE during the procedure.


          A failure occurred in N = 15/99 patients (15.2%) mainly due to refractory hypoxia. The odd ratios (OR) for THRIVE failure were: OR = 6.6 [2.9‐35] for overweight (BMI >25 kg/m 2); OR = 3.8 [1.7‐18.7] for ASA score >2; OR = 4.7 [2.3‐24.7] for the use of CO 2 laser. Elderly patients and patients with pulmonary pathology were not statistically at greater risk of THRIVE failure. No adverse event was described.


          This work confirms the feasibility of laryngeal microsurgery under THRIVE, including with CO 2 laser. Overweight, ASA >2 and lower fraction of inspired oxygen during CO 2 laser use increased the risk for orotracheal intubation.

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          Most cited references31

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          Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

          Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy–hypoxaemia–re-oxygenation cycles can escalate to airway loss and the ‘can't intubate, can't ventilate’ scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25–81]) years. The median (IQR [range]) Mallampati grade was 3 (2–3 [2–4]) and direct laryngoscopy grade was 3 (3–3 [2–4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9–19 [5–65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9–15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min−1. We conclude that THRIVE combines the benefits of ‘classical’ apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop–start process to a smooth and unhurried undertaking.
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            Mechanical Ventilation: State of the Art

            Mechanical ventilation is the most used short-term life support technique worldwide and is applied daily for a diverse spectrum of indications, from scheduled surgical procedures to acute organ failure. This state-of-the-art review provides an update on the basic physiology of respiratory mechanics, the working principles, and the main ventilatory settings, as well as the potential complications of mechanical ventilation. Specific ventilatory approaches in particular situations such as acute respiratory distress syndrome and chronic obstructive pulmonary disease are detailed along with protective ventilation in patients with normal lungs. We also highlight recent data on patient-ventilator dyssynchrony, humidified high-flow oxygen through nasal cannula, extracorporeal life support, and the weaning phase. Finally, we discuss the future of mechanical ventilation, addressing avenues for improvement.
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              Apnoeic oxygenation in adults under general anaesthesia using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) – a physiological study

              Apnoeic oxygenation during anaesthesia has traditionally been limited by the rapid increase in carbon dioxide and subsequent decrease in pH. Using a Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) technique a slower increase in carbon dioxide than earlier studies was seen. Notably, apnoeic oxygenation using THRIVE has not been systematically evaluated with arterial blood gases or in patients undergoing laryngeal surgery. The primary aim of this study was to characterize changes in arterial P O 2 , P CO 2 and pH during apnoeic oxygenation using THRIVE under general anaesthesia.

                Author and article information

                OTO Open
                OTO Open
                OTO Open
                John Wiley and Sons Inc. (Hoboken )
                11 June 2024
                Apr-Jun 2024
                : 8
                : 2 ( doiID: 10.1002/oto2.v8.2 )
                : e125
                [ 1 ] Department of Otolaryngology–Head and Neck Surgery Foch Hospital Suresnes France
                [ 2 ] School of Medicine, UFR Simone Veil Université Versailles Saint‐Quentin‐en‐Yvelines (Paris Saclay University) Montigny‐le‐Bretonneux France
                [ 3 ] Department of Otolaryngology Elsan Polyclinic of Poitiers Poitiers France
                [ 4 ] Department of Human Anatomy and Experimental Oncology, Faculty of Medicine, UMONS Research, Institute for Health Sciences and Technology University of Mons (UMons) Mons Belgium
                [ 5 ] Division of Laryngology and Broncho‐Esophagology EpiCURA Hospital Baudour Belgium
                [ 6 ] Phonetics and Phonology Laboratory (UMR 7018 CNRS, Université Sorbonne Nouvelle/Paris 3) Paris France
                [ 7 ] Department of Anesthesiology, Foch Hospital School of Medicine Suresnes France
                [ 8 ] Simulation Center Foch Hospital Suresnes France
                Author notes
                [*] [* ] Corresponding Author: Robin Baudouin, MD, MSc, Department of Otolaryngology–Head and Neck Surgery, Foch Hospital, 40 rue Worth, 92 150 Suresnes, France.

                Email: r.baudouin@ 123456hopital-foch.com

                Author information
                © 2024 The Authors. OTO Open published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology–Head and Neck Surgery Foundation.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                : 01 January 2024
                : 27 January 2024
                Page count
                Figures: 1, Tables: 4, Pages: 8, Words: 5038
                Original Research
                Original Research
                Custom metadata
                April–June 2024
                Converter:WILEY_ML3GV2_TO_JATSPMC version:6.4.4 mode:remove_FC converted:11.06.2024

                airways management,apneic oxygenation,carbon dioxide laser,laryngeal microsurgery,laryngoscopy,thrive


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