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      The effect of intraoperative transnasal humidified rapid-insufflation ventilatory exchange on emergence from general anesthesia in patients undergoing microlaryngeal surgery: a randomized controlled trial

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          Abstract

          Background

          Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has received extensive attention for its utility in tubeless anesthesia. Still, the effects of its carbon dioxide accumulation on emergence from anesthesia have not been reported. This randomized controlled trial aimed at exploring the impact of THRIVE combined with laryngeal mask (LM) on the quality of emergence in patients undergoing microlaryngeal surgery.

          Methods

          After research ethics board approval, 40 eligible patients receiving elective microlaryngeal vocal cord polypectomy were randomly allocated 1:1 to two groups, THRIVE + LM group: intraoperative apneic oxygenation using THRIVE followed by mechanical ventilation through a laryngeal mask in the post-anesthesia care unit (PACU), or MV + ETT group: mechanically ventilated through an endotracheal tube for both intraoperative and post-anesthesia periods. The primary outcome was duration of PACU stay. Other parameters reflecting quality of emergence and carbon dioxide accumulation were also recorded.

          Results

          Duration of PACU stay (22.4 ± 6.4 vs. 28.9 ± 8.8 min, p = 0.011) was shorter in the THRIVE + LM group. The incidence of cough (2/20, 10% vs. 19/20, 95%, P < 0.001) was significantly lower in the THRIVE + LM group. Peripheral arterial oxygen saturation and mean arterial pressure during intraoperative and PACU stay, Quality of Recovery Item 40 total score at one day after surgery and Voice Handicap Index-10 score at seven days after surgery were of no difference between two groups.

          Conclusions

          The THRIVE + LM strategy could accelerate emergence from anesthesia and reduce the incidence of cough without compromising oxygenation. However, these benefits did not convert to the QoR-40 and VHI-10 scores improvement .

          Trial registration

          ChiCTR2000038652.

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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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            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.
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              A randomised controlled trial comparing transnasal humidified rapid insufflation ventilatory exchange (THRIVE) pre-oxygenation with facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia.

              Pre-oxygenation is an essential part of rapid sequence induction of general anaesthesia for emergency surgery, in order to increase the oxygen reservoir in the lungs. We performed a randomised controlled trial of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) pre-oxygenation or facemask pre-oxygenation in patients undergoing emergency surgery. Twenty patients were allocated to each group. No patient developed arterial oxygen saturation < 90% during attempted tracheal intubation. Arterial blood gases were sampled from an arterial catheter immediately after intubation. The mean (SD) PaO2 was 43.7 (15.2) kPa in the THRIVE group vs. 41.9 (16.2) kPa in the facemask group (p = 0.722); PaCO2 was 5.8 (1.1) kPa in the THRIVE group vs. 5.6 (1.0) kPa in the facemask group (p = 0.631); arterial pH was 7.36 (0.05) in the THRIVE group vs. 7.34 (0.06) in the facemask group (p = 0.447). No airway rescue manoeuvres were needed, and there were no differences in the number of laryngoscopy attempts between the groups. In spite of this, patients in the THRIVE group had a significantly longer apnoea time of 248 (71) s compared with 123 (55) s in the facemask group (p < 0.001). Transnasal humidified rapid insufflation ventilatory exchange is a practicable method for pre-oxygenating patients during rapid sequence induction of general anaesthesia for emergency surgery; we found that it maintained an equivalent blood gas profile to facemask pre-oxygenation, in spite of a significantly longer apnoea time.
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                Author and article information

                Contributors
                yuan.han@fdeent.org
                Journal
                BMC Anesthesiol
                BMC Anesthesiol
                BMC Anesthesiology
                BioMed Central (London )
                1471-2253
                13 June 2023
                13 June 2023
                2023
                : 23
                : 202
                Affiliations
                [1 ]GRID grid.411079.a, ISNI 0000 0004 1757 8722, Department of Anesthesiology, , Eye & ENT Hospital of Fudan University, ; Xuhui District, Shanghai, 200031 China
                [2 ]GRID grid.16821.3c, ISNI 0000 0004 0368 8293, Institute of Translational Medicine, Shanghai Jiao Tong University, ; Minhang District, Shanghai, China
                [3 ]GRID grid.411079.a, ISNI 0000 0004 1757 8722, Department of Otolaryngology, , Eye & ENT Hospital of Fudan University, ; Xuhui District, Shanghai, China
                Article
                2169
                10.1186/s12871-023-02169-y
                10262498
                37312020
                e011cd43-1985-4d85-bf8d-0f5de2ba59ff
                © The Author(s) 2023

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 19 December 2022
                : 8 June 2023
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001809, National Natural Science Foundation of China;
                Award ID: 82171264
                Award Recipient :
                Funded by: Shanghai Municipal Health and Family Planning Commission Research Project
                Award ID: 2019SY015
                Award Recipient :
                Funded by: Science and Technology Commission of Shanghai Municipality
                Award ID: 21511102000
                Award Recipient :
                Funded by: Medical Engineering Fund of Fudan University
                Award ID: yg2021-008
                Award Recipient :
                Funded by: Shanghai Municipal Health Commission
                Award ID: 202240315
                Award Recipient :
                Funded by: the Natural Science Foundation of Shanghai
                Award ID: 21ZR1411300
                Award Recipient :
                Funded by: Shenkang Clinical Study Foundation of Shanghai
                Award ID: SHDC2020CR4061
                Award Recipient :
                Categories
                Research
                Custom metadata
                © BioMed Central Ltd., part of Springer Nature 2023

                Anesthesiology & Pain management
                thrive,laryngeal mask,tubeless anesthesia,microlaryngeal surgery,emergence from general anesthesia

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