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• W1570056859 abstract "Patel and Nouraei report that the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) technique ‘has the potential to transform the practice of anaesthesia’ by ‘extending the safe apnoeic window’ following induction of general anaesthesia and neuromuscular blockade 1. Their method uses the reported but under-used technique of aventilatory mass flow (AVMF), also known as apnoeic mass movement oxygenation (AMMO) 2, but may have important limitations. The first of these relates to airway patency following induction of general anaesthesia. For THRIVE to succeed, there must be some retention of anatomical patency between the nasal device and the lungs to allow uninterrupted flow of gas throughout the airway management sequence. Obviously, the nasal passages must be patent. General anaesthesia, however, results in a variable degree of upper airway closure. We note that the authors used application of jaw thrust to manage this. Whist closure was traditionally thought to result mainly from posterior displacement of the tongue, it is more likely to involve the soft palate and epiglottis 3. There is no clear relationship between depth of anaesthesia and closure (‘collapsibility’) 4, 5. The important conclusion is that induction of anaesthesia may result in airway closure. Additionally, application of cricoid force may obstruct the airway 6. Should closure be complete, the efficacy of THRIVE is lost. We also suggest that accumulations of airway secretions, mucus or blood in the airway are also potential causes of interruption of gasflow. It is important to provide neuromuscular blockade and maintain anaesthesia. The authors used a propofol infusion; if this is not chosen, intermittent administration must ensure protection from awareness. The second limitation relates to obesity, a prevalent clinical challenge. The authors advise that THRIVE extends safe apnoea time to 5 min in the ‘morbidly obese’. However, this length of safe apnoea time can be achieved using simple nasal cannulae only, at a flow rate of 5 l.min−1 with the patients in a 25° head-up position 7, 8 to maintain arterial oxygen saturation at 100% after 4 min 9 or extend saturation > 95% from 3.5 to 5.3 min 10, in subjects with BMI > 35 kg.m−2. We think that THRIVE is an important clinical advance but, like all therapeutic interventions, has limitations, some of which will be unpredictable. THRIVE should be viewed not as an isolated improvement but as part of a sequence of ‘optimisation of oxygenation’. We would like to re-emphasise that a combination of methods, allied to the standard of pre-oxygenation monitored using end-tidal concentration, may provide the safest approach during induction. Pre-oxygenation with assisted spontaneous breathing and positive end-expiratory pressure may be of additional benefit in improving oxygenation in the obese patient 11, 12, with AMMO methods employed if there is apnoea. These should not detract, however, from other approaches to predictable, problematic airway management, in particular proactive, awake techniques." @default.
• W1570056859 created "2016-06-24" @default.
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• W1570056859 date "2015-05-10" @default.
• W1570056859 modified "2023-10-05" @default.
• W1570056859 title "Failure to THRIVE" @default.
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• W1570056859 doi "https://doi.org/10.1111/anae.13093" @default.
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