Transnasal Humidified Rapid Insufflation Ventilatory Exchange With Nasopharyngeal Airway Facilitates Apneic Oxygenation: A Randomized Clinical Noninferiority Trial

Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

Addressing desaturation in a tracheal stenosis patient using the transnasal humidified rapid-insufflation ventilatory exchange technique during tracheostomy: A case report

RATIONALE

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is used in tracheostomy but not in cases of airway obstruction. This case report explores the use of THRIVE for managing airway obstruction during tracheostomy in patients with subglottic and tracheal stenosis, thereby addressing the current knowledge gap and exploring its potential for airway management.

PATIENT CONCERNS

A 63-year-old female with subglottic and tracheal stenoses underwent tracheostomy. Multiple attempts to establish a patent airway were unsuccessful, and oxygen saturation dropped to 56%.

DIAGNOSIS

Endotracheal tube was directed toward the tracheal wall, causing airway obstruction.

INTERVENTIONS

THRIVE was administered to the patient. Subsequently, the tube position was adjusted to enhance ventilation.

OUTCOMES

The patient's oxygen saturation increased to 99%. The postoperative complications, including subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium, resolved. The patient was discharged on postoperative day 9.

LESSONS

THRIVE could be considered a temporary measure to enhance oxygenation before initiating a definitive treatment strategy.

Oxygenation during the apnoeic phase preceding intubation in adults in prehospital, emergency department, intensive care and operating theatre environments

BACKGROUND

Apnoeic oxygenation is the delivery of oxygen during the apnoeic phase preceding intubation. It is used to prevent respiratory complications of endotracheal intubation that have the potential to lead to significant adverse events including dysrhythmia, haemodynamic decompensation, hypoxic brain injury and death. Oxygen delivered by nasal cannulae during the apnoeic phase of intubation (apnoeic oxygenation) may serve as a non-invasive adjunct to endotracheal intubation to decrease the incidence of hypoxaemia, morbidity and mortality.

OBJECTIVES

To evaluate the benefits and harms of apnoeic oxygenation before intubation in adults in the prehospital, emergency department, intensive care unit and operating theatre environments compared to no apnoeic oxygenation during intubation.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 4 November 2022.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs that compared the use of any form of apnoeic oxygenation including high flow and low flow nasal cannulae versus no apnoeic oxygenation during intubation. We defined quasi-randomization as participant allocation to each arm by means that were not truly random, such as alternation, case record number or date of birth. We excluded comparative prospective cohort and comparative retrospective cohort studies, physiological modelling studies and case reports.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. hospital stay and 2. incidence of severe hypoxaemia. Our secondary outcomes were 3. incidence of hypoxaemia, 4. lowest recorded saturation of pulse oximetry (SpO2), 5. intensive care unit (ICU) stay, 6. first pass success rate, 7. adverse events and 8.

MORTALITY

We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included 23 RCTs (2264 participants) in our analyses. Eight studies (729 participants) investigated the use of low-flow (15 L/minute or less), and 15 studies (1535 participants) investigated the use of high-flow (greater than 15 L/minute) oxygen. Settings were varied and included the emergency department (2 studies, 327 participants), ICU (7 studies, 913 participants) and operating theatre (14 studies, 1024 participants). We considered two studies to be at low risk of bias across all domains. None of the studies reported on hospital length of stay. In predominately critically ill people, there may be little to no difference in the incidence of severe hypoxaemia (SpO2 less than 80%) when using apnoeic oxygenation at any flow rate from the start of apnoea until successful intubation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.66 to 1.11; P = 0.25, I² = 0%; 15 studies, 1802 participants; low-certainty evidence). There was insufficient evidence of any effect on the incidence of hypoxaemia (SpO2 less than 93%) (RR 0.58, 95% CI 0.23 to 1.46; P = 0.25, I² = 36%; 3 studies, 489 participants; low-certainty evidence). There may be an improvement in the lowest recorded oxygen saturation, with a mean increase of 1.9% (95% CI 0.75% to 3.05%; P < 0.001, I² = 86%; 15 studies, 1525 participants; low-certainty evidence). There may be a reduction in the duration of ICU stay with the use of apnoeic oxygenation during intubation (mean difference (MD) ‒1.13 days, 95% CI ‒1.51 to ‒0.74; P < 0.0001, I² = 46%; 5 studies, 815 participants; low-certainty evidence). There may be little to no difference in first pass success rate (RR 1.00, 95% CI 0.93 to 1.08; P = 0.79, I² = 0%; 8 studies, 826 participants; moderate-certainty evidence). There may be little to no difference in incidence of adverse events including oral trauma, arrhythmia, aspiration, hypotension, pneumonia and cardiac arrest when apnoeic oxygenation is used. There was insufficient evidence about any effect on mortality (RR 0.84, 95% CI 0.70 to 1.00; P = 0.06, I² = 0%; 6 studies, 1015 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There was some evidence that oxygenation during the apnoeic phase of intubation may improve the lowest recorded oxygen saturation. However, the differences in oxygen saturation were unlikely to be clinically significant. This did not translate into any measurable effect on the incidence of hypoxaemia or severe hypoxaemia in a group of predominately critically ill people. We were unable to assess the influence on hospital length of stay; however, there was a reduction in ICU stay in the apnoeic oxygenation group. The mechanism for this is unclear as there was little to no difference in first pass success or adverse event rates.

High-flow nasal oxygen reduces the incidence of hypoxia in sedated hysteroscopy for assisted reproduction

Backgrounds and aims

Pain is the main reason for hysteroscopy failure. In day-surgical settings, hysteroscopy procedures are commonly performed with the patient under sedation. Hypoxia is the most common adverse event during sedation and can lead to severe adverse events. This study aimed to compare the incidence of hypoxia when using high-flow nasal oxygen (HFNO) with that when using regular nasal oxygen in patients undergoing hysteroscopy with sedation.

Materials and methods

In this single-center, prospective, randomized, single-blinded study, 960 female patients undergoing elective diagnostic or operative hysteroscopy were randomly enrolled into the following two groups: the regular nasal group [O₂ (3–6 L/min) covered by an HFNO] and the HFNO group [O₂ (30–60 L/min)] from September 2021 to December 2021. All women were sedated with propofol (1.5 mg/kg) and remifentanil (1.5 μg/kg) in the operating room. The primary outcome was the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s).

Results

HFNO decreased the incidence of hypoxia (75% ≤ SpO₂ < 90%, < 60 s), subclinical respiratory depression (90% ≤ SpO₂ < 95%) and severe hypoxia (SpO₂ < 75% for any duration or 75% ≤ SpO₂ < 90% for ≥ 60 s) from 24.38 to 0.83%, from 11.25 to 1.46% and from 3.75 to 0%, respectively (P < 0.001).

Conclusion

In procedures conducted to treat female infertility, HFNO can reduce hypoxia during hysteroscopy in patients sedated with propofol, and it can prevent the occurrence of subclinical respiratory depression and severe hypoxia.

Comparison of 10.6 μm Laser Moxibustion with Traditional Moxibustion in Knee Osteoarthritic Therapy: A Randomized Noninferiority Clinical Trial

Objective: To investigate the noninferiority of 10.6 μm laser moxibustion (LM) to traditional moxibustion (TM) in knee osteoarthritis (KOA). Methods: Ninety-two patients were recruited and randomly placed into one of two groups: 10.6 μm LM or TM in a 1:1 ratio. Each patient received 12 sessions of LM or TM, focusing on the ST-35 and Ashi acupoint. The sessions took place over 4 weeks, three times a week, and were followed up over 8 weeks. The endpoint outcomes were separated into two categories, primary and secondary. The primary endpoint was assessed at the end of the 4-week treatment, using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. The secondary endpoint was evaluated at the end of the trial and consisted of the WOMAC function and stiffness score, visual analog pain [visual analog scale (VAS)] score, and 15-m walking time test. In addition, safety evaluation was performed throughout the trial. Results: Among the 92 randomized participants, 86 (93.48%) completed the trial; 43 in each group. The WOMAC pain score improved dramatically between the LM and TM groups, with a mean difference of 20.61 [95% confidence interval (CI): -2.28 to 43.50]. Given that the lower boundary of 95% CI was greater than -18.49, noninferiority was established. In addition, both LM and TM significantly decreased the WOMAC (pain, function and stiffness) score, VAS score (p < 0.05), and the 15-m walking time at the end of the trial. Interestingly, there were not significant differences between LM and TM (p > 0.05), suggesting that both are equally effective in treating KOA. Finally, among the 92 patients, 17 (18.48%) adverse effects were documented, namely 5 (10.87%) in the LM-treated group and 11 (26.09%) in the TM-treated group. Conclusions: 10.6 μm LM is not inferior to TM in treating KOA. Moreover, both LM and TM dramatically alleviated knee pain and enhanced function of knees. Clinical Trial Registration number: ISRCTN registry trial identifier: 14604492.