Apneic Technique in Laryngotracheal Surgery

Use of THRIVE for Apneic Oxygenation in Transoral Laser Microlaryngeal Surgery: A Scoping Review

OBJECTIVES

Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted.

DATA SOURCES AND REVIEW METHODS

A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023.

RESULTS

From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS.

CONCLUSION

THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 134:4203-4212, 2024.

Bedside preoperative predictors of difficult laryngeal exposure in microlaryngeal surgery

PURPOSE

Successful microlaryngeal surgery relies on an adequate laryngeal exposure. Recognizing the likelihood of challenging exposure prior to microlaryngeal surgery may assist in selecting the appropriate surgical approach and even prompt consideration of alternative treatment options. We aim to apply the mini-Laryngoscore, a preoperative assessment tool, to our study population and incorporate novel variables to optimize the prediction model.

METHODS

This single-center prospective cohort study included 80 consecutive patients undergoing elective microlaryngeal surgery, from January 1, to June 30, 2023. Each patient underwent a presurgical evaluation of 15 parameters and an intraoperative scoring of the anterior commissure visualization. These parameters were assessed for their association with difficult laryngeal exposure, using multiple logistic regression analysis. We created a novel prediction model for DLE and compared it with the existing model, the mini-Laryngoscore.

RESULTS

Out of 80 patients, 24 (30%) patients had difficult laryngeal exposure, including 3 cases (3.8%) in which visualization of the anterior commissure was not possible. A large neck diameter (OR, 1.4; CI 1.1-1.9) and the presence of upper teeth (OR, 8.9; CI 1.3-62.8) were independent risk factors for a difficult laryngeal exposure, while a larger interincisors gap was the only independent protector factor (OR, 0.3; CI 0.1-0.8). The logistic regression model combining these three independent risk factors displayed a high discriminative value AUC = 0.89 (CI 0.81-0.97). The predictive performance of the mini-Laryngoscore was 0.73 (CI 0.62-0.85).

CONCLUSION

Combining two parameters from the mini-Laryngoscore (upper jaw dental state and interincisors gap distance) with neck circumference measurement can accurately predict the risk of difficult laryngeal exposure.

High-flow Nasal Cannula versus Conventional Ventilation in Laryngeal Surgery: A Systematic Review and Meta-analysis

High-flow nasal cannula (HFNC) is an emerging option for maintaining oxygenation in patients undergoing laryngeal surgery, as an alternative to traditional tracheal ventilation and jet ventilation (JV). However, the data on its safety and efficacy is sparse. This study aims to aggregate the current data and compares the use of HFNC with tracheal intubation and jet ventilation in adult patients undergoing laryngeal surgery. We searched PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), Embase (Excerpta Medica Database), Google Scholar, Cochrane Library, and Web of Science. Both observational studies and prospective comparative studies were included. Risk of bias was appraised with the Cochrane Collaboration Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) or RoB2 tools and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for case series. Data were extracted and tabulated as a systematic review. Summary statistics were performed. Meta-analyses and trial sequential analyses of the comparative studies were performed. Forty-three studies (14 HFNC, 22 JV, and seven comparative studies) with 8064 patients were included. In the meta-analysis of comparative studies, the duration of surgery was significantly reduced in the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) group, but the number of desaturations, need for rescue intervention, and peak end-tidal CO₂ were significantly increased compared to the conventional ventilation group. The evidence was of moderate certainty and there was no evidence of publication bias. In conclusion, HFNC may be as effective as tracheal intubation in oxygenation during laryngeal surgery in selected adult patients and reduces the duration of surgery but conventional ventilation with tracheal intubation may be safer. The safety of JV was comparable to HFNC.