Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.
Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways.
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DOI：
10.1111/anae.12923
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发表时间：
2015-03
期刊：
影响因子：
10.7
通讯作者：
Nouraei SA
中科院分区：
文献类型：
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作者：
Patel A;Nouraei SA
紧急和困难的气管插管是一项危险的工作，连续的喉镜检查-低氧血症-再氧合循环可能会升级为气道丧失和“无法插管，无法通气”的情况。 2013年至2014年间，我们延长了25名接受全身麻醉下咽或喉气管手术的困难气道患者的呼吸暂停时间。这是通过连续输送经鼻高流量湿化氧气来实现的，最初是为了提供预氧合，并在静脉诱导麻醉和神经肌肉阻滞期间继续作为后氧合，直到确保确定的气道。呼吸暂停时间从施用神经肌肉阻滞时开始，到喷射通气、正压通气或重新开始自主通气时结束。在此期间，通过下颌推力保持上呼吸道通畅。 15 名男性和 10 名女性使用了经鼻湿化快速吹入换气 (THRIVE)。治疗时的平均年龄（SD [范围]）为 49（15 [25–81]）岁。中位数（IQR [范围]）Mallampati 分级为 3 (2–3 [2–4])，直接喉镜检查分级为 3 (3–3 [2–4])。有12名肥胖患者，9名患者有喘鸣声。中位呼吸暂停时间（IQR [范围]）为 14 (9–19 [5–65]) 分钟。没有患者经历动脉饱和度<90%。呼吸暂停后潮气末（四名患者为动脉）二氧化碳水平的平均值（SD [范围]）为 7.8 (2.4 [4.9–15.3]) kPa。呼气末二氧化碳的增加率为 0.15 kPa.min−1。我们得出的结论是，THRIVE 将“经典”呼吸暂停氧合的优点与持续气道正压和通过流量依赖的死腔冲洗进行气体交换结合起来。它有可能改变麻醉实践，将紧急和困难插管中确保确定气道的性质从受压的停止-启动过程改变为平稳、从容的过程。
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.