Transnasal Humidified Rapid‐Insufflation Ventilatory Exchange (THRIVE) vs. Facemask Breathing Pre‐oxygenation for Rapid Sequence Induction in Adults: a Prospective Randomised Non‐blinded Clinical Trial

Lodenius Å , Piehl J, Östlund A et al.

Anaesthesia 2018; 73(5): 564-571

Aim Of Study

To evaluate whether THRIVE used for pre-oxygenation in rapid sequence induction (RSI) of anaesthesia can safely extend apnoea time during laryngoscopy and intubation.

Design (& Location)

Prospective randomised non-blinded clinical trial (Sweden).

Methodology

Adult patients requiring RSI for emergency surgery were pre-oxygenated for 3 minutes using one of two strategies: traditional facemask (n=39) or THRIVE (n=40).

Primary Outcome

Lowest SpO₂ during intubation.

Secondary Outcomes

Change in SpO₂ (ΔSpO₂); level of ETCO₂ in the first breath after intubation; visual inspection of the pharynx during intubation for signs of regurgitation.

Statistics

Numerical variables were analysed using an independent samples t-test or the Mann-Whitney U-test. Categorical variables were compared using the Pearson Chi-square test.

Results

Median (range) lowest SpO₂ during intubation was no different: 99% (70-100%) in the facemask group vs. 99% (96-100%) in the THRIVE group (p=0.097). However, five patients in the facemask group desaturated below 93% vs. none in the THRIVE group (p=0.019).

ΔSpO₂ was significantly different: median (range) was 0% (-1 to -29%) in the facemask group vs. 0% (-1 to -2%) in the THRIVE group (p=0.005). Level of ETCO₂ in the first breath after intubation did not differ between groups: mean 5.3 in the facemask group vs. 5.0 in the THRIVE group (p=0.18). No evidence of regurgitation was observed on inspection of the pharynx in any of the patients in the study.

Conclusions/Discussions

THRIVE may offer superior pre-oxygenation for adults requiring RSI for emergency surgery compared with traditional facemask.

Stated Limitations from Study

Out of hours surgery was excluded, as were patients with BMI >35kg/m². Apnoea time was relatively short in this study (median 109s vs. 116s in the facemask and THRIVE groups respectively).

Discussion from Journal Club Meeting

Earlier evidence suggests that nasopharyngeal airway pressure increases by approximately 1cmH₂O per 10L/min of flow.

Summary by Dr J Major. Journal Club Meeting 10 May 2018.