Difficult airway poll

[IlDestriero]

Simple poll about THRIVE in difficult airways.
We all sedate known or potentially difficult airways because we believe/know we can intubate them without the need for an awake fiberoptic intubation.
Do you use THRIVE on these patients?
Poll results are not public, so your vote is anonymous.
Feel free to comment.
EDITED to add that “THRIVE” above can refer to modifications to the method that effectively do the same thing.

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[dchz]

if the obstruction is at the larynx or glottis having oxygen before the obstruction seems.... ineffective.

I also don't see how this is superior to a mask or nasal cannula.

 

[shepardsun]

I also don't see how this is superior to a mask or nasal cannula.

I think vs mask and regular nasal cannula it provides a little bit of CPAP and apneic oxygenation increasing time to critical desaturation.

 

[dchz]

I think vs mask and regular nasal cannula it provides a little bit of CPAP and apneic oxygenation increasing time to critical desaturation.

This is true only if you close the mouth and lips... unless the CPAP can provide like 100PSI to jet oxygenate from the nose...

the time to critical desat is still the same as the mouth opening for intubation will make this device pretty pointless. No?

 

[Psai]

http://www.airwayworld.com/wp-conte...-Humidified-Oxygen-for-a-Difficult-Airway.pdf

WTf 17 minutes of apnea time? That's ridiculous. I only need 17 seconds though

 

[vector2]

This is true only if you close the mouth and lips... unless the CPAP can provide like 100PSI to jet oxygenate from the nose...

the time to critical desat is still the same as the mouth opening for intubation will make this device pretty pointless. No?

In regard to the pt you haven't induced yet, the flows with HFNC at 50-60L/m are such that it doesn't matter if the patient is mouth breathing or not. The flow is so high that it effectively washes out all oropharyngeal and LTB anatomic deadspace so very little atmospheric air is entrained. Studies have confirmed that set FiO2 with HFNC is very close to measured FiO2, i.e. orders of magnitude better than regular nasal cannulas. This can be overcome though if the patient is tachypneic and taking huge Vt breaths through the mouth with high peak inspiratory flow, however this is an unlikely situation is a mildly sedated AFOI pt who's breathing comfortably when the procedure starts.


Just FYI, this concept has been studied a decent bit in the ED and ICU literature:

Preoxygenation & apneic oxygenation using a nasal cannula

Nasal Cannula Apneic Oxygenation Prevents Desaturation During Endotracheal Intubation: An Integrative Literature Review

Also, this article on "Delayed Sequence Intubation" is a must read
Delayed Sequence Intubation (DSI)

 

[MoMoGesiologist]

Don't have this available but if it really does apneic oxygenation and prolongs apnea time to desat then heck yea I would use it for scary airways. Just induce and take time to intubate. No more awake intubations!

 

[Bryan O’Blivion]

Have not used THRIVE as I don't readily have access to the equipment necessary, i.e. source of 70 LPM, humidifier, Optiflow. Most anesthesia machines I am familiar with have an aux supply limited to 10 LPM. However a cannula or buccal RAE tube attached to the aux does consistently prolong the time to desaturation during apnea, as long as a patent airway is maintained, like with a laryngoscope. Has worked well for me. I have heard anecdotes about gastric insufflation. Hasn't been a problem for me. There are a couple of papers by Levitan et al that describe the effective use of cannulas in the EMS setting.

 

[deleted697535]

http://www.airwayworld.com/wp-conte...-Humidified-Oxygen-for-a-Difficult-Airway.pdf

WTf 17 minutes of apnea time? That's ridiculous. I only need 17 seconds though

I can't remember ever having an apnea time of 17 mins. Who's intubating these people and why is it taking so long?

 

[deleted59964]

Don't have this available but if it really does apneic oxygenation and prolongs apnea time to desat then heck yea I would use it for scary airways. Just induce and take time to intubate. No more awake intubations!

it works extremely well but it’s not a panacea - you still need a patent airway. jaw thrust while waiting to intubate helps, during laryngoscopy i reckon the airway is almost always l
patent. if it isn’t you are really up sh$& creek

 

[urge]

Simple poll about THRIVE in difficult airways.
We all sedate known or potentially difficult airways because we believe/know we can intubate them without the need for an awake fiberoptic intubation.
Do you use THRIVE on these patients?
Poll results are not public, so your vote is anonymous.
Feel free to comment.
EDITED to add that “THRIVE” above can refer to modifications to the method that effectively do the same thing.

First, what the heck is THRIVE?

If you mean a High Flow Nasal Cannula, those things are garbage compare to BiPAP.

 

[anbuitachi]

Is THRIVE similar to supernova

 

[deleted697535]

The whole thing is horsesh1t. Unblinded, biased, industry fueled crap.

What are the numbers need to treat?

If you think you can wheel this out at 3 o clock in the morning and it will save a mom from crashing you're dreaming.
Just put the bloody tube in

 

[AdmiralChz]

I’ve never heard of anyone having such equipment in the OR. So, no way.

Also, 82% of responders don’t know what THRIVE is.

 

[caligas]

What about simple nasal cannula o2 at 15-25 L/min during intubation of difficult airway?

 

[Onefellswoop87]

Here is a technique that just requires an oral RAE and tape:
Cut off the murphy's eye of the oral rae and connect that end to supplemental oxygen. Remove the circuit connector from the oral RAE and insert that end into the patient's mouth along the inside of their cheek, and then tape it to the outside of their cheek.

https://journals.lww.com/anesthesia...enation_During_Prolonged_Laryngoscopy.23.aspx
"Patient characteristics were similar in both study arms. Recipients of buccal oxygenation were less likely to exhibit Spo2 < 95% during 750 seconds of apnea. Median (interquartile range [IQR]) apnea times with Spo2 ≥ 95% were prolonged in this group; 750 (389–750) versus 296 (244–314) seconds, P < .0001."

 

[Mman]

Thrive? You mean the stickers that fat girls stick on their arms that supposedly release vitamins and burn fat and then post on facebook and instagram about how they are THRIVING?

Do you THRIVE?

This MLM pyramid BS angers me even more than Rodan and Fields.

 

[deleted59964]

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a step forward in apnoeic oxygenation, paradigm-shift in ventilation, or both? | BJA: British Journal of Anaesthesia | Oxford Academic

https://watermark.silverchair.com/a...wEEVQV9yJKzjM-yScPCmS-Ol2BWdICxH25qp9fd-edA2w

thrive - transnasal humidified rapid insufflation ventilatory exchange.

I don't care what the brand is, putting 50 - 70L/min of humidified O2 down someone's nose prolongs time to desaturation.
It's a useful technique for difficult airways - or patients who desaturate quickly (eg. morbid obesity). It's also great to extubatne back on to for the morbidly obese or those with OSA.

We have 2 set ups in our OR.
We lag behind ICU and ED in it's use but we're finding it has a place

 

[Ronin786]

There's a nasal CPAP machine you can use as well that is supposed to do a better job of providing continuous flow with less L/min.

 

[abolt18]

Good conversation and interesting reading shared by many of you. Thank you. I'm now quite intrigued.

 

[caligas]

What about simple nasal cannula o2 at 15-25 L/min during intubation of difficult airway?

Well, I just tried standard nasal canula 25/min on BMI 70. She desaturated quickly. So N=1, negative study.

 

[vector2]

Well, I just tried standard nasal canula 25/min on BMI 70. She desaturated quickly. So N=1, negative study.

Did she have coexisting respiratory failure? One of the take home points is that apneic oxygenation is useless for ppl with impending respiratory arrest or bad pulmonary disease.

 

[caligas]

Did she have coexisting respiratory failure? One of the take home points is that apneic oxygenation is useless for ppl with impending respiratory arrest or bad pulmonary disease.

No, otherwise “healthy”

I just figured that her airway was completely closed off with induction, or maybe need higher flows. Who knows.

 

[abolt18]

No, otherwise “healthy”

I just figured that her airway was completely closed off with induction, or maybe need higher flows. Who knows.

From what some of those studies shared, between obstruction of the airway (mucho excess soft tissue) and the rapid development of atelectasis and therefore shunt in these patients is a major issue. In the study with the buccal airflow they put all the patients in reverse Trendelenburg to 30° pre induction. Though, they only looked at obese patients and not morbid or super morbid obese (which seems to make up ~50% of my patient population).

 

[rakotomazoto]

We had THRIVE where I trained, don't have access now. Used it 10-20 times on super sick patients in the OR and ICU, never had a desaturation. Also never took anything near 17 minutes to secure the airway, but that's another topic...

In my experience, it seemed to work much better than simple nasal cannula.

 

[Psai]

I've never tried hi flow in the OR but I agree that just plain nasal cannula does not work for preoxygenation and apneic oxygenation.

 

[sigrhoillusion]

http://www.airwayworld.com/wp-conte...-Humidified-Oxygen-for-a-Difficult-Airway.pdf

WTf 17 minutes of apnea time? That's ridiculous. I only need 17 seconds though

That's what she told us...

 

[fakin' the funk]

Oh, you mean HFNC, aka high flow nasal cannula.

Seems like a cool idea.

Good luck getting it in the OR (it is a machine that lives on a pole, likely in your RT department).

And no $hit, it's not as good as Bipap, whoever said that (??).

 

[hippuppy]

Simple poll about THRIVE in difficult airways.
We all sedate known or potentially difficult airways because we believe/know we can intubate them without the need for an awake fiberoptic intubation.
Do you use THRIVE on these patients?
Poll results are not public, so your vote is anonymous.
Feel free to comment.
EDITED to add that “THRIVE” above can refer to modifications to the method that effectively do the same thing.

Have you been using THRIVE? How do you monitor CO2? I think the idea may be a game changer if used in the appropriate setting.