The Safety and Efficacy of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Laryngologic Surgery

Abstract

Objectives: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is an intraoperative ventilatory technique that allows avoidance of tracheal intubation (TI) or jet ventilation (JV) in selected laryngologic surgical cases. Unimpeded access to all parts of the glottis may improve surgical precision, decrease operative time, and potentially improve patient outcomes. The objective of this prospective, randomized, patient-blinded, 2-arm parallel pilot trial was to investigate the safety and efficacy of THRIVE use for adult patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration.

Methods: Twenty adult, American society of anesthesiology class 1-3 patients with body mass index (BMI) < 35 kg/m² were randomly assigned to either an experimental THRIVE group or active comparator conventional ventilation group (TI or supraglottic high-frequency JV [SHFJV]). Primary outcomes included intraoperative oxygenation, anesthesia awakening/extubation time, time to laryngoscopic suspension, number of intraoperative suspension adjustments, and operative time. Secondary patient outcomes including postanesthesia and functional patient recovery were investigated.

Results: Compared to TI/SHFJV, THRIVE use was associated with significantly lower intraoperative oxygenation (SpO₂ 93.0 ± 5.6% vs. 98.7 ± 1.6%), shorter time to suspension (1.8 ± 1.1 minutes vs. 4.3 ± 2.1 minutes), fewer suspension adjustments (0.4 ± 0.5 vs. 1.7 ± 0.9), and lower postoperative pain scores on recovery room admission (1.3 ± 1.9 vs. 3.7 ± 2.9) and discharge (0.9 ± 1.3 vs. 2.7 ± 1.8). The study was underpowered to detect other possible outcome differences.

Conclusion: We confirm the safe intraoperative oxygenation profile of THRIVE for selected patients undergoing nonlaser laryngologic surgery of short-to-intermediate duration. THRIVE facilitated surgical exposure and improved early patient recovery, suggesting a potential economic benefit for outpatient laryngologic procedures. The results of this exploratory study provide a framework for designing future adequately powered THRIVE trials.

Trial register: ClinicalTrials.gov (NCT03091179).

Level of evidence: II Laryngoscope, 2020.

Keywords: Laryngologic surgery; airway management; apneic oxygenation; high-flow nasal cannula; high-flow nasal oxygen; transnasal humidified rapid-insufflation ventilatory exchange.