Comparison between Standard preoxygenation and Transnasal Humidified Rapid-
Insufflation Ventilatory Exchange (THRIVE) in Difficult Airway during Induction of

Anaesthesia

Z Belamaric, D Nagore, JP Jimeno, A Bilbao, T Garth, K Plummer

Department of Perioperative Medicine, St. Bartholomew’s Hospital, London, UK

Background and Goal of Study

Securing the airway can prove to be a challenge for the anaesthetist and may require use of

different tools and change of strategy. In this phase it is pivotal to improve the oxygenation and

prevent desaturation.

We compared THRIVE and standard preoxygenation during induction of anaesthesia in patient

with predicted difficult airways.

Materials and Methods

30 adult patients, undergoing elective surgery in whom the presence of difficult airway was known

or strongly anticipated based on unfavourable predictors (BMI>35, decreased thyro-mental

distance, limited mouth opening, limited neck extension, Mallampati score ≥ 3) were randomised

into two groups:

1) Standard 5 minutes pre-oxygenation (100% FiO2) + mask ventilation between intubation

attempts

2) THRIVE: 5 minutes pre-oxygenation with THRIVE (100% FiO2) at a rate of 60 l/min +

continuous THRIVE until a definitive airway was secured.

Induction was standardised for both groups as Fentanyl (2 mcg/kg) + Propofol (2 mg/kg) +

Rocuronium (0.6 mg/kg) with background maintenance of Propofol infusion (0.3 mg/kg/min).

Intubation was performed in all 30 cases by the same Consultant Anaesthetist.

Primary end-point of the study was the number of desaturation episodes (SpO2< 92%) until a

definitive airway was secured.

Secondary end-points included time to secure the airway, adverse effects (airway trauma,

bradycardia, hypo/hypertension) and the number of laryngoscopy attempts.

Results

The 2 groups were similar in demographic parameters.

Mean baseline SpO2 was 97.8 % in both groups.

The mean time to secure the airway was 161.9+/-49.6 sec for THRIVE and 166.7+/-54.7 sec for

the Standard group (p value =0.80).There was 1 adverse effect in THRIVE and 4 in Standard

group (p value=0.24). The mean number of laryngoscopy attempts was 1.73 in THRIVE and 2 in

Standard group (p value=0.5).

The number of desaturation episodes was significantly different: no episodes for THRIVE vs. 4

episodes for the Standard group (p value=0.03).

Conclusion

Although there was no statistically significant difference in the time or number of attempts to secure

the airway or in the incidence of adverse effects, THRIVE significantly reduced the number of

desaturation episodes. In our opinion THRIVE may prove to be an useful tool especially in cases of

unexpected difficult intubation.

References

-Baraka AS, Taha SK, Aouad MT, El-Khatib MF, Kawkabani NI. Preoxygenation: comparison of

maximal breathing and tidal volume breathing techniques. Anesthesiology 1999; 91: 612– 6.

-Baillard C, Fosse JP, Sebbane M, et al. Noninvasive ventilation improves preoxygenation before

intubation of hypoxic patients. American Journal of Respiratory and Critical Care Medicine 2006;

174: 171–7.

-Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25 degrees head-up

position than in the supine position in severely obese patients: a randomized controlled study.

Anesthesiology 2005; 102: 1110–5.

-Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal

intubation in the critically ill. Intensive Care Medicine 2008; 34: 1835–4

Comparison between Standard Preoxygenation and Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) in Difficult Airway during Induction of Anaesthesia