RESUMEN
High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.
RESUMEN
BACKGROUND: The presence of a pseudodiverticulum of the anterior pharyngeal wall, or prominent "pharyngeal bar," is a well-known phenomenon that occurs following total laryngectomy, which can be visualized by nasolaryngoscopy or videofluoroscopy. Among the different techniques of pharyngeal reconstruction, there is higher incidence following primary vertical multilayered closure. It has been postulated to cause dysphagia and lack of dietary progression despite a paucity of data. However, the direct impact of pseudodiverticulum is less clear and anecdotally its presence and severity does not necessarily correlate with dysphagia. METHODS: A retrospective case series was performed of all consecutive patients who underwent total laryngectomy or laryngopharyngectomy between 2015 and 2022 at two tertiary head and neck institutions. All patients underwent routine videofluoroscopy postoperatively for swallow assessment. The presence of pseudodiverticulum on postoperative contrast swallow study was recorded to investigate the relationship with patient's ability to tolerate oral intake at 3 months discharge from the hospital. RESULTS: Of 50 laryngectomized patients (mean age 63.8 ± 10.0, 86% male), the main closure techniques were primary vertical (n = 9, 18%), primary T-closure (n = 14, 28%), and flap reconstruction (n = 27, 54%). Pseudodiverticulum was identified in 19 cases (38%). 43 patients underwent primary surgery and 30 had adjuvant radiotherapy. The presence of pseudodiverticulum was significantly associated with vertical primary closure versus non-vertical (T-closure or flap reconstruction) techniques (χ2 (df 1) = 7.4, p = 0.007, OR = 5.7, 95% CI 1.3-24.7). Pseudodiverticulum was not associated with an increased inability to tolerate solid intake or full diet compared to patients without pseudodiverticulum. 26.3% of patients with pseudodiverticulum were on full diet compared to 25.8% of patients without. The vertical closure technique showed no difference in ability to maintain solid intake compared with non-vertical closure; however, no patients were on full diet. Only one patient in the pseudodiverticulum group required surgical management during the study period for retention. CONCLUSION: The presence of a pseudodiverticulum does not appear to be significantly associated with a need for postoperative dietary modification. The authors postulate that postlaryngectomy dysphagia is multifactorial with sensorimotor aperistalsis of the pharynx and cricopharyngeal stenosis. While a pseudodiverticulum is a common phenomenon, patients did not require modification of diet at higher rates than those without, and they seldom require intervention.
RESUMEN
OBJECTIVES: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.