{"id":8875,"date":"2024-09-12T05:24:50","date_gmt":"2024-09-12T05:24:50","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-journal\/?p=8875"},"modified":"2025-04-09T10:25:41","modified_gmt":"2025-04-09T10:25:41","slug":"anaesthesia-for-airway-procedures-without-intubation-a-tubeless-ventilation-using-thrive-a-case-report","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-september-2024\/anaesthesia-for-airway-procedures-without-intubation-a-tubeless-ventilation-using-thrive-a-case-report\/","title":{"rendered":"ANAESTHESIA FOR AIRWAY PROCEDURES \u2013 WITHOUT INTUBATION – A TUBELESS VENTILATION USING THRIVE – A CASE REPORT"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]<\/p>\n

65-year-old male k\/c\/o carcinoma vocal cord which was diagnosed 10 months back for which he received radiotherapy and underwent microlaryngeal excision of laryngeal papilloma. Then he had h\/o voice change for last 2 months and PET CT revealed SUBGLOTTIC GROWTH for which he was posted for Direct Laryngoscopy + biopsy.<\/p>\n

PREOPERATIVE PLANNING:<\/b><\/strong><\/h2>\n
    \n
  • Routine investigations were done and blood investigations were found to be within normal limits. ECG- NSR; ECHO- N LV.<\/li>\n
  • After discussion with surgeon, plan of anaesthesia and risk associated with anaesthesia and procedure were clearly explained to patient and attender with written consent.<\/li>\n
  • NPO guidelines were followed.<\/li>\n
  • Pre-medication \u2013 INJ PANTOPRAZOLE 40 MG IV INJ PALANOSETRON 0.075 MG were given.<\/li>\n<\/ul>\n

    INTRAOPERATIVE MANAGEMENT:<\/b><\/strong><\/h2>\n
      \n
    • Patient was positioned supine and ASA Standard monitors were attached and nasal cannula of THRIVE was placed.<\/li>\n
    • Preoperative saturation \u2013 98% under room air.<\/li>\n
    • Preoxygenation was started with 100% oxygen at a rate of 20 l\/min for 3 minutes.<\/li>\n
    • Intravenous anaesthesia was started with Inj midazolam 1 mg; Inj fentanyl 100mcg; Inj propofol 80 mg.<\/li>\n
    • Oxygen flow rate of THRIVE was increased to 50-60 l\/min, once the patient lost consciousness and jaw thrust was used to maintain airway patency until insertion of surgical laryngoscope.<\/li>\n
    • After establishing adequate bag and mask ventilation, INJ atracurium 15mg was given.<\/li>\n
    • Anaesthesia was maintained with TIVA using propofol in titrated doses.<\/li>\n
    • Oxygen saturation was maintained for 15 minutes, then patient had desaturation {spo2 <90% }, bag and mask ventilation was done intermittently to achieve oxygenation once during the 45 mins \u00a0duration of procedure.<\/li>\n
    • Specified THRIVE equipment delivered high flow nasal oxygen varied from 10-60 l\/min with an FI02 of 1 throughout the procedure.<\/li>\n
    • Neuromuscular blockade was reversed with neostigmine.<\/li>\n
    • Jaw thrust with bag-mask ventilation was commenced until return of spontaneous respiration.<\/li>\n
    • The patient was shifted to the recovery room, maintaining his own airway \u00a0\u00a0and got discharged on the same day.<\/li>\n<\/ul>\n

      DISCUSSION:<\/b><\/strong><\/h2>\n
        \n
      • As sharing an airway between the surgeon and the anaesthesiologist is a difficult and challenging task, apnoeic oxygenation <\/i><\/em>technique is a reliable method of maintaining oxygenation during short upper airway procedures.<\/li>\n
      • Upper airway surgeries can be performed under endotracheal tube or tubeless technique such as jet ventilation, intermittent apnoeic ventilation and THRIVE.<\/li>\n<\/ul>\n

        THRIVE – TRANSNASAL HUMIDIFIED RAPID INSUFFLATION VENTILATORY EXCHANGE:<\/b><\/strong><\/h2>\n
          \n
        • A novel technique which utilizes high flow [60-70l\/min] 100%oxygen, which is humidified, warmed to 37 degree C and administered via nasal cannula.<\/li>\n
        • Follows a physiological phenomenon of Aventilatory mass flow \u00a0for providing apnoeic oxygenation\u00a0<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

          \"\"<\/b><\/strong><\/h2>\n

          PHYSIOLOGICAL BENEFITS<\/b><\/strong>\u00a0<\/i><\/b><\/em><\/strong><\/h2>\n
            \n
          • <\/i><\/b>INCREASE IN APNOEIC TIME AND CARBON DIOXIDE CLEARANCE :<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

            THRIVE via HFNC has extended the apnoeic window by up to 65 minutes, while reducing the rise in rate of CO2.<\/p>\n

              \n
            • <\/i><\/b>GAS CONDITIONING -HEATING AND HUMIDIFICATION:<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

              By warming and humidifying the gas, high flow reduce the metabolic rate of respiration. Humidification prevent drying of secretions and thus reduce mucus plugging, atelectasis and hypoxia.<\/p>\n

                \n
              • <\/i><\/b>FIXED FI02 DELIVERY AND DEAD SPACE WASHOUT:<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                It implies minimal room air entrainment.<\/p>\n

                  \n
                • <\/i><\/b>POSITIVE AIRWAY PRESSURE<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                  HFNO supplies positive airway pressure of approximately 1cmH2O per 10l\/min flow rate.<\/p>\n

                  <\/b>BENEFITS IN ANAESTHESIA PRACTICE <\/b><\/strong><\/h2>\n
                    \n
                  • <\/i><\/b>DIFFICULT AIRWAY MANAGEMENT<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                    This technique affords the luxury of time<\/i><\/em>\u00a0to think and utilize the other method of securing the airway while maintaining oxygenation <\/i><\/em>and reduces the morbidity. One should be aware that this is not applicable in complete upper airway obstruction.<\/p>\n

                      \n
                    • <\/i><\/b>AIRWAY MANAGEMENT IN OBESE AND PREGNANT PATIENTS<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                      Both have risk for aspiration and desaturation, this technique is used for preoxygenation to decrease the apnoeic period. \u00a0Used as an adjuvant to assist alveolar recruitment post extubation.<\/p>\n

                        \n
                      • <\/i><\/b>TUBELESS FIELD SURGERY<\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                        To provide an unobscured surgical field<\/i><\/em> while maintaining oxygenation and anaesthesia during airway procedures \u00a0including upper airway and larynx \u00a0such as vocal cord biopsy, balloon dilatation, subglottic stenosis, bronchoscopy, endoscopy.<\/p>\n

                          \n
                        • In this technique patient can be spontaneously breathing or apnoeic with full muscle relaxation, while anaesthesia is maintained with TIVA.<\/li>\n
                        • It prolongs the safe apnoea time and has low risk for barotrauma. Prevents ETT related injury, avoids vocal cord movement and interruptions of intermittent intubation.<\/li>\n<\/ul>\n
                            \n
                          • <\/i><\/b>RESPIRATORY SUPPORT DURING PROCEDURAL SEDATION <\/i><\/b><\/em><\/strong><\/li>\n<\/ul>\n

                            Used in conscious sedation procedures such as bronchoscopy , colonoscopy, gastroscopy \u00a0where supplemental oxygen is required.<\/p>\n

                            \"\"<\/b><\/strong><\/h2>\n

                            LIMITATIONS:<\/b><\/strong><\/h2>\n

                            Hypercapnia is a valid concern as monitoring of end tidal co2 throughout the procedure is difficult.<\/p>\n

                            CONCLUSION:<\/b><\/strong><\/h2>\n

                            THRIVE has improved our practice and patient safety in difficult airway. Combination of THRIVE with TIVA offers a good alternative to conventional anaesthesia with microlaryngeal tubes and jet ventilation in short airway procedures.<\/p>\n

                            REFERENCES:<\/strong><\/h2>\n
                              \n
                            • 1 May 2018 | Reza Nouraei, James Richard Shorthouse, James Keegan, Fran Haigh, Kate Heathcote, Anil Patel, Michael Girgis | ENT, Head and Neck, Laryngology \/ Swallowing \/ Voice<\/li>\n
                            • Bharathi MB, Kumar MRA, Prakash BG, Shetty S, Sivapuram K, Madhan S. New Visionary in Upper Airway Surgeries-THRIVE, a Tubeless Ventilation. Indian J Otolaryngol Head Neck Surg. 2021 Jun;73(2):246-251. doi: 10.1007\/s12070-021-02491-2. Epub 2021 Mar 30. PMID: 34150599; PMCID: PMC8163920.<\/li>\n<\/ul>\n

                               <\/p>\n

                              \"\"Dr Velmurugan Desingh<\/strong>
                              \nHead of the Department,<\/em>
                              \nDepartment of Anaesthesiology<\/em>
                              \nKauvery Hospital, Chennai<\/p>\n

                               <\/p>\n

                               <\/p>\n

                              \"\"Dr S. Dhiveya<\/strong>
                              \nSecond Year DNB Resident,<\/em>
                              \nDepartment of Anesthesiology,<\/em>
                              \nKauvery Hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"

                              [vc_row][vc_column][vc_column_text] 65-year-old male k\/c\/o carcinoma vocal cord which was diagnosed 10 months back for which he received radiotherapy and underwent microlaryngeal excision of laryngeal papilloma. Then he had h\/o voice<\/p>\n","protected":false},"author":2,"featured_media":8876,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[79],"tags":[],"class_list":["post-8875","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-september-2024"],"yoast_head":"\nANAESTHESIA FOR AIRWAY PROCEDURES \u2013 WITHOUT INTUBATION - A TUBELESS VENTILATION USING THRIVE - A CASE REPORT<\/title>\n<meta name=\"description\" content=\"5-year-old male k\/c\/o carcinoma vocal cord which was diagnosed 10 months back for which he received radiotherapy and underwent microlaryngeal excision of laryngeal papilloma.\" \/>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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