THRIVE in Anesthesia: A Revolutionary Airway Management Technique
THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) is a transformative airway management technique that delivers high-flow (30-70 L/min) warmed humidified oxygen through nasal cannulae, significantly extending safe apnea time while providing CO2 clearance, thereby revolutionizing the management of difficult airways in anesthesia. 1
Mechanism and Physiological Principles
THRIVE delivers warmed, humidified oxygen at high flow rates (30-70 L/min) through nasal cannulae, creating a continuous positive airway pressure effect while maintaining airway patency 1
Unlike traditional apneic oxygenation techniques, THRIVE not only extends the apnea time but also improves CO2 clearance, preventing the rapid increase in CO2 typically seen during apnea 1, 2
The mechanism of CO2 clearance is thought to be mediated by the interaction between supraglottic flow vortices generated by the high nasal flow and cardiopneumatic movements 1, 2
The rate of CO2 increase during THRIVE is approximately 0.15-0.24 kPa/min, significantly slower than traditional apneic oxygenation techniques 2, 3
Clinical Applications
Difficult Airway Management: THRIVE provides extended safe apnea time (median 14 minutes, range 5-65 minutes) without desaturation, transforming difficult intubations from pressured emergencies to controlled procedures 3
Tubeless Laryngeal Surgery: THRIVE enables unimpeded surgical access to the glottis without the need for tracheal intubation or jet ventilation, potentially improving surgical precision 4
Pre-oxygenation Tool: Can be used during induction in both anticipated and unanticipated difficult airway scenarios 5
Emergence from Anesthesia: Facilitates oxygenation during emergence from anesthesia 5
Advantages Over Traditional Techniques
THRIVE provides significantly longer safe apnea times compared to conventional preoxygenation techniques 1
Warmed and humidified oxygen allows for higher flow rates (30-70 L/min) that would be intolerable with cold, dry oxygen (limited to 10-15 L/min) 1
Facilitates surgical exposure with fewer suspension adjustments during laryngeal procedures 4
May improve early patient recovery with lower postoperative pain scores compared to traditional ventilation techniques 4
Patient Selection and Limitations
Most studies have focused on ASA I-II patients with BMI <30-35 kg/m² 4, 2
While effective in obese patients, careful patient selection is recommended as studies have shown variable results in patients with higher BMI 6, 2
Monitoring of CO2 and/or pH is strongly recommended during prolonged apneic periods with THRIVE 2
Not suitable for procedures requiring laser use due to the high oxygen concentration and fire risk 4
Evolution of Apneic Oxygenation Techniques
Pharyngeal Insufflation: Early technique using 3-10 L/min oxygen via nasal catheter placed in the oropharynx, providing approximately 10 minutes of safe apnea time 1
NO DESAT (Nasal Oxygenation During Efforts to Secure A Tube): Described by Levitan in 2010, uses simple nasal cannulae at flow rates up to 15 L/min during intubation 1
THRIVE: Represents the most advanced technique, using 30-70 L/min of warmed, humidified oxygen, significantly extending apnea time while providing CO2 clearance 1
Common Pitfalls and Considerations
Maintaining upper airway patency with jaw thrust is essential for effective oxygenation during THRIVE 3
Despite excellent oxygenation, CO2 will continue to accumulate, albeit at a slower rate than traditional apneic oxygenation 2
Alternative routes (oral THRIVE) may be considered in cases where the nasal route is contraindicated (e.g., epistaxis, basal skull fracture) 6
Regular monitoring of oxygen saturation and, when possible, end-tidal or arterial CO2 is crucial during prolonged apnea 2
THRIVE represents a significant advancement in airway management that has been incorporated into difficult airway guidelines, potentially transforming the approach to securing definitive airways in emergency and difficult intubation scenarios 5, 3.