What is the 'thrive and no desat' technique for anesthesia management?

THRIVE and NO DESAT Techniques for Anesthesia

Direct Answer

THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) and NO DESAT (Nasal Oxygenation During Efforts Securing A Tube) are advanced apneic oxygenation techniques that extend safe apnea time during airway management by delivering high-flow oxygen through nasal cannulae, with THRIVE representing the most sophisticated approach using 30-70 L/min of warmed, humidified oxygen. 1

Evolution of Apneic Oxygenation Techniques

The development of these techniques represents a progression in preventing hypoxemia during airway management:

NO DESAT Technique

• Described by Levitan in 2010, NO DESAT uses simple nasal cannulae at flow rates up to 15 L/min during intubation attempts 1
• This technique provides continuous oxygen delivery throughout the intubation process, extending safe apnea time beyond traditional pre-oxygenation alone 1
• The flow rate is limited to 10-15 L/min because cold, dry oxygen at higher rates would be intolerable to patients 1

THRIVE Technique

• THRIVE represents the most advanced evolution, delivering warmed, humidified oxygen at significantly higher flow rates of 30-70 L/min through nasal cannulae 1
• The warming and humidification allow these much higher flow rates that would otherwise be intolerable 1
• THRIVE creates a continuous positive airway pressure effect while maintaining airway patency 1

Physiological Mechanisms

How THRIVE Works Differently

• Unlike traditional apneic oxygenation, THRIVE not only extends apnea time but also improves CO2 clearance, preventing the rapid CO2 accumulation typically seen during apnea 1
• The CO2 clearance mechanism is mediated by the interaction between supraglottic flow vortices generated by high nasal flow and cardiopneumatic movements 1
• THRIVE provides significantly longer safe apnea times compared to conventional pre-oxygenation techniques 1

Comparison to Standard Pre-oxygenation

• In healthy adults breathing room air, desaturation to SpO2 90% occurs within only 1-2 minutes of apnea 2
• With effective standard pre-oxygenation, safe apnea time extends to 6-8 minutes 2
• THRIVE extends this window even further while providing the added benefit of CO2 management 1

Clinical Applications

High-Risk Populations

These techniques are particularly valuable in patients at increased risk of rapid desaturation:

• Obese patients have reduced functional residual capacity and desaturate in as little as 2.5 minutes when supine 2
• Obese patients should be positioned at 25-30° head-up, which increases functional residual capacity and extends safe apnea time by approximately 30% 2
• Pregnant women have decreased functional residual capacity and increased metabolic demands, making them prone to rapid desaturation 2

Integration with Standard Airway Management

• The target for pre-oxygenation remains achieving an end-tidal oxygen fraction (FeO2) ≥90%, representing adequate lung denitrogenation 2
• A tight mask-to-face seal is essential during pre-oxygenation, with fresh gas flow rate of ≥10 L/min required 2
• NO DESAT or THRIVE can then be applied during the apneic period to maintain oxygenation during intubation attempts 1

Critical Technical Considerations

Equipment Requirements

• THRIVE requires specialized high-flow nasal cannula systems capable of delivering warmed, humidified oxygen at 30-70 L/min 1
• NO DESAT can be performed with standard nasal cannulae but is limited to 15 L/min flow rates 1
• Capnography should be used to confirm adequate pre-oxygenation, as absence of a capnograph trace indicates significant mask leak 2

Positioning Strategy

• A 20-30° head-up position should be standard practice, as it increases functional residual capacity, improves laryngoscopy view, and may reduce gastro-esophageal reflux 2
• This positioning is especially critical in obese patients where supine positioning dramatically reduces apnea tolerance 2
• Failure to position the patient head-up is the most common error in airway management 2

Important Caveats and Limitations

When These Techniques Are Most Beneficial

• These techniques are most valuable during anticipated difficult intubation scenarios where multiple attempts may be required 1
• The UK's NAP4 audit revealed that difficult or failed intubation represented 39% of incidents related to airway control 2
• Hypoxemia during induction remains a major cause of preventable anesthetic mortality 2

Complementary Strategies

• These techniques should be combined with other airway safety measures, including full neuromuscular blockade reversal before extubation 3
• Use of a peripheral nerve stimulator to ensure train-of-four ratio of 0.9 or above is recommended 3
• Multimodal analgesia techniques and opioid-sparing strategies reduce respiratory depression risk 3

Atelectasis Considerations

• While 100% oxygen during pre-oxygenation causes atelectasis, this should be followed by a recruitment maneuver (inflation to 40 cm H2O for 10 seconds) 4
• Pre-oxygenation with 80% O2 may cause minimal atelectasis but decreases time to hypoxemia from 7 to 5 minutes 5
• The priority during induction is maximizing oxygen stores to prevent hypoxemia, even if this causes some atelectasis that can be subsequently recruited 2