Carbon dioxide clearance during apnoea with high‐flow nasal oxygen: epiphenomenon or a failure to <scp>THRIVE</scp>?

Toner, Andrew J.

doi:10.1111/anae.14848

Cited by 14 publications

(23 citation statements)

References 22 publications

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“…Overall, the rate of increase was 0.23 (0.05) kPa min À1 , which suggests that ventilatory exchange is indeed a phenomenon. 3 This is similar to the rate of increase seen in studies of non-obese patients, 9,13,27 which supports our contention that obesity itself (with appropriate airway management) does not preclude apnoeic gas exchange. Our analysis is limited to those patients who tolerated 18 min of apnoea without arterial oxygen desaturation but our findings suggest that, in this group, the efficiency of this process is not substantially different to that in non-obese patients.…”

Section: Apnoeic Ventilationsupporting

confidence: 86%

“…Evidence for the latter has been derived from comparison of studies reporting Pa CO2 increase during apnoea with 25 (~0.45 kPa min À1 ) and without 9,13,26,27 airway obstruction (as low as 0.15 kPa min À1 ). However, these comparisons are confounded by experimental design, particularly the use of proxy measures such as end-tidal carbon dioxide concentration, 3 which has been shown to be an imprecise marker of Pa CO2 . 9 This study provides direct evidence of Pa CO2 changes in 60 patients during 18 min of apnoea, the largest such dataset published to date.…”

Section: Apnoeic Ventilationmentioning

confidence: 99%

“…Whether high-flow nasal oxygen (HFNO) delivery promotes apnoeic ventilation remains a subject of debate. 3 Obesity has been associated with failure of apnoeic oxygenation techniques. 4 In the UK, more than a quarter of adults are obese and obesity is increasingly common worldwide.…”

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confidence: 99%

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Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Schutzer-Weissmann¹,

Wojcikiewicz²,

Karmali³

et al. 2023

British Journal of Anaesthesia

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Background: Obesity is a risk factor for airway-related incidents during anaesthesia. High-flow nasal oxygen has been advocated to improve safety in high-risk groups, but its effectiveness in the obese population is uncertain. This study compared the effect of high-flow nasal oxygen and low-flow facemask oxygen delivery on duration of apnoea in morbidly obese patients. Methods: Morbidly obese patients undergoing bariatric surgery were randomly allocated to receive either high-flow nasal (70 L min À1 ) or facemask (15 L min À1 ) oxygen. After induction of anaesthesia, the patients were apnoeic for 18 min or until peripheral oxygen saturation decreased to 92%. Results: Eighty patients were studied (41 High-Flow Nasal Oxygen, 39 Facemask). The median apnoea time was 18 min in both the High-Flow Nasal Oxygen (IQR 18e18 min) and the Facemask (inter-quartile range [IQR], 4.1e18 min) groups. Five patients in the High-Flow Nasal Oxygen group and 14 patients in the Facemask group desaturated to 92% within 18 min. The risk of desaturation was significantly lower in the High-Flow Nasal Oxygen group (hazard ratio¼0.27; 95% confidence interval [CI], 0.11e0.65; P¼0.007). Conclusions: In experienced hands, apnoeic oxygenation is possible in morbidly obese patients, and oxygen desaturation did not occur for 18 min in the majority of patients, whether oxygen delivery was high-flow nasal or low-flow facemask. High-flow nasal oxygen may reduce desaturation risk compared with facemask oxygen. Desaturation risk is a more clinically relevant outcome than duration of apnoea. Individual physiological factors are likely to be the primary determinant of risk rather than method of oxygen delivery. Clinical trial registration: NCT03428256.

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Section: Apnoeic Ventilationsupporting

confidence: 86%

Section: Apnoeic Ventilationmentioning

confidence: 99%

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Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Schutzer-Weissmann¹,

Wojcikiewicz²,

Karmali³

et al. 2023

British Journal of Anaesthesia

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“…and mean increase in end-tidal carbon dioxide of 0.12 kPa.min À1 ). High-flow nasal oxygen techniques have been claimed to produce significant carbon dioxide clearance and thus provide a degree of ventilation as well as as the subject of future randomised control trials [15]. It is also noteworthy that historical studies showed significantly higher rates of carbon dioxide rise during apnoea than more recent evidence.…”

Section: Discussionmentioning

confidence: 99%

Low‐flow apnoeic oxygenation for laryngeal surgery: a prospective observational study

et al. 2019

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Summary Laryngeal surgery requires a shared airway and close collaboration between surgeon and anaesthetist in order to optimise operating conditions. Apnoeic oxygenation uses the principle of aventilatory mass flow to maintain oxygenation of pulmonary capillary blood under apnoeic conditions while minimising laryngeal movement. Concerns regarding accumulation of carbon dioxide and resultant acidaemia have limited the use of the technique. We performed a prospective study of low‐flow apnoeic oxygenation for patients undergoing microlaryngoscopy under general anaesthesia in order to evaluate the ability of the technique to maintain oxygenation and determine the resultant rate of carbon dioxide accumulation. Sixty‐four patients undergoing microlaryngoscopy under general anaesthesia were studied between November 2016 and December 2018. Intra‐operative oxygenation was provided via a 10‐French oxygen catheter placed into the trachea delivering oxygen at 0.5–1.0 l.min−1. Data regarding apnoea time, peripheral oxygen saturation and venous blood gas concentrations were recorded. The mean (SD) duration of apnoea was 18.7 (7.2) min. Apnoeic oxygenation allowed successful completion of the surgical procedure in 62/64 patients. Mean (SD) rate of rise of the venous partial pressure of carbon dioxide was 0.15 (0.10) kPa.min−1. Operating conditions were recorded qualitatively as being adequate in all cases. No adverse effects were reported. Low‐flow intra‐tracheal apnoeic oxygenation is a simple, effective and inexpensive technique to maintain oxygenation for laryngeal surgery.

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“…[4][5][6][7] A recent editorial called for randomized trials to address the limited data on carbon dioxide clearance during high-flow apneic oxygenation. 8 In this issue of Anesthesiology, Riva et al shares a response to the call: a single-center, five-armed, randomized, controlled noninferiority trial of the use of high-flow nasal cannulas in apneic oxygenation. 9 They randomized healthy adult patients undergoing elective surgical procedures requiring general anesthesia to five groups of 25 participants each with a wide range of rates and varying routes of oxygen delivery: minimal-flow via endotracheal tube; low-, medium-and high-flow nasal oxygen with continuous jaw thrust; and a control group consisting of high-flow nasal oxygen with continuous video laryngoscopy.…”

mentioning

confidence: 99%

Can We Finally Take the “VE” Out of THRIVE?

Simpao

London

2021

Anesthesiology

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Carbon dioxide clearance during apnoea with high‐flow nasal oxygen: epiphenomenon or a failure to THRIVE?

Cited by 14 publications

References 22 publications

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Apnoeic oxygenation in morbid obesity: a randomised controlled trial comparing facemask and high-flow nasal oxygen delivery

Low‐flow apnoeic oxygenation for laryngeal surgery: a prospective observational study

Can We Finally Take the “VE” Out of THRIVE?

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