THRIVE to the rescue.

Abstract

Dear Editor, “Transnasal humidified rapid insufflation ventilator exchange (THRIVE)” works on the principle of ventilation without ventilator movements. With THRIVE, ventilation occurs with a noninvasive nasal cannula, with high flow humidified oxygen at 30–60 L/min. These high flows create a distending alveolar pressure or positive end-expiratory pressure (PEEP) up to 7 cm of water, which prevents airway collapse and atelectasis.[1,2] We describe two cases in which the use of THRIVE helped prevent reintubation postoperatively. Case 1: A 61-year-old male was operated for robotic radical cystectomy under general anesthesia in lithotomy and Trendelenburg position for 8 h. After extubation within a few minutes, he started to desaturate. Blood gas showed pH-7.33/pCO2-46.5/pO2-47.2/sat-76.4%. Bilateral lung basal atelectasis secondary to the position during the procedure was the probable diagnosis. In view of persistent hypoxia and the possibility of worsening oxygenation, the choice was noninvasive ventilation (NIV) or reintubation. However, NIV was logistically not possible in the OT. THRIVE (OptiFlow THRIVE system by Fisher and Paykel Healthcare Ltd, Auckland, New Zealand), was started at 30 L/min. Within few minutes, the saturation picked to 100%. Blood gas done after 30 min of THRIVE showed pH-7.38, pCO2-35, pO2-107.9, satulation-97.5%. As the patient was breathing comfortably and hemodynamically stable, he was shifted to the intensive care unit (ICU) with facemask oxygen for transfer. THRIVE was continued in the ICU for another 2 h and finally weaned off to a nasal cannula of 2 L/min. Case 2: A 61-year-old lady was operated for breast microdocectomy under general anesthesia, post-operatively the patient was extubated after which her respiratory rate was 36–38 per min with oxygen saturation of 88%–90% on 10 L oxygen non rebreathing mask and blood pressure of 213/102 mm Hg. Chest auscultation revealed bilateral crepts. Suspecting it to be pulmonary edema, injection furosemide IV was administered, and nitroglycerine (NTG) infusion was started. Her blood gas showed pH- 6.99, pCO2- 116, pO2- 85, pHCO3- 19, oxygen saturation-90%. After the initiation of THRIVE at 40 L/min over the next 10 min, her saturation started picking up to 97%–98%, and her respiratory rate settled to 18–20 per mi. Eventually her THRIVE flow was reduced to 20 L/min. Her blood gas was pH- 7.32, pCO2- 50.6, PO2 -140, HCO3-26 and was shifted to the ICU. After 2 h of THRIVE in the ICU, her blood gas was pH-7.3, pCO2- 41, pO2- 138, pHCO3- 25. Thrive delivers gases at a flow rate that exceeds the patient’s peak inspiratory flow rate.[3] It helps to recruit the lungs. It washes out the upper airway dead space, creating an oxygen reservoir and increasing the tidal volume, probably explaining the mechanism for decreasing the PCO2.[4] By increasing the end-inspiratory lung volume, it decreases the work of breathing.[5] The warm and humidified inspired gases decrease airway inflammation and improve drainage of respiratory secretions.[4] THRIVE can be an important additional tool to provide oxygen in the post-operative period to prevent reintubation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.