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Transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) in the coronavirus disease 2019 pandemic

Part of: JLO Coronavirus Collection

Published online by Cambridge University Press:  07 January 2021

S Y Hey ,
P Milligan ,
R M Adamson ,
I J Nixon  and
A F McNarry
S Y Hey
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, NHS Lothian, Edinburgh, UK
P Milligan
Affiliation:
Department of Anaesthesia, NHS Lothian, Edinburgh, UK
R M Adamson
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, NHS Lothian, Edinburgh, UK
I J Nixon
Affiliation:
Department of Otolaryngology and Head and Neck Surgery, NHS Lothian, Edinburgh, UK
A F McNarry*
Affiliation:
Department of Anaesthesia, NHS Lothian, Edinburgh, UK
*
Author for correspondence: Dr Alistair F McNarry, Department of Anaesthesia, St John's Hospital, NHS Lothian, LivingstonEH54 6PP, Scotland, UK E-mail: alistair.mcnarry@nhslothian.scot.nhs.uk
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Abstract

Background

Since the start of the coronavirus disease 2019 pandemic, transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) has been classified as a high-risk aerosol-generating procedure and is strongly discouraged, despite a lack of conclusive evidence on its safety.

Methods

This study aimed to investigate the safety of transnasal humidified rapid-insufflation ventilatory exchange usage and its impact on staff members. A prospective study was conducted on all transnasal humidified rapid-insufflation ventilatory exchange cases performed in our unit between March and July 2020.

Results

During the study period, 18 patients with a variety of airway pathologies were successfully managed with transnasal humidified rapid-insufflation ventilatory exchange. For each case, 7–10 staff members were present. Appropriate personal protective equipment protocols were strictly implemented and adhered to. None of the staff involved reported symptoms or tested positive for coronavirus disease 2019, up to at least a month following their exposure to transnasal humidified rapid-insufflation ventilatory exchange.

Conclusion

With strictly correct personal protective equipment use, transnasal humidified rapid-insufflation ventilatory exchange can be safely employed for carefully selected patients in the current pandemic, without jeopardising the health and safety of the ENT and anaesthetic workforce.

Keywords

Airway ManagementAnesthesiaContinuous Positive Airway PressureCOVID-19InsufflationIntubationLarynxOxygenTrachea
Type
Short Communications
Information
The Journal of Laryngology & Otology , Volume 135 , Issue 1 , January 2021 , pp. 86 - 87
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
Copyright © The Author(s), 2021. Published by Cambridge University Press

Introduction

The ENT UK guidelines for changes in ENT during the coronavirus disease 2019 (Covid-19) pandemic, published in March 2020, are centred on the protection of our ENT workforce from nosocomial transmission of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2).1 As all airway surgery may be aerosol-generating and any patient may harbour infection, all staff involved in such cases are at potential risk.Reference Healy, Cloyd, Brenner, Kupfer, Anam and Schechtman2 Various publications have further addressed the safety concerns and implications of the pandemic on airway service provision from both ENT and anaesthetic perspectives.Reference Cook, El-Boghdadly, McGuire, McNarry, Patel and Higgs3–Reference Balakrishnan, Schechtman, Hogikyan, Teoh, McGrath and Brenner5

Transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) has been classified as a high-risk aerosol-generating procedure and is strongly discouraged by several sources.Reference Wax and Christian6–Reference Cheung, Ho, Cheng, Cham and Lam8 In addition, a worldwide shortage of medical oxygen supply had further prompted scrutiny around the use of high-flow nasal oxygen. While high-flow nasal oxygen has been used in many cohorted intensive care units, the lack of conclusive evidence on the safety of transnasal humidified rapid-insufflation ventilatory exchange continues to be a matter of debate among airway practitioners.Reference Healy, Cloyd, Brenner, Kupfer, Anam and Schechtman2

Case report

In our unit, we have continued to utilise transnasal humidified rapid-insufflation ventilatory exchange in selected cases, following careful airway risk assessment and shared decision-making.

In keeping with current guidelines, we report the successful management of 18 patients who underwent transnasal humidified rapid-insufflation ventilatory exchange from March to July 2020 (Figure 1).

Fig. 1. Total daily new cases of coronavirus disease 2019 (Covid-19) in NHS Lothian and dates (red-dotted) on which transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) was performed in our unit. (Data courtesy of John Frace, University of Highlands and Islands, Scotland.)

For each case, there were 7–10 staff members present, including operating theatre nurses, anaesthetists and surgeons. Appropriate personal protective equipment (PPE) protocols, such as use of a fitted filtering facepiece code 3 (FFP3) mask, fluid-resistant gown, gloves and eye shields, were strictly implemented and adhered to by all staff members in attendance. None of the staff involved reported symptoms or tested positive for Covid-19 following their exposure to transnasal humidified rapid-insufflation ventilatory exchange. This was observed for up to at least a month following their participation in any transnasal humidified rapid-insufflation ventilatory exchange cases.

Discussion

The most recent guidance on airway management for the endemic phase of Covid-19 suggests that use of high-flow nasal oxygen should be considered relatively, rather than absolutely, contraindicated.Reference Cook, McGuire, Mushambi, Misra, Carey and Lucas9 We have previously reported its benefit in patients for whom attempted conventional intubation may be traumatic or dangerous.Reference To, Harding, Scott, Milligan, Nixon and Adamson10 Patients with conditions such as subglottic stenosis have not disappeared during the pandemic, and we continue to provide ENT emergency and oncology services. Challenging airways are not uncommonly encountered, highlighting the potentially beneficial role of transnasal humidified rapid-insufflation ventilatory exchange.

While our cohort is limited in size, the non-availability of regular and routine testing of asymptomatic staff at our local trust precludes comments on the possibility of any subclinical infection, or the infection of patients by staff members. Nonetheless, with the ongoing lack of conclusive evidence, our observational outcome suggests that with strictly correct PPE use, transnasal humidified rapid-insufflation ventilatory exchange can, in carefully selected patients, be safely used during the current pandemic, without jeopardising the health and safety of the ENT and anaesthetic workforce.

Acknowledgement

We would like to thank Mr John Frace for his invaluable contribution with the collation of regional Covid-19 data and facilitation of the study.

Competing interests

None declared

Footnotes

Dr A F McNarry takes responsibility for the integrity of the content of the paper

References

ENT UK guidelines for changes in ENT during COVID-19 pandemic. In: https://www.entuk.org/ent-uk-guidelines-changes-ent-during-covid-19-pandemic [28 August 2020]Google Scholar
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Figure 0

Fig. 1. Total daily new cases of coronavirus disease 2019 (Covid-19) in NHS Lothian and dates (red-dotted) on which transnasal humidified rapid-insufflation ventilatory exchange (‘THRIVE’) was performed in our unit. (Data courtesy of John Frace, University of Highlands and Islands, Scotland.)