A review of the use of transnasal humidified rapid insufflation ventilatory exchange for patients undergoing surgery in the shared airway setting

  • Lucy HuangEmail author
  • Nuwan Dharmawardana
  • Adam Badenoch
  • Eng H. Ooi
Review Article


Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) is a recent technique that delivers warm humidified high flow oxygen to patients, allowing for prolonged apneic oxygenation. A review of current literature was performed to determine the use of THRIVE in apneic patients undergoing surgery in a shared airway setting. An initial free hand search was done to identify keywords followed by a systematic search of major databases with no date or language restrictions. Inclusion criteria include all apneic patients who receive THRIVE for any operative procedure. Fifteen studies fulfilled the inclusion criteria. There were ten case series, two case reports, two review articles and one randomized controlled trial. All of the studies discussed the use of THRIVE during laryngopharyngeal surgeries. The median apnea time reported ranged between 13 and 27 min. There were no significant complications reported as a result of using THRIVE. Most studies identified in this review were observational in nature involving laryngopharyngeal procedures. They have demonstrated THRIVE to be effective in providing apneic oxygenation during short procedures in adult patients. Further studies are required to determine the limitations of safe use in specific populations and when THRIVE is combined with diathermy or laser use.


Apneic oxygenation High flow nasal oxygen Laryngeal surgery Otorhinolaryngology THRIVE 


Compliance with ethical standards

Conflict of interest

There is no conflict of interest to declare.

Ethical approval

Ethical approval is not required as this is a narrative review.

Supplementary material

540_2019_2697_MOESM1_ESM.docx (11 kb)
Supplementary material 1 (DOCX 11 kb)
540_2019_2697_MOESM2_ESM.docx (13 kb)
Supplementary material 2 (DOCX 13 kb)


  1. 1.
    Mir F, Patel A, Iqbal R, Cecconi M, Nouraei SA. A randomised controlled trial comparing transnasal humidified rapid insufflation ventilatory exchange (THRIVE) pre-oxygenation with facemask pre-oxygenation in patients undergoing rapid sequence induction of anaesthesia. Anaesthesia. 2017;72(4):439–43.CrossRefGoogle Scholar
  2. 2.
    Helviz Y, Einav S. A systematic review of the high-flow nasal cannula for adult patients. Crit Care. 2018;22(1):71.CrossRefGoogle Scholar
  3. 3.
    Patel A, Nouraei SA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. 2015;70(3):323–9.CrossRefGoogle Scholar
  4. 4.
    Moller W, Celik G, Feng S, Bartenstein P, Meyer G, Oliver E, Schmid O, Tatkov S. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985). 2015;118(12):1525–32.CrossRefGoogle Scholar
  5. 5.
    Rudlof B, Hohenhorst W. Use of apneic oxygenation for the performance of pan-endoscopy. Otolaryngol Head Neck Surg. 2013;149(2):235–9.CrossRefGoogle Scholar
  6. 6.
    Gustafsson IM, Lodenius A, Tunelli J, Ullman J, Jonsson Fagerlund M. Apnoeic oxygenation in adults under general anaesthesia using transnasal humidified rapid-insufflation ventilatory exchange (THRIVE)—a physiological study. Br J Anaesth. 2017;118(4):610–7.CrossRefGoogle Scholar
  7. 7.
    Parke RL, Bloch A, McGuinness SP. Effect of very-high-flow nasal therapy on airway pressure and end-expiratory lung impedance in healthy volunteers. Respir Care. 2015;60(10):1397–403.CrossRefGoogle Scholar
  8. 8.
    Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol. 2018;18(1):143.CrossRefGoogle Scholar
  9. 9.
    Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32.CrossRefGoogle Scholar
  10. 10.
    Lyons C, Callaghan M. Apnoeic oxygenation with high-flow nasal oxygen for laryngeal surgery: a case series. Anaesthesia. 2017;72(11):1379–87.CrossRefGoogle Scholar
  11. 11.
    Valdinger S, Norris A, Rollason C, Sycamore H, Evans D. Transnasal humidified rapid-insufflation ventilatory exchange in ENT surgery: a case series. Anaesthesia. 2017;72:76.CrossRefGoogle Scholar
  12. 12.
    Margarson M. Nasal high flow oxygen therapy: what the anaesthetist should know. J Clin Monit Comput. 2017;31(3):498.Google Scholar
  13. 13.
    Davies S, Vaidya A, Shankar R, Patel S. When plan A fails. Anaesthesia. 2018;73:41.CrossRefGoogle Scholar
  14. 14.
    Lee SJ, Quek KH. Facilitating airway surgery in a morbidly obese patient using transnasal humidified rapid insufflation ventilatory exchange (THRIVE). Case Rep Anesthesiol. 2018;2018:5310342.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Kotwinski D, Paton L, Langford R. The role of high flow nasal oxygen therapy in anaesthesia. Br J Hosp Med (Lond). 2018;79(11):620–7.CrossRefGoogle Scholar
  16. 16.
    Ridgway R, Dumbarton T, Brown Z. Update on ENT anaesthesia in children. Anaesth Intensive Care Med. 2019;20(1):56–60.CrossRefGoogle Scholar
  17. 17.
    To K, Harding F, Scott M, Milligan P, Nixon IJ, Adamson R, McNarry AF. The use of transnasal humidified rapid-insufflation ventilatory exchange in 17 cases of subglottic stenosis. Clin Otolaryngol. 2017;42(6):1407–10.CrossRefGoogle Scholar
  18. 18.
    Tam K, Jeffery C, Sung CK. Surgical management of supraglottic stenosis using intubationless optiflow. Ann Otol Rhinol Laryngol. 2017;126(9):669–72.CrossRefGoogle Scholar
  19. 19.
    Yang S-H, Wu C-Y, Tseng W-H, Cherng W-Y, Hsiao T-Y, Cheng Y-J, Chan KC. Nonintubated laryngomicrosurgery with transnasal humidified rapid-insufflation ventilatory exchange: a case series. J Formos Med Assoc. 2019;118:1138–43.CrossRefGoogle Scholar
  20. 20.
    Maupeu L, Raguin T, Hengen M, Diemunsch P, Schultz P. Indications of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in laryngoscopy, a prospective study of 19 cases. Clin Otolaryngol. 2019;44:182–6.CrossRefGoogle Scholar
  21. 21.
    Rajan S, Joseph N, Tosh P, Kadapamannil D, Paul J, Kumar L. Effectiveness of transnasal humidified rapid-insufflation ventilatory exchange versus traditional preoxygenation followed by apnoeic oxygenation in delaying desaturation during apnoea: a preliminary study. Indian J Anaesth. 2018;62(3):202–7.CrossRefGoogle Scholar
  22. 22.
    Lau J, Loizou P, Riffat F, Stokan M, Palme CE. The use of THRIVE in otolaryngology: our experiences in two Australian tertiary facilities. Aust J Otolaryngol. 2019;2:22.CrossRefGoogle Scholar
  23. 23.
    Huang L, Athanasiadis T, Woods C, Dharmawardana N, Ooi EH. The use of transnasal humidified rapid insufflation ventilatory exchange in laryngeal and pharyngeal surgery: Flinders case series. Aust J Otolaryngol. 2019;2:17.CrossRefGoogle Scholar
  24. 24.
    Waters E, Kellner M, Milligan P, Adamson RM, Nixon IJ, McNarry AF. The use of transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in one hundred and five upper airway endoscopies. A case series. Clin Otolaryngol. 2019. Scholar
  25. 25.
    Ebeling CG, Riccio CA. Apneic oxygenation with high-flow nasal cannula and transcutaneous carbon dioxide monitoring during airway surgery: a case series. A&A Pract. 2019;12:366–8.Google Scholar
  26. 26.
    Ritchie JE, Williams AB, Gerard C, Hockey H. Evaluation of a humidified nasal high-flow oxygen system, using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care. 2011;39(6):1103–10.CrossRefGoogle Scholar
  27. 27.
    Onwochei D, El-Boghdadly K, Oakley R, Ahmad I. Intra-oral ignition of monopolar diathermy during transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). Anaesthesia. 2017;72(6):781–3.CrossRefGoogle Scholar
  28. 28.
    Stuermer KJ, Ayachi S, Gostian AO, Beutner D, Huttenbrink KB. Hazard of CO(2) laser-induced airway fire in laryngeal surgery: experimental data of contributing factors. Eur Arch Otorhinolaryngol. 2013;270(10):2701–7.CrossRefGoogle Scholar
  29. 29.
    Santos P, Ayuso A, Luis M, Martinez G, Sala X. Airway ignition during CO2 laser laryngeal surgery and high frequency jet ventilation. Eur J Anaesthesiol. 2000;17(3):204–7.CrossRefGoogle Scholar
  30. 30.
    Casey KR, Fairfax WR, Smith SJ, Dixon JA. Intratracheal fire ignited by the Nd-YAG laser during treatment of tracheal stenosis. Chest. 1983;84(3):295–6.CrossRefGoogle Scholar
  31. 31.
    Eger EI, Severinghaus JW. The rate of rise of PaCO2 in the apneic anesthetized patient. Anesthesiology. 1961;22:419–25.CrossRefGoogle Scholar
  32. 32.
    Stock MC, Schisler JQ, McSweeney TD. The PaCO2 rate of rise in anesthetized patients with airway obstruction. J Clin Anesth. 1989;1(5):328–32.CrossRefGoogle Scholar
  33. 33.
    Jooste KH. Anaesthesia in bronchography; endotracheal insufflation of oxygen during apnoea. Anaesthesia. 1955;10(1):59–66.CrossRefGoogle Scholar
  34. 34.
    O’Croinin D, Ni Chonghaile M, Higgins B, Laffey JG. Bench-to-bedside review: permissive hypercapnia. Crit Care. 2005;9(1):51–9.CrossRefGoogle Scholar
  35. 35.
    Bautista AF, Akca O. Hypercapnia: is it protective in lung injury? Med Gas Res. 2013;3(1):23.CrossRefGoogle Scholar
  36. 36.
    Riva T, Pedersen TH, Seiler S, Kasper N, Theiler L, Greif R, Kleine-Brueggeney M. Transnasal humidified rapid insufflation ventilatory exchange for oxygenation of children during apnoea: a prospective randomised controlled trial. Br J Anaesth. 2018;120(3):592–9.CrossRefGoogle Scholar
  37. 37.
    Riva T, Theiler L, Jaquet Y, Giger R, Nisa L. Early experience with high-flow nasal oxygen therapy (HFNOT) in pediatric endoscopic airway surgery. Int J Pediatr Otorhinolaryngol. 2018;108:151–4.CrossRefGoogle Scholar
  38. 38.
    Riva T, Seiler S, Stucki F, Greif R, Theiler L. High-flow nasal cannula therapy and apnea time in laryngeal surgery. Paediatr Anaesth. 2016;26(12):1206–8.CrossRefGoogle Scholar
  39. 39.
    Humphreys S, Rosen D, Housden T, Taylor J, Schibler A. Nasal high-flow oxygen delivery in children with abnormal airways. Paediatr Anaesth. 2017;27(6):616–20.CrossRefGoogle Scholar
  40. 40.
    Caruso TJ, Gupta A, Sidell DR, Darling C, Rodriguez S, Fonseca A, Tsui B. The successful application of high flow nasal oxygen during microdirect laryngoscopy and bronchoscopy in patients under 7 kg. J Clin Anesth. 2019;52:27–8.CrossRefGoogle Scholar
  41. 41.
    Gormley S, Crean P. Basic principles of anaesthesia for neonates and infants. BJA Educ. 2001;1(5):130–3.Google Scholar
  42. 42.
    Fraioli RL, Sheffer LA, Steffenson JL. Pulmonary and cardiovascular effects of apneic oxygenation in man. Anesthesiology. 1973;39(6):588–96.CrossRefGoogle Scholar
  43. 43.
    Don HF, Wahba M, Cuadrado L, Kelkar K. The effects of anesthesia and 100 per cent oxygen on the functional residual capacity of the lungs. Anesthesiology. 1970;32(6):521–9.CrossRefGoogle Scholar
  44. 44.
    Berthoud MC, Peacock JE, Reilly CS. Effectiveness of preoxygenation in morbidly obese patients. Br J Anaesth. 1991;67(4):464–6.CrossRefGoogle Scholar
  45. 45.
    Booth AWG, Vidhani K, Lee PK, Thomsett CM. SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. Br J Anaesth. 2017;118(3):444–51.CrossRefGoogle Scholar
  46. 46.
    Wang ML, Hung MH, Chen JS, Hsu HH, Cheng YJ. Nasal high-flow oxygen therapy improves arterial oxygenation during one-lung ventilation in non-intubated thoracoscopic surgery. Eur J Cardio-Thorac Surg. 2018;53(5):1001–6.CrossRefGoogle Scholar

Copyright information

© Japanese Society of Anesthesiologists 2019

Authors and Affiliations

  1. 1.Department of Otorhinolaryngology Head and Neck SurgeryFlinders Medical CentreBedford ParkAustralia
  2. 2.Discipline of Surgery, College of Medicine and Public HealthFlinders UniversityBedford ParkAustralia
  3. 3.Department of Anesthesia and Pain ManagementFlinders Medical CentreBedford ParkAustralia

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