Thrive

THRIVE

1. THRIVE / STRIVE-Hi Dr Shreyas Kate

2. Conventional O2 Therapy First line therapy for acute resp failure Nasal Prongs, Non Rebreathing face mask Limitation: Mismatch b/w oxygen flow and patient ‘s inspiratory flow Peak inspiratory flow may vary b/w 30 and 120 L/min during resp failure

3. Low Flow High FLow nasal cannula aerosol masks simple face mask air-entrainment nebulizers partial rebreathing mask air-O2 blenders nonrebreathing mask Venturi masks Tracheostomy collar Conventional O2 Therapy

4. Preoxygenation

5. The end points of maximal alveolar preoxygenation end-tidal O 2 concentration (Et O2 ) of approximately 90% Endtidal nitrogen concentration (Et N2 ) of 5% Factors affecting the efficacy FIO2, duration of breathing and the VA/FRC ratio Preoxygenation

6. High flow nasal cannula HFNC

7. What is HFNC Oxygen therapy? Uses air/oxygen blender to deliver FiO2 range from 0.21 to 1.0 Active humidity /temperature controlled -37 Cel and humidified at 44 mg H2O/L Generates flows up to 40,60,70 L/min HFNC

8. Oxygen delivery to the alveoli depends on many factors Oxygen flow rate FiO2 being delivered Device interface Patient demand (Vt, RR, PIFR) HFNC

9. Equipment

10. Different devices

11. Physiologic effects of HFNC

12. Adverse Effects of Lack of Humidification cessation of the flow of tracheal mucus widespread loss of the cilia detachment or sloughing of the epithelium subepithelial vascular congestion excessive water loss by the nasal mucosa HFNC

13. USES: Neonates ( counteract a lack of surfactant) Hypercapnic Respiratory Failure Hypoxemic Respiratory Failure ( FLORALI trial) Postextubation Preoxygenation ( denitrogenate the lungs) Acute Heart Failure Sleep Apnea HFNC

14. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange THRIVE

15. Apnoeic window Cannot intubate, cannot ventilate Apnoeic oxygenation Introduction

16. 1909 by Samuel Meltzer : Ventilation without ventilatory movements (direct and continuous intratracheal oxygen insufflation ) Arthur Slutsky using tracheal insufflation of O2 (TRIO) 1980s and 1990s, ‘oscillatory ventilation’, which continues to be used in highly-selected cases in paediatric ventilation, and ‘constant-flow ventilation’ History

17. Aventilatory mass flow (AVMF) Negative pressure gradient of up to 20 cmH2O Apnoeic oxygenation has been used both experimentally and clinically as a strategy to extend the apnoeic window Physiology

18. Physiology rate of rise of carbon dioxide levels was between 0.35 and 0.45 kPa.min1( 2.62 to 3.37 mm Hg/min )

19. Physiology High-flow nasal oxygen(70-90L/min) loops around the soft palate exits through the mouth highly turbulent ‘ primary supraglottic vortex ’ This vortex bypasses the upper airways generate a positive airway pressure reduces upper airway collapsibility and distal airway atelectasis interaction b/w supraglottic vortex from above and cardiogenic oscillations from below

20. Pre-oxygenate for 10 min at 40 degrees of head-up inclination with the nasal cannula (70 L/min) Intravenous induction of anaesthesia then commenced with boluses of propofol, fentanyl, and rocuronium, followed by a peripheral infusion of propofol Nasal oxygenation maintained at the same rate of 70 l/min until the definitive airway was secured Technique

21. Uses of THRIVE Reduced oxygen reserve Procedural sedation Difficult airway Shared Airway

22. Spontaneous respiration using iv anaesthesia STRIVE-hi

23. Spontaneously breathing  HFNO An increased FiO 2 Generation of positive airway pressure Improved respiratory mechanics  Reduced upper airway resistance Introduction

24. Technique Tubeless anaesthesia   Use of a standardized propofol titration method use of HFNO 30 L/min for 01 min 50 L/min for 02 min in a 10–20 degrees reverse Trendelenburg position 70 L/min when loss of consciousness occurred

25. Awake patients respiratory supportive care preoperative preoxygenation postoperative support Sedated patients   procedural bronchoscopy awake fibreoptic intubation  Asleep patients  with obstructive sleep apnoea (OSA) Clinical Benefits

26. THANK YOU