No ventilation, yet full oxygenation - Åse Lodenius - SSAI2017
•Download as PPTX, PDF•
3 likes•712 views
A talk by Åse Lodenius at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Content delivered in collaboration between scanFOAM, SSAI & SFAI.
More Related Content
What's hot
What's hot (20)
Similar to No ventilation, yet full oxygenation - Åse Lodenius - SSAI2017
Similar to No ventilation, yet full oxygenation - Åse Lodenius - SSAI2017 (20)
More from scanFOAM
More from scanFOAM (20)
Recently uploaded
Recently uploaded (20)
No ventilation, yet full oxygenation - Åse Lodenius - SSAI2017
- 1. Åse Lodenius, MD, DESA Karolinska University Hospital Perioperative Medicine and Intensive Care Åse Lodenius 1 No ventilation –yet full oxygenation 08/09/2017
- 2. No conflicts of interest to declare. 08/09/2017 Åse Lodenius 2
- 3. Åse Lodenius 3 Anesthesia and hypoxia 08/09/2017 Cheney et al. Anesthesiology 2006, Auroy et al. Anaesth 2009, Cook et al. Anaesth 2010, Cook et al. BJA 2011, Schiff et al. BJA 2014.
- 4. 08/09/2017 Åse Lodenius 4 Benumof et al. Anesthesiol 1997, Farmery and Roe. BJA 1996. Anesthesia and hypoxia
- 5. 08/09/2017 Åse Lodenius 5 Teller et al, Anesthesiology 1988, Taha et al, Anaesthesia 2006, Ramachandran et al, J Clin Anesth 2010 Apneic oxygenation
- 7. Åse Lodenius 7 Patel and Nouraei. Anaesthesia 2015;70:323-329 08/09/2017 Apneic oxygenation and THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange)
- 8. Apneic oxygenation and increase of CO2 Åse Lodenius 8 RateofriseofCO2duringapnoea(kPa/min) 08/09/2017 Patel and Nouraei. Anaesthesia 2015;70:323-329
- 9. Use of the THRIVE technique (Optiflow™) is increasing worldwide Apneic oxygenation using Optiflow ™ only described in the THRIVE study (end tidal CO2 monitoring) Evaluation of blood gases and pH over time during THRIVE of vital interest 08/09/2017 Åse Lodenius 9 Background to physiology study on THRIVE Patel et al. Anaesthesia 2015;70:323-329, Miguel-Montanes et al. Crit Care Med 2015;43:574-83, Badiger et al. BJA;115(4):629-32 Optiflow™
- 10. 08/09/2017 Åse Lodenius 10
- 11. Aim of Study : To characterize changes in arterial PO2, PCO2 and pH during apneic oxygenation using THRIVE under general anesthesia Åse Lodenius 1108/09/2017 Apnoeic oxygenation in adults under general anaesthesia using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) – a physiological study
- 12. Åse Lodenius 12 Method • Adult patients with ASA class 1-2, BMI < 30, elective laryngeal surgery in general anesthesia • Oxygenation with THRIVE 40-70L/min warm humidified 100% O2 in nasal cannula peroperatively • Continuous measurement of SpO2,TcCO2 • Arterial blood sampling every 5 minutes. 08/09/2017
- 13. 08/09/2017 Åse Lodenius 13 30 patients, age 51 ± 13 years, BMI 25 ±4 completed the protocol Mean apnea time was 22,5 ±4,5 min. Results
- 14. 0 5 10 15 20 25 30 90 95 100 Apnoea duration (min) SpO2(%) 60 08/09/2017 Åse Lodenius 14 Results: • no desaturation below 91% • mean SpO2 never below 98% 0 10 20 30 85 90 95 100 Apnoea duration (min) SpO2atendofapnoea(%) 15 (kPa) BL
- 15. 08/09/2017 Åse Lodenius 15 Results 0 10 20 30 Apnoea duration (min) 0 10 20 30 0 5 10 15 Apnoea duration (min) PaCO2atendofapnoea(kPa) 0 10 20 30 0 5 10 Apnoea duration (min) PaCO2(kPa) PaCO2 tcCO2 PaCO2 tcCO2 0 10 20 30 0 5 10 Apnoea duration (min) PaCO2(kPa) PaCO2 tcCO2 0 5 10 15 20 25 30 0 5 10 7.0 7.1 7.2 7.3 7.4 7.5 Apnoea duration (min) PaCO2(kPa) PaCO2 pH pH CO2 increase Arterial: 0.24 ± 0.04 kPa/min End-tidal: 0.12 ± 0.04 kPa/min BL
- 16. Results: rise of CO2 compared to the Patel and Nouraei study Åse Lodenius 16 RateofriseofCO2duringapnoea(kPa/min) 2017-05-22 Patel and Nouraei. Anaesthesia 2015;70:323-329 Our study Arterial CO End tidal CO2
- 17. Patients can safely be oxygenated using THRIVE provided they have an open airway. The rise in carbon dioxide is lower compared to older studies and therefore the THRIVE concept makes it possible to extend the apneic window. Monitoring of CO2 should be used. 08/09/2017 Åse Lodenius 17 Conclusions
- 18. 08/09/2017 Åse Lodenius 18
- 19. 08/09/2017 Åse Lodenius 19 Traditional Optiflow™ Pre-oxygenation in rapid sequence induction anaesthesia for emergency surgery in adults; THRIVE versus facemask breathing. A prospective randomised non-blinded clinical trial. Poster presentation. Lodenius et al, SSAI 2017
- 20. 08/09/2017 Åse Lodenius 20 No difference in PaO2 between groups Difference in mean (SD) total apnea time: • THRIVE group 248 sec (4 min 13 sec) • facemask group 123 sec (2 min 5 sec)
- 21. Åse Lodenius 21 Aims of the study 1. Primary: To compare the lowest SpO2 within 1 minute after intubation when pre-oxygenating with THRIVE (Optiflow™) or facemask in rapid sequence induction (RSI) of anaesthesia. 2. Secondary: a. To compare the number of patients who desaturate <93% during intubation b. To assess occurrence of gastric regurgitation c. To evaluate patient discomfort 08/09/2017
- 22. 08/09/2017 Åse Lodenius 22 • 80 adult patients (>18 years, non-pregnant, BMI < 35) presenting for emergency surgery were included. • Randomized for pre-oxygenation with either THRIVE (Optiflow™) or traditional tight occluding mask • Pre-oxygenation with 100 % O2 for minumum 3 min Facemask fresh gas > 10 l/min or Optiflow™ 40 l/min 70 l/min at apnea • Measuring lowest SpO2 within 1 minute of intubation, time for apnea and intubation. Assessing gastric regurgitation in pharynx. Method
- 23. 08/09/2017 Åse Lodenius 23 Data from 79 of 80 adult patients (>18 years) presenting for emergency surgery were analyzed. No difference between groups regarding sex, age, BMI, ASA physical status, comorbidity or type of surgery. Results Variabel Facemask (n=39) THRIVE (n=40) p-value Cormack-Lehane grade 0.28 1 24 (61.6%) 29 (72.5%) 2 10 (25.6%) 10 (25%) 3 5 (12.8%) 1 (2.5%) 4 0 (0%) 0 (0%) 0.5 Intubation attempts 1 (1-4) 1 (1-2) 0.53 Intubation time (seconds) 64 (51) 55 (28) 0.99 Apnea time (seconds) 121 (57) 124 (44) 0.49
- 24. 08/09/2017 Åse Lodenius 24 Result primary outcome: median lowest SpO2 during intubation 99% with range (70-100%) facemask group and (96-100%) THRIVE group (p = 0.097)
- 25. 08/09/2017 Åse Lodenius 25 Facemask (n= 39) THRIVE (n= 40) Result secondary outcome: 5 (12,5%) patients had SpO2 <93% during intubation when using facemask vs none in THRIVE group (p= 0,019)
- 26. No regurgitation of gastric content to the pharynx No difference in perceived discomfort assessed with VAS. VAS was rated 2 (0-10) in the facemask group and 1 (0-8) for the THRIVE group (p = 0.44) 08/09/2017 Åse Lodenius 26 Result secondary output:
- 27. Indication that THRIVE is safe to use for pre-oxygenation in rapid sequence induction for emergency surgery in this study population. THRIVE may offer an advantage compared to pre-oxygenation with facemask shown in this study as a difference in numbers of patients desaturating in SpO2 below 93%. 08/09/2017 Åse Lodenius 27 Conclusion Manuscript has been submitted.
- 28. THANK YOU FOR YOUR ATTENTION 08/09/2017 Åse Lodenius 28
- 29. QUESTION 1 How many of you use THRIVE, that is Optiflow™ during pre- oxygenation in the operation ward? 1. Yes 2. No 3. Occasionally 08/09/2017 Åse Lodenius 29
- 30. QUESTION 2 How many of you use THRIVE, that is Optiflow™ during pre- oxygenation in the ICU? 08/09/2017 Åse Lodenius 30 1. Yes 2. No 3. Occasionally
- 31. QUESTION 3 Should we use THRIVE, that is Optiflow™, during pre- oxygenation for all rapid sequence inductions? 08/09/2017 Åse Lodenius 31 1. Yes 2. No 3. Occasionally
Editor's Notes
- Hi. My name is Talk about THRIVE and apneic oxygenation and how it can be used in the operation ward today. Brief introduction but mainly present 2 studies that we have conducted at KS.
- I have no conflicts of interest to declare.
- ANESTHESIA COMPLICATIONS RELATED TO THE AIRWAY have diminished over the years. We have well known data, here from the ASA Closed Claims Analysis reported in 2006, that show how respiratory events resulting in death and brain damage have decreased over time from the mid 70:ies. But still hypoxia remains a significant problem that can have a dramatic impact on outcome, as has been shown in NAP4 among other studies. TO PREVENT HYPOXIA…
- To prevent hypoxia during anesthesia-induced apnea pre-oxygenation with 100% oxygen is standard practice. Pre-oxygenation denitrogenates the lungs and creates an oxygen reserve, mainly in the FRC, that can be utilized during apnea. Pre-oxygenation prolongs the time to desaturation substantially. Even so; some patients that undergo anesthesia desaturate in spite of the pre-oxygenation. What else can be done to prevent hypoxia? IN ORDER TO FURTHER PROLONG THE TIME TO DESATURATION
- Apneic oxygenation can be used. AP OX has been evaluated in both animals and humans since the early 20th century. It has been shown that oxygenation can be well kept for considerable time but also that the limiting factor for its use is the accumulation of CO2 and the lowering of pH which eventually will affect the circulation. As was the case with malignant arrhythmias in the Frumin study from the 50:ies. In a couple of more recent studies apneic oxygenation with delivery of nasopharyngeal oxygen has been used to extend the apnea time during intubation. In these studies a moderate flow of oxygen of 3-15 L/min was provided. The saturation was well preserved for up to 10 minutes in normal weight individuals but could also be extended in the obese. AS A FURTHER EXTENSION OF THIS TECHNIQUE Teller: 12 ASA 1-2 pat. med/utan 3l O2 i pharynx. SpO2 91% efter 6,8 min på luft, SpO2 ≥ 97% i de 10 min (innan försöket avbröts) Taha: 30 ASA 1-2 pat (15 + 15 st) 5l O2 i pharynx vs ktrll grupp. Time to desat 95%: 3,6 min vs SpO2 100% i 6 min innan försök avbröts. Ramach: 30 obese (BMI 30-35) randomis till 5 L/min O2/ej O2. 3 findings: a) time to desat 95%↑ 5.29 vs 3.49 min b) more pat that kept SPO2>95% vid 6 min 8/15 vs 1/15 c)lägsta SpO2vid 6 min: 94 vs 88%
- APNEIC OXYGENATION using Optiflow with nasal cannulae and a very high flow of oxygen up to 70 L/min was presented in a landmark study , the THRIVE study, by Patel and Nouraei in 2015. THRIVE WAS… Transnasal Humidified Rapid-Insufflation Ventilatory Exchange technique.
- WAS USED for apneic oxygenation until the airway was secured when managing patients with difficult airways in a case series of 25 patients. The patients were on THRIVE OX for a median time of 14 minutes, the time varied between 5 and 65 min. None of the patients desaturated below 90%. THE SECOND REMARKABLE FINDING WITH THE THRIVE STUDY…
- WAS A SLOWER RISE in carbon dioxide than in earlier studies, approx 0,15 kPa/min. CO2 accumulation in earlier studies, with low flow of oxygen, was about 0,5 kPa/min, as you all are well familiar with. The CO2 rise in the THRIVE study was comparable to two studies were oxygen was delivered directly in the trachea with moderate and very high flow. That means there seems to be partial wash out of CO2 whith this high flow of oxygen although the mechanism is not entirely clear. The CO2 level was measured in endtidal gas, before and after the apneic oxygenation. THE RATIONALE FOR THE STUDY THAT WE CONDUCTED IS THE FACT THAT… (Rudlof & Hohenhorst: 0,5 l/min in trachea Watson et al: 45 l/min in trachea.)
- Use of THRIVE is increasing. Optiflow is a well-known device in the intensive care and has been used for > a decade in patients that are weaned from a ventilator or even as an alternative respiratory support. In the same manner it has also been used postoperatively, after extubation. The use postoperatively or in the ICU is in spontaneously breathing patients. Apneic oxygenation, in an anesthetised and paralysed patient, using Optiflow had only been described in one study, the THRIVE study in 2015 (in these 25 patients) and monitoring of CO2 was endtidal. It had not been evaluated with arterial blood gases. THIS WAS DONE IN OUR STUDY…
- THAT WAS Published in the BJA in april this year and Highlighted in an editorial. THE AIM OF THE STUDY WAS
- THE AIM OF THE STUDY WAS …to characterize changes in arterial PO2, PCO2 and pH during apneic oxygenation using THRIVE under general anesthesia. We were very inspired and encouraged by our friends and colleagues from London. THE STUDY WAS CONDUCTED…
- At the ENT operation ward KS in adult patients, (ASA 1-2), undergoing shorter laryngeal surgery. They had general anesthesia TCI with propofol and remifentanil. NMB was induced with rocuronium. Pre-oxygenation and sole mode of ventilation, in these anesthetised and paralysed patients, was THRIVE, 100 % oxygen, 40 L/min, increased to 70 L/min after anesth induction. The anesthesiologist was careful to keep the airway open at all times. Vital parameters and transcutaneous CO2 were measured. Blood gases were sampled every 5 minutes. 30 PATIENTS WITH A MEAN AGE…
- Thirty patients with a mean age 51 ± 13 years and BMI 25 ± 4 completed the study. Mean apnea duration was 22.5± 4.5 min. This is during surgery. No respiration trace on the screen!! WE FOUND THAT OXYGENATION USING THRIVE…
- Oxygenation was well kept. Left graph: SpO2 was never below 91% for any individual with a mean value never below 98%. Right graph shows: oxygen saturation for each individual at end of apnea. Each dot representing one individual. AS FOR THE RISE IN CO2…
- We found the rise in arterial CO2 during apnea to be 0.24 ± 0.04 kPa/min which is lower than average values traditionally presented. ETCO2 was measured during spontaneous breathing before anesthesia induction and on the first breath of controlled ventilation at end of apnea. The rise of end tidal CO2 0,12 kPa/min. Consistent with the original THRIVE study by Patel and Nouraei. Top left: arterial carbon dioxide for each individual at end of apnea. Each dot representing one individual. Bottom left graph: the rise of transcutaneous and arterial CO2over time. No difference in transcutaneous and arterial CO2could be seen. Bottom right: CO2 and its relation to pH over time. No pH was lower than 7,13. WHEN WE PLOT OUR RESULTS
- WHEN WE PLOT OUR RESULTS into the graph from the original THRIVE study we find well correlating results. BASED ON THESE FINDINGS…
- Conclusion: Based on these results we can say that THRIVE can safely be used for oxygenation in anesthetized patients during apnea. Provided they have an open airway at all times! The lower rise in carbon dioxide compared to the classical studies makes it possible to extend the apneic time period. Our recommendation is that monitoring of CO2 should be used SINCE ENDTIDAL MONITORING IS NOT POSSIBLE during THRIVE and apnea. THE EDITORIAL BY DR NEKHENDZY STATED THAT …
- Optiflow has found it´s place in anesthesia. And that it can be used for shorter surgery but also providing extra safety when managing a diffcult airway. Safe oxygenation during apnea seems desirable if the apnea period is prolonged, especially in rapid sequence induction of anesthesia, when manual ventilation is avoided. WHICH LED US TO THE SECOND STUDY THAT I HAVE PRESENTED AS A POSTER HERE AT THIS MEETING …
- THIS WAS A randomized controlled trial comparing pre-oxygenation with either the traditional tight occluding facemask or THRIVE in patients presenting for emergency surgery where RSI was indicated. This had not previously been done when we started our trial. BUT WE FOUND OURSELVES
- We found ourselves beaten in the race by our British colleagues F Mir and co-workers who performed a similar trial of 40 patients that was published in March 2017 when we just had finished our data collection. Primary outcome in the Mir study was partial pressure of O2. No difference in arterial oxygen pressure between the 2 groups was seen. That was in spite of a longer total apnea time in the THRIVE group compared to facemask. Nevertheless: THRIVE was not inferior to facemask but a benefit for THRIVE could not be shown. THE PRIMARY AIM IN OUR PRE-OXYGENATION STUDY…
- The primary aim was to compare the lowest oxygen saturation within 1 min of intub using either THRIVE or facemask pre-oxygenation. We also compared the number of patients that desaturated below SpO2 93%, assessed occurrence of gastric regurg and patient discomfort. THE STUDY WAS CONDUCTED AT THE Trauma and Emerg Dept at K.Hosp and 80 patients….
- 80 adult patients were included. They were randomized to receive pre-ox with either THRIVE or facemask. Pre-ox with 100% O2 for a minimum of 3 min. FM: fresh gas flow at least 10 l/min THRIVE: 40 70 l/min Lowest SpO2 within 1 minute of intub. As well as time for apnea and intub. DATA FROM 79 OF THE 80 INCLUDED PATIENTS WERE ANALYZED…
- There were no differences regarding patient characteristics or type of surgery between the 2 groups. There also were no differences in difficulty of intubation or time for apnea and intubation between groups. AS FOR PRIMARY OUTCOME:
- In spite of an apparent difference in outcome a statistical difference in median lowest SpO2 during intubation between the two groups could not be seen (p = 0.097). Median lowest SpO2 during intubation, until one minute after the tracheal tube was put in place, was 99% in both groups with range (70-100%) for the facemask group and (96-100%) for the THRIVE group. (Fig 1) ALTHOUGH WE DID SEE A DIFFERENCE IN SECONDARY OUTCOME Mean values for lowest SpO2 until one minute after intubation were 99.2% (1.0) and 96.8% (5.8) for the THRIVE and facemask group, respectively.
- 5 out of 39 patients desaturated below 93%, our predefined limit, when the facemask was used vs none in the THRIVE-group which was a significant difference. THERE WERE NO SIGNS…
- No signs of regurgit of gastric content. We also found no difference in perceived discomfort with a medium rating of VAS 2 (0-10) in the facemask group and 1 (0-8) for the THRIVE group (p = 0.44). TO CONCLUDE: Our findings indicate…
- OUR FINDINGS indicate that THRIVE is safe to use for pre-oxygenation in rapid sequence induction for emergency surgery in this setting. (BMI< 35, non-pregnant, not requiring NIV to keep oxygen saturation before anesthesia start) We found no benefit in our primary outcome but THRIVE may offer an advantage compared to pre-oxygenation with facemask shown in this study as a difference in numbers of patients desaturating in SpO2 below 93%. Manuscript is submitted, hope for publication soon.