THRIVE in Airway Management

Primary Indication and Mechanism

The American Society of Anesthesiologists recommends THRIVE as an apneic oxygenation technique to maximize oxygenation during unanticipated and emergency difficult airway management, particularly in "cannot oxygenate or ventilate" scenarios, with a recommended flow rate of 30-70 L/min of warmed, humidified oxygen 1, 2

The British guidelines recommend THRIVE (or high-flow nasal oxygen at 30-70 L/min) as an optimal oxygenation technique during rapid sequence intubation in critically ill adults, particularly those with pulmonary shunt and limited respiratory reserve 3, 4
THRIVE should be applied throughout all airway management efforts, from preoxygenation through intubation attempts, to extend safe apnea time beyond the 6-8 minutes achieved with standard preoxygenation alone 4

The British Journal of Anaesthesia states that severe facial trauma or suspected skull base fractures are absolute contraindications to high-flow nasal oxygenation, including THRIVE 4

The British Journal of Anaesthesia recommends a flow rate of 30-70 L/min of warmed, humidified oxygen for adult patients using THRIVE 3, 4

The British Journal of Anaesthesia recommends applying tight-fitting facemask with CPAP (5-10 cm H2O) if oxygenation is impaired, targeting end-tidal oxygen ≥90%, and continuing nasal oxygen/THRIVE throughout all intubation attempts 4

The British Journal of Anaesthesia warns that concomitant use of THRIVE during facemask ventilation with a tight-fitting mask can result in dangerously high airway pressures, and recommends either moving THRIVE cannulae to corner of mouth or temporarily discontinuing THRIVE during facemask ventilation 4

The 2022 ASA Difficult Airway Guidelines explicitly list "high-flow nasal cannula oxygen/transnasal humidified rapid insufflation ventilatory exchange" as a recommended technique to maximize oxygenation during emergency difficult airway management, with a strength of evidence considered moderate 1, 2
The 2018 British guidelines for critically ill adults recommend THRIVE/HFNO as optimal oxygenation techniques, though they note evidence shows no harm but no definitive outcome benefits, making the evidence inconclusive for routine use 4

THRIVE delivers warmed, humidified oxygen at high flow rates (30-70 L/min) through nasal cannulae, creating a continuous positive airway pressure effect while maintaining airway patency 5, 6
Unlike traditional apneic oxygenation techniques, THRIVE not only extends the apnea time but also improves CO2 clearance, preventing the rapid increase in CO2 typically seen during apnea 7, 5
The mechanism of CO2 clearance is thought to be mediated by the interaction between supraglottic flow vortices generated by the high nasal flow and cardiopneumatic movements 5

THRIVE provides significantly longer safe apnea times compared to conventional preoxygenation techniques 5, 7, 6
Warmed and humidified oxygen allows for higher flow rates (30-70 L/min) that would be intolerable with cold, dry oxygen (limited to 10-15 L/min) 5

Pharyngeal Insufflation: Early technique using 3-10 L/min oxygen via nasal catheter placed in the oropharynx, providing approximately 10 minutes of safe apnea time 5, 7
NO DESAT (Nasal Oxygenation During Efforts to Secure A Tube): Described by Levitan in 2010, uses simple nasal cannulae at flow rates up to 15 L/min during intubation 7, 8
THRIVE: Represents the most advanced technique, using 30-70 L/min of warmed, humidified oxygen, significantly extending apnea time while providing CO2 clearance 5, 6