Oxygenation –

Peri intubation, Apnoeic, THRIVE

Dr Mahima Lakhanpal
Assistant Professor
Santosh Medical College
PREOXYGENATION
Preoxygenation
Administration of Oxygen prior to induction of
Anaesthesia.
To increase the oxygen reserve.
Thereby delay the onset of arterial
oxyhemoglobin desauration during apnea.
Preoxygenation Goals
Achieve 100% oxygenation saturation prior to
procedure.

Denitrogenate the residual capacity of the lung,

maximizing oxygen storage.

Denitrogenate and maximally oxygenate the

bloodstream.

Thus prolong SAFE APNEA TIME

Whole body

FRC

Blood

Tissue
Pregnancy
Pregnancy
“Preoxygenation before intubating management
of the difficult airway” added by ASA Task Force
on Management of the Difficult Airway in 2003.

Cannot Intubate Cannot Ventilate largely

unpredictable.

Routine preoxygenation has become a new

minimum standard of care.

Preoxygenation before tracheal extubation is vital

- added in 2012 guidelines by Difficult Airway
Society.
Techniques Of Preoxygenation
A) Tidal Volume Breathing
- For 3 min
- Flow rate as low as 5L/min is effective.
- Increasing FGF from 5- 10 L/min has little effect.

B) Deep Breathing

- 4 Deep Breaths in 0.5 min
- 8 Deep Breaths in 1 min
- Extended Deep Breathing (12, 16 breaths)
- Single Vital capacity breath.
Comparison of Tidal Volume or Deep Breathing
technique
C) Preoxygenation and an Additional
Maneuver
- CPAP
- O2 insufflation
- BiPAP
Steps for Proper Preoxygenation
Anaesthesia circuit flushed by high O2 flow.

Non leaking face mask used to avoid air

entrainment.

An O2 flow of 5L/min for TVB and 10L/min for deep

breathing.

Can be improved by putting the patient in

30ᴼ - 45ᴼ head up position. (FRC increases)
Clinical End Points of Preoxygenation
Movement of reservoir bag in and out with
inhalation and exhalation.

Presence of normal capnogram and end tidal

CO2.

 End tidal O2 Conc (EtO2) > 90% (lung contain

>2000 ml of O2 i.e 8-10 times VO2).

 End tidal N2 Conc (EtN2) - 5%.

Breathing Systems for Preoxygenation
Mapelson A
Mapelson D
Circle system
NasOral system

 Mapelson A & Circle system- O2 flow 5 L/min For TVB.

 Mapelson D – O2 flow 10 L/min for TVB.
 Irrespective of anaesthesia circuit – 10 L/min for DB
NasOral System
Factors Affecting Efficacy Of
Preoxygenation
Inspired O2 concentration
- Leak
- System used
- FGF, types of breathing (TVB or DB)

Duration of Breathing

VA/FRC
Factors Affecting Efficiency Of
Preoxygenation

Capacity of O2 Loading
- PAO2 and FRC
- Arterial O2 content (CaO2)
- Cardiac Output (CO)

Oxygen Consumption (Vo2)

 APNEIC
OXYGENATION
APNEIC OXYGENATION

 Persistant oxygenation in absence of ventilation.

(Aventilatory Mass Flow – AVMF)

 Firstdescribed in 1956 Holmdahl during

bronchoscopies.

 Apneic oxygenation in conjunction withtraditional

preoxygenation techniques can extend the
SAFE APNEA PERIOD.
Physiology of Apneic Oxygenation
Physiology of Apneic Oxygenation
 O2 diffuses to the capillary blood with 250 mL/min rate.

 During apnea, CO2 production does not change, but elimination is

almost paused.

 Diffusion slows down to only 10-20 mL/min .

 As a result of this negative pressure gradient, a mass flow of gas

from pharynx to alveoli occur.

 CO2 levels keep increasing.

 This causes a decrease in pH and respiratory acidosis.

Methods of Apneic Oxygenation
1) Nasal Prongs
 (Low flow nasal Oxygen – NO DESAT i.e Nasal
Oxygenation During Efforts Securing a Tube)
 Flow 5-15 L/min
 FiO2 of 24%- 44 %
Methods of Apneic Oxygenation
2) Nasopharyngeal Catheter

Naso-Flo nasopharyngeal airway in mannequin’s right naris. Arrow

indicates oxygen insufflation port of the Naso-Flo airway connected to
auxiliary oxygen tubing
 Methods of Apneic Oxygenation
3) Buccal Oxygen Insufflation

Modified 3.5 mm Ring-Adair-Elwyn (RAE) tube for

insufflation of buccal oxygen. Image from left to right
demonstrates: intact RAE tube; connector removed from
tube and distal end cut above the Murphy eye; modified
RAE tube with oxygen tubing attached to cut end.
Methods of Apneic Oxygenation
4) Laryngeal Oxygen Insufflation

Dual use laryngoscope blade with Adapted macintosh laryngoscope blade

am internal lumen within the blade for laryngeal oxygen insufflation. A 14 fr
that allow for laryngeal O2 suction catheter is secured to the blade.
insufflation. Proximal end of the catheter is connected
to secondary oxygen tubing.
 Methods of Apneic Oxygenation
5) Nasal Continuous Positive Airway Pressure

.
 Methods of Apneic Oxygenation
6) High Flow Nasal Oxygen – THRIVE
(THRIVE – Transnasal humidified rapid insufflation
ventilator exchange)

.
 THRIVE
Transnasal humidified rapid insufflation ventilator exchange

 Technique that uses warmed and humidified

oxygen administrated via high flow nasal cannula
to achieve apneic oxygenation and ventilation.

• Flow rate upto 70 litres per min.

• Heated and Humidified- 100% relative humidity ,

. 37 degree celsius.
 THRIVE
Transnasal humidified rapid insufflation ventilator exchange

• Prevents drying up of oral

and nasal mucosa.

• Improve ciliary function

with removal of secretions.

• Creates a flow-dependent
. positive airway pressure.
 THRIVE
Transnasal humidified rapid insufflation ventilator exchange

 Every 10 L/min increase in airflow increases airway

pressure by 0.5-1 cm H2O.

 Continuous positive airway pressure opens upper airway.

 Possible to obtain FiO2 0.21-1 with 60-70 L/min flow.

. 
Improved washout of CO2 – Flow dependent dead space
flushing
 THRIVE
Transnasal humidified rapid insufflation ventilator exchange

Advantage:

 Continuous flow dependent positive pressure.

 Reduces atelectasis.

.
 Elimination of CO2
 Methods of Apneic Oxygenation
7) Supraglottic Jet Oxygenation and
Ventilation (SJOV)

.
Methods of Apneic
Oxygenation
 Novel minimally invasive technique of jet ventilation

above the level of vocal cords using a specialised nasal

tube.

 Feasible ventilation technique in both spontaneously

breathing and apnoeic patients.

 Also been used as a rescue oxygenation/ventilation

method in complete ventilation failure scenarios.
Methods of Apneic
Oxygenation
 A jet of High oxygen flow (>30 L/min at high
frequency) is delivered using driving pressures
between10 and 30 psi.

 This ensures rapid delivery of oxygen in a pulsatile

manner into the trachea leading to an exchange of
gases.

 Complications – Barotrauma, Mucosal drying, Nasal

bleed
Key points
 Routine preoxygenation with 100% O2 is considered a
safety measure.

 Essential in patients with decrease O2 loading or

increased VO2 or difficult airway.

 Most common and effective method – TVB for 3-5 min

or deep breathing for 1 – 1.5 min.

 Apneic oxygenation should be considered in anticipated

difficult airway and other special conditions.