Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) use in a pediatric population
A prospective, randomized controlled trial.
Journal of Clinical Anesthesia
Submitted April 2026 by Dr Erik Anderson
Background:
Maintenance of oxygenation during micro-laryngoscopy and bronchoscopy is an anaesthetic challenge for paediatric anaesthetists. Anaesthesia goals are for a spontaneously breathing patient without an airway in situ. Ideally, patients should not move, cough, breath-hold or desaturate whilst still remaining adequately anaesthetised with minimal disruptions to surgical access.
Tubeless upper airway surgery in children is challenging and may be performed on complex paediatric patients with concurrent upper airway, cardiac or respiratory pathology. These procedures are often interrupted for rescue oxygenation.
Overview/ Summary:
Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a safe method to deliver oxygen to paediatric patients but its role in preventing desaturation in paediatric patients undergoing tubeless airway surgery is still being investigated.
This study compared THRIVE versus standard care during airway procedures.
The primary aim was to assess the incidence of “relative desaturation events” i.e. patients who had at least one desaturation episode defined as a 4% drop from the patients’ baseline
Secondary aims were to assess:
- overall frequency (total number) of “relative desaturation events (above)”
- frequency of desaturations below 90%- “absolute desaturations”
- surgical interruptions due to airway conditions
Methods and interventions
This is a prospective, randomised control trial conducted across three paediatric centres in the USA on patients aged 2 months to 18 years for elective surgery cases over a 40-month period (2020 to 2024).
Exclusion criteria: emergency surgeries, cyanotic heart conditions, Jet ventilated, COVID 19 positive, already- intubated patients, tracheostomy or contraindication to THRIVE (papillomatosis or facial fractures), neonates
Baseline sats were measured on each patient using a Massimo Pulse Co-oximeter.
All patients were placed in surgical suspension for the airway surgery.
The THRIVE group received 2l/kg/min oxygen flows (max 70L/min) via the Optiflow system
The standard care group received oxygen via side-port of suspension laryngoscope or via ETT placed in oropharynx; i.e not actually standardised
Desaturations and airway interventions e.g. jaw thrust, Bag mask ventilation and intubations were captured by a research assistant in the OT.
Context of this study:
In July 2024, the High-flow nasal oxygen for children’s airway surgery to reduce hypoxemic events (HAMSTER) trial was published in the Lancet respiratory medicine journal. This was a multi-centre randomised trial in 5 tertiary centres in Australia which evaluated children 0-16 years randomised to undergo THRIVE oxygen therapy versus standard oxygen therapy for tubeless upper airway surgery. The results failed to show any benefit of THRIVE over standard therapy. There were no differences in adverse events and no difference in reducing desaturation-related surgical interruptions.
A limitation of the HAMSTER study was that it did not assess relative desaturation compared to the patient’s own baseline sats. This study evaluates relative desaturation as a secondary outcome.
Results:
Despite aiming for a sample size of 600 participants, only 144 participants were included.
- There were 73 patients in the THRIVE group and 71 patients in the standard care group
- Ages ranged from 2-18 years (mean age 5.1 years)
- Average procedure time 541 seconds
Primary outcome:
No difference 2 groups and incidence of relative desaturations < 4% of baseline
Secondary outcomes: - There was a difference in overall number of relative desaturations, with double the incidence in the standard care group compared to the THRIVE group
- There was also difference in the total number of desaturation events in the 2 groups - also double in the standard care group
- There was no difference in the number of absolute desaturations below 90% in the 2 groups
- There was no difference in number of surgical disruptions in the 2 groups
Limitations:
- Disproportionately low number of African-heritage patients
- Elective cases; complex patients, those with severe illness and emergencies were excluded
- Anaesthetists were not blinded to technique
- Titration of Fi02 and anaesthesia maintenance technique not standardised in standard care
- Exclusion criteria as above - certain patient groups were not evaluated
- Smaller sample size than initially planned
Take home message:
This study results agree with the results of the HAMSTER trial in Australia; they demonstrate and reinforce the non-superiority of THRIVE over standard care in tubeless airway procedures
Furthermore, there was:
- No difference in the frequency of patients that desaturated 4% from baseline or below 90%
- No difference in interruptions of surgical procedure
There was a difference in the overall number of desaturations events - THRIVE may benefit certain patients with cardiac/ respiratory risk factors. This warrants further investigation.
This study does not cover several important populations including emergency cases, complex disease, cyanotic heart conditions and neonates; further study would be required to evaluate THRIVE in these groups.
